LETTERS TO THE EDITOR

 

Foreign bodies as infrequent cause of liver abscess

Cuerpo extraño como causa infrecuente de absceso hepático

 

 

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Key words: Liver abscess. Foreign bodies. Perforation hollow viscera.

Palabras clave: Absceso hepático. Cuerpo extraño. Perforación víscera hueca.

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Dear Editor,

Most ingested foreign bodies pass through the gastrointestinal tract without causing intestinal damage or complications. Only when become lodged or are associated with toxicity, they must be identified and removed (1).

We present two cases of patients who have had a liver abscess secondary to ingestion of foreign bodies after intestinal perforation of hollow viscera are housed in the liver causing local infection.

 

Case report 1

Male, 48 years-old with epigastric pain, fever, fatigue and nausea. He reported selective pain in right upper quadrant. Abdominal X-ray was anodyne. Only leukocytosis with left shift stressed in blood test. The abdominal ultrasound diagnosed a 20 x 20 mm abscess in hepatic fissure. Abdominal CT showed a hypodense collection of 20 x 10 mm at round ligament, microbubble air and linear hyperdense image inside, compatible with foreign body (Fig. 1). Reviewing X-ray, is subsequently possible to differentiate a hiperdensity. Requestioning the patient, confirmed symptoms began the day after he ate rabbit. It was decided exploratory laparotomy, we drained the collection and removed the foreign body, without apparent macroscopic perforation of hollow viscera.

Case report 2

Female, 66 years-old with epigastric pain for last 15 days without others symptoms. In abdominal ultrasound, we could see a hepatic abscess, segment II and IV, with a maximum diameter of 10 cm. In CT-scan it is possible to see the hepatic abscess with a metallic foreign body inside, probably a needle. Because of it, we decided an emergency surgery to drain the abscess and remove the foreign body, finding a perforation in anterior gastric wall, being necessary suture it. Pathology clarified the origin of foreign body, not a needle, was a bone, probably a chicken bone which patient accidentally ingested previously.

 

Discussion

Hepatic abscesses secondary to foreign body after perforation of hollow viscera are rare (0-5%). It was first described in 1898, counting only up today 50 cases (2). Most frequent foreign bodies are fish or chicken bones, after perforate stomach or duodenum (3). We have found no cases reported in the literature after the accidental ingestion of rabbit bones.

Preoperative diagnosis is difficult, because most of patients do not remember ingestion and clinic is nonspecific. Due to advancement of imaging techniques, it is increasingly easy to get to it. As in our cases, CT is the gold standard nowadays for diagnosis of hepatic abscess secondary to foreign bodies (4).

The recommended treatment is surgery, an exploratory laparotomy to drain the abscess and remove the foreign body (5). To repair the gastrointestinal perforation is necessary, although in several cases, as the first case we report in our paper, it is not possible to find it. Other techniques as percutaneous drainage, endoscopic approach o medical treatment, have been reported (6).

 

Luis Tallón-Aguilar, Diego Antonio Bernal-Moreno, Marta López-Porras, Luis Miguel Marín-Gómez and Felipe Pareja-Ciuró
Department of General and Digestive Surgery. Hospitales Universitarios Virgen del Rocío. Sevilla, Spain

 

References

1. Lin CH, Chen AC, Tsai JD, Wei SH, Hsueh KC, Lin WC. Endoscopic removal of foreign bodies in children. Kaohsiung J Med Sci 2007;23 (9):447-52.         [ Links ]

2. Ammari I, Longueira Suárez R, Lamas Ferreiro JL, Iribarren Díaz M, Toscano Novella A, Martínez Vázquez C. Foreign body: an uncommon cause of liver abscess. Gastroenterol Hepatol 2009;32(3):179-80.         [ Links ]

3. Santos SA, Alberto SC, Cruz E, Pires E, Figueira T, Coimbra E, et al. Hepatic abscess induced by foreign body: case report and literature review. World J Gastroenterol 2007;13(9):1466-70.         [ Links ]

4. Clarençon F, Scatton O, Bruguière E, Silvera S, Afanou G, Soubrane O, et al. Recurrent liver abscess secondary to ingested fish bone migration: report of a case. Surg Today 2008;38(6):572-5.         [ Links ]

5. Karamarkovic AR, Djuranovic SP, Popovic NP, Bumbasirevic VD, Sijacki AD, Blazic IV. Hepatic abscess secondary to a rosemary twig migrating from the stomach into the liver. World J Gastroenterol. 2007;13 (41):5530-2.         [ Links ]

6. Mukkada RJ, Chettupuzha AP, Francis VJ, Mathew PG, Chirayath SP, Koshy A. Endoscopic removal of chicken bone that caused gastric perforation and liver abscess. Indian J Gastroenterol 2007;26:246-7.         [ Links ]