2435 An Uncommon Case of Hepatic Abscess From Fish Bone Ingestion: A Case Report With Successful Conservative Management

Abstract

INTRODUCTION: Accidental ingestion of foreign bodies is infrequently seen in clinical practice and can be fatal. Liver abscess from enterohepatic migration of an ingested foreign body is extremely rare and is usually associated with perforation, peritonitis from rupture of the hepatic abscess and sepsis. Lack of specific symptoms, unacknowledged ingestion by the patient and a low clinical suspicion, complicate our arrival at an accurate diagnosis. Here, we report a case of hepatic abscess secondary to fish bone ingestion, without peritonitis, that was managed conservatively and without extraction of the foreign body. CASE DESCRIPTION/METHODS: Our patient is a 64 y/o lady who came in with sharp, right sided abdominal pain, fever and anorexia for a week. She was febrile upon arrival with leukocytosis and mild transaminitis with total bilirubin 2.7. Other monitored vitals were stable. CT abdomen revealed a 6.9 cm abscess at the junction of the right and left hepatic lobes which was promptly drained percutaneously by IR. Despite clinical improvement with drainage and antibiotics, persistent leukocytosis was appreciated. A repeat CT showed a small residual liver abscess and a sharp, linear radiopaque foreign body adjacent to the pylorus with perigastric stranding. Upon further questioning, patient recollected having had fish prior to onset of symptoms. Endoscopy was unsuccessful in identifying the exit tract from the upper GI tract. Reimaging confirmed migration of the fishbone towards the falciform fissure and gastrohepatic ligament. The position of the fish bone posed a challenge for percutaneous extraction and Surgery recommended against exploratory laparotomy as patient had marked clinical improvement. Follow up imaging a month later showed the fish bone to be in stable position, in an asymptomatic patient. DISCUSSION: 80% – 90% of ingested foreign bodies usually pass through the gut without any intervention. Foreign body ingestion is generally an unconscious event, that the patient rarely recalls, which complicates the preoperative diagnosis in most cases. In the case of liver abscess unresponsive to drainage and antibiotic therapy, this possibility needs to be entertained, despite its low incidence. Besides antibiotics and abscess drainage for size >5 cm, surgical or endoscopic retrieval of the foreign body has always been the conventional treatment. However, medical management should be considered for patients, like ours, without signs of severe sequelae.