An unusual cause of a liver abscess
A 56 year old female presented to the A+E with dizziness and a fall. Prior to this event the patient has had 3 days with a fever, productive cough, abdominal pain, and vomiting. She has a past medical history of diabetes, high cholesterol, hypertension and IHD. On examination, her significant findings were she was diaphoretic, lethargic, and had right lower quadrant pain. Her temperature was 39.7°C with a heart rate of 127 and blood pressure of 125/95. A CT scan with intravenous contrast was ordered and a foreign body was noted with an abscess formation. The foreign body was suspected to be a fishbone.
The patient was found to have a phlegmonous lesion measuring 9.4 cm x 7 cm with a foreign body in situ in segment 4B of her liver which entered from the distal portion of the stomach into the fissure of ligamentum of terres. Initially the patient was started on antibiotics and was hemodynamically stable. During her inpatient stay she became hypotensive and had severe lactic acidosis with septic shock. A percutaneous insertion of a catheter was performed. The patient did not improve so an open liver abscess drainage was done and no foreign body could be retrieved. The patient underwent a repeat CT, the same foreign body was still present with a residual abscess. A new percutaneous catheter was placed and the patient improved and was send to a rehabilitation facility and eventually discharged home with no complications.
Ingestion and migration of a foreign body resulting in a liver abscess is extremely rare. To date there are only 88 cases reported. Of these cases 33% are due to the ingestion of a fishbone. The classic signs of liver abscess fever, right upper quadrant pain and jaundice are rarely seen. Instead patients present with epigastric pain, fever, chills, anorexia, nausea and vomiting or even weight loss. Not only are the signs not diagnostic for this group of patient most patients also do not recall if they swallowed a fishbone. The most common diagnosis before surgery is often acute appendicitis or diverticulitis. Once the diagnosis of liver abscess has been made if the abscess if less than 5cm antimicrobial monotherapy can be attempted. If the liver abscess is greater than or equal to 5cm percutaneous drainage is recommended. In this patient she had both treatments and failed and this was follwed by a laparotomy for open drainage which resulted in improvement of the abscess size and symptoms but no foreign body could be retrived. To the best of our knowledge this is the fourth case of a liver abscess due to a foreign body ingestion that has sucessfully been treated without the removal of the foreign body.
