Migrated toothpick as cause of liver abscess

Clinical History

A 78-year-old man was admitted to our hospital with a 1-week history of fever (38-40°C) and intermittent right upper quadrant pain, accompanied by diarrhoea, nausea and vomiting. Physical examination demonstrated abdominal tenderness in the right upper abdomen.
Upon laboratory evaluation, white blood cell count and C-reactive protein level were elevated.

Imaging Findings

Abdominal radiographs revealed rare air-fluid levels in right abdomen and meteoric distension of ileocolic loops.
Contrast-enhanced CT of the abdomen demonstrated a large hypodense mass in the IV hepatic segment, measuring 7.5 cm x 6 cm, with lobulated margins and peripheral enhancement, consistent with abscess. CT images also showed a thin ring of low-attenuation in the hepatic parenchyma surrounding the mass (Fig. 1). Maximum intensity projection (MIP) images revealed a hyperdense, linear foreign body within the liver abscess that extended into the hepato-gastric ligament (Fig. 2-3)
The liver abscess was treated with parenteral antibiotic therapy and percutaneous drainage. Surgical removal of the foreign body was successfully performed without complication. Final pathological diagnosis demonstrated a 4.5 cm long toothpick.

Discussion

Foreign body ingestion is not an uncommon problem observed in clinical practice. However, the associated complication of bowel perforation and migration of the foreign body to the liver is rare. It is usually caused by objects with sharp or pointed ends, such as sewing needles, dental plates, fish and chicken bones.
The most common sites of perforation are the stomach and duodenum [1-4], but perforation could happen at any site of the gastrointestinal system.
In our case, the site of bowel perforation was not identified intra-operatively. The location of the toothpick between the IV segment of the liver and hepato-gastric ligament suggests that the most plausible site of perforation could be the gastric antrum.
Symptoms related to foreign body ingestion are variable and non-specific. Generally, patients rarely recall the episode of the ingestion and the migrating foreign body may remain silent until they cause abscesses or systemic infections.
The first radiological approach to the patient is plain radiograph that may not identify all the foreign bodies. For example, non-radio-opaque foreign bodies (as a toothpick), are improbable to be identified [5].
Ultrasonography (US) is helpful to identify foreign bodies, generally hyperechoic, and to locate the abscess [6].
Actually CT is the gold standard for identification of ingested foreign bodies [7] and contrast-enhanced CT can make an accurate description and diagnosis of hepatic abscess. Moreover CT, using MPR (Multiplanar Reconstructions) or MIP reconstructions may help to identify the site of perforation, when it is detectable.
Treatment is surgery with exploratory laparotomy, endoscopy or laparoscopy [8].
In conclusion, in case of ingestion and liver migration of a toothpick, ultrasonography is helpful in the diagnosis but the gold standard is contrast-enhanced CT, which can locate the foreign body and demonstrate the liver abscess.
If there is perforation of the gastrointestinal tract, CT can help the surgeon to recognise the lesion and guide treatment.

Differential Diagnosis List

Final Diagnosis

Liver abscess secondary to perforation by an ingested toothpick

URL:	https://www.eurorad.org/case/13470
DOI:	10.1594/EURORAD/CASE.13470
ISSN:	1563-4086