A fishy tale: Foreign body ingestion resulting in hepatic abscess formation

A 75-year-old man presented to the emergency department with a two-week history of dyspnoea, epigastric pain, and constipation. Physical examination revealed a distended abdomen and pyrexia. His past medical history included surgically managed colorectal carcinoma and COPD. Blood tests showed raised inflammatory markers and deranged liver enzymes.

An abdominal CT scan with contrast showed a multiloculated predominantly cystic mass, measuring approximately up to 8.1 x 8.6 x 5.9 cm within the left lobe of the liver in segment II/III. It demonstrated mass effect with distortion of the liver capsule and hepatic vessels with some peripheral enhancement in the portal venous phase.  A thin linear structure of high density (740 HU) measuring 3 cm in length was noted lying vertically within the mass, consistent with a foreign body.

A subsequent contrast-enhanced MRI liver characterised the large multiloculated multiseptated complex mass within the liver. The hyperintense signals were suggestive of a fluid/necrotic component in T2-weighted sequences. Post-contrast axial T1-weighted FS sequences showed only enhancement of the walls and internal septations. Peripheral restricted diffusion on DWI and ADC sequences was observed. No suspicious intralesional nodular or soft tissue enhancements were noted. Findings were consistent with a large, complex liver abscess involving segment II and III of the liver in association with a foreign body.

The above radiological findings were consistent with the presence of a hepatic abscess. There are a multitude of causes for the formation of hepatic abscesses with biliary tract disease as a leading cause. Other sources include disseminated portal vein infections, infective endocarditis, amoebic infections or through the introduction of a foreign body [1]. In this instance, the apparent cause was the hyperdense linear structure, likely an ingested migrating foreign body.

Ingestion of a foreign body is a common presentation in the emergency department and most cases resolve without intervention. However, rare cases have been reported where foreign bodies have perforated the upper gastrointestinal tract, typically at the duodenum and stomach. These cases have often been surgically managed with removal of the foreign body; typically, a fishbone [2]. Perforating foreign bodies have also been reported to migrate to the liver leading to infection and abscess formation [3].

The history and clinical signs are often non-specific in these patients, and imaging is pivotal in obtaining a diagnosis [4]. Our patient was initially managed as an infective exacerbation of COPD and subacute bowel obstruction. An abdominal CT scan showed the foreign body and hepatic abscess.

Given the anatomical proximity of the stomach with the liver, in the absence of a clear history, the working hypothesis was the foreign body perforated the lesser curvature of the stomach which abuts the left lobe of the liver, migrating through the gastrohepatic ligament in the lesser omentum. This is consistent with the non-specific history and presentation and correlates with the anatomy and radiological findings. Cultures from the aspirated sample grew streptococcus constellatus, an organism typically found in the oral cavity, correlating with the above hypothesis [5].

Most reported cases of hepatic abscess following foreign body perforation have been surgically managed with either a laparoscopy or laparotomy [2]. Our patient had percutaneous drainage of the abscess with intravenous antibiotics with complete resolution of symptoms avoiding surgical intervention. This is one of the few cases where the patient was discharged home without removal of the foreign body, avoiding potential complications associated with surgery [6,7]. Since discharge, our patient had an ultrasound scan of the liver which showed abscess resolution and they have had no further symptoms associated with the foreign body.

Learning Points

1. Adjacent visceral involvement is possible from an enteric or gastric perforation and migration.
2. Surgical intervention may not be necessitated in patients with foreign body ingestion.

Written informed patient consent for publication has been obtained.