Liver abscess secondary to fish bone migration from the duodenum

Abstract

A 59-year-old woman was admitted with persistent fever for 2 weeks in spite of medication treatment and progressive persistent epigastric dullness after fever onset 10 days later. Abdominal computed tomography revealed a linear high-density lesion between the liver abscess and the duodenal bulb. Percutaneous abscess drainage and antibiotics treatment were performed. The panendoscopy demonstrated a healed duodenal ulcer without any foreign body. Therefore, she underwent the lateral segmentectomy, fistulectomy and duodenorrhaphy. Operative findings revealed one 4-cm fish bone within the duodenohepatic fistula, which was located at the duodenal bulb attached to the liver (Fig. 1). She was discharged on post-operative day 12 and felt well during outpatient department follow-up. Liver abscess combined with hepato-enteric fistula is a rare clinical manifestation. There are two mechanisms of relation between liver abscess and hepato-enteric fistula. One is liver abscess rupture into alimentary tract. The other is perforated bowel wall leading to liver abscess formation. Intestinal perforation by foreign body ingestion is one of the bowel perforation factors and the incidence is approximately 1%. In the past, liver abscess secondary to foreign body penetrating from the alimentary tract was a surgical indication. Recently, some reports suggest non-operative treatment by abscess drainage, antibiotics administration and endoscopic removal of foreign body. We combined operative and non-operative therapy for this complicated case. According to the patient’s history, the process by which this fish bone penetrated through the duodenal wall may be slow ongoing and migration is more likely. When it ‘migrated’ out of the duodenal serosa and then the fistular orifice was covered by new growing mucosa, this duodenohepatic fistula and the fish bone became invisible. This is the possible mechanism of the liver abscess secondary to fish bone migration from the duodenum.