Introduction

The liver is the most frequent location of intra-abdominal visceral abscesses.

Pyogenic liver abscess is a rare and severe disease with an annual incidence of 2.3 cases per 100,000 people¹ and a mortality rate of 7-16%²,³.

In Western countries, pyogenic liver abscesses are usually polymicrobial, while in East Asian countries, these abscesses are monomicrobial (mainly produced by Klebsiella pneumoniae) and could be related to colorectal cancer⁴.

There are different mechanisms of infection of the liver parenchyma. Nowadays, the most frequent is the ascending infection from the biliary tract, associated with biliary diseases (biliary lithiasis, stenosis of extra- and intrahepatic bile duct, or bilioenteric anastomosis)⁵.

Currently, less frequent routes are portal vein pyemia (due to an intraabdominal infectious process) or systemic bacteremia as a result of hematogenous seeding from a distant infectious focus (such as infectious endocarditis)⁶. Another less frequent route is the systemic circulation (bacteremia) as a result of hematogenous seeding from a distant infectious focus, such as infectious endocarditis⁶.

Liver abscesses secondary to a foreign body are an exceptional situation. The most frequent pathogenesis in these circumstances is gastric perforation by a fish bone that migrating to the liver and generating an abscess. In this context, the abscess will most often be located in the left hepatic lobe, while the most frequent location of liver abscess is usually the right hepatic lobe⁷.

Case presentation

A 73-year-old woman with no medical history of relevance presented to the emergency department with a 2-week history of fever, asthenia, nausea, and intermittent diffuse abdominal pain. The abdominal examination did not show signs of peritoneal irritation. Elevation of acute-phase reactants and spontaneous coagulopathy was observed.

An exploratory abdominal ultrasound was performed showing a hypoechoic liver collection in the left hepatic lob. The study was completed with a computed tomography (CT) scan that revealed a liver abscess with a hyperdense image into the parenchyma of the left hepatic lobe (Fig. 1). With the diagnosis of pyogenic liver abscess associated with foreign body, antibiotic treatment was initiated with piperacillin-tazobactam (4/0.5) every 8 h, during 5 days. Although the patient had a good response to the antibiotic treatment, with disappearance of the fever, normalization of coagulation, and decrease of the acute phase reactants, a residual collection with a foreign body persisted in the liver. After evaluating this clinical case in a multidisciplinary committee, a surgical approach to the liver abscess was indicated to remove the foreign body. We have ruled out the possibility of percutaneous drainage because this procedure would not allow the removal of the foreign body. Based on previous published experiences, we decided to perform a minimally invasive approach.

Figure 1 A-B: abdominopelvic CT, axial and sagittal section respectively. Marked with a yellow arrow an image of hyperdense foreign body. 

Exploratory laparoscopy showed an important inflammatory plastron between the duodenum and the left hepatic lobe. After dissection of adhesions, a pearly and hard filamentous foreign body was found into the liver parenchyma. The foreign body was extracted and it impressing as a fish bone (Figs. 2 and 3).

Figure 2 Intraoperative image of the fish bone in contact with the first duodenal portion and embedded in the liver parenchyma. 

Figure 3 Full image of 3 cm long fishbone. 

The post-operative period evolves favorably without adverse events. The patient was being discharged on the 5^th post-operative day with resolution of the abscess. On follow-up, the patient remains asymptomatic, without any sequelae.

Discussion

Perforation and migration from the digestive tract of a foreign body are the origin of some liver abscesses of unknown origin with a poor medical response. In these types of abscesses, the removal of the foreign body is essential for a complete resolution. Fish bone⁸-¹⁰ is the most prevalent of this foreign body described in the medical literature, although other types of foreign bodies have been reported, such as chicken bones¹¹-¹³ and toothpicks¹⁴,¹⁵.

The most frequent symptoms in these patients were fever and epigastric pain, without underlying medical conditions¹⁰.

The migration of the foreign body usually involves a perforation the gastric antrum, pylorus, or first and second part of the duodenum. For this reason, the most frequent location of this type of abscess is the left hepatic lobe.

Liver abscesses have also been described in the right hepatic lobe by foreign bodies that have migrated from the right colon or duodenum¹⁰.

In most patients, the foreign body can be identified by CT, although sometimes there is no extraluminal migration and foreign body could be removed by endoscopy¹⁶.

In patients with cryptogenic liver abscesses with no detectable foreign body, this condition should be suspected if the abscess shows the following features:

Frequently, there is no extraluminal migration and foreign body could be removed endoscopically, when this foreign body has migrated out of the digestive tract, surgical extraction by a minimally invasive approach is safe and feasible⁸,¹⁷,¹⁸.

Key Points: