Regístrese
Buscar en
Cirugía Española (English Edition)
Toda la web
Inicio Cirugía Española (English Edition) Fish Bone-related Intrahepatic Abscess. An Underdiagnosed Condition?
Journal Information
Vol. 97. Issue 2.
Pages 116-118 (February 2019)
Vol. 97. Issue 2.
Pages 116-118 (February 2019)
Scientific letter
DOI: 10.1016/j.cireng.2018.08.002
Full text access
Fish Bone-related Intrahepatic Abscess. An Underdiagnosed Condition?
Absceso intrahepático por espina de pescado. ¿Una condición infradiagnosticada?
Visits
...
Alberto Gómez Portilla
Corresponding author
agomezpor@gmail.com

Corresponding author.
, Bernardo Ezurmendia, Ernesto Martín, Eduardo López de Heredia, Jesús Muriel López
Hospital Universitario de Araba Sede Santiago Apóstol, Departamento de Cirugía General, Universidad del País Vasco, Vitoria, Álava, Spain
Article information
Full Text
Bibliography
Download PDF
Statistics
Figures (2)
Full Text

Only 1% of the accidental ingestion of foreign bodies results in gastrointestinal perforation. Perforations by fish bones, often described in South East Asian populations, have the unusual characteristic of being paucisymptomatic until secondary complications occur. Fish-bone related intra-hepatic abscesses, although underreported and limited to isolated case reports, are rather unusual severe conditions and remain a therapeutic challenge. The main difficulty is to correlate the clinical picture of sepsis with both the intrahepatic abscess and the possibility of a foreign body. In all but two cases1,2 the piercing source reported has been found in the upper gastrointestinal tract, namely, the stomach and the duodenum. The fish-bone became embedded in the left lobe of the liver in most cases. The preoperative diagnosis is seldom made. The plain radiography is an unreliable tool in the diagnosis because fish-bones are usually not radio-opaque. Today, the extensive use of modern radioimaging by computed tomography scan (CT-Scan) has proved to be more helpful on the detection of ingested foreign bodies. Prompt recognition and early intervention are essential. If encapsulated abscess formations cannot be completely resolved by an interventional approach, a surgical procedure should be needed. Undiagnosed cases may result in recurrent liver abscess and sepsis and, sometimes, in the death of the patient. The mortality reported in a recent review was 17.6%.3

This scientific letter presents the cases of two patients satisfactorily treated in our Unit, as well as an updated review of the literature. Our first case was a 50-year-old woman who perfectly recalled the sequence of events from the unintentional ingestion of the foreign body to the development of liver complications. She started her family summer holidays celebrating the Festivity of Saint James’ day, the 25th of July, in Santiago de Compostela with a typical fish and seafood stew for dinner. She would never forget the severe epigastric pain and the horrible night she suffered, but as she did not want to interrupt her family's holidays, she treated herself with OmeprazolR twice a day and clear liquids for the next 3 days, and she improved progressively of her epigastric transfixive pain. She spent the rest of her holidays without any further symptomathology, and it was not until three weeks later that she needed urgent medical attention in our Hospital. She suffered from fever, shaking chills and shivering, persistent epigastric dullness and her temperature rose to 41°C. A CT-Scan revealed a hepatic abscess of unknown origin (Fig. 1A). She was treated percutaneously with abscess drainage and systemic antibiotics. But her encapsulated abscess formation could not be completely resolved. A new postdrainage CT-Scan showed an atrophic left hepatic lobe with a residual hepatic abscess and a high-density linear lesion inside (Fig. 1 B). Therefore, she underwent a laparoscopic left lateral liver bisegmentectomy (Segments II–III) (Fig. 1C). The vitreous foreign body, of about 2.5cm in length, which was extracted from the abscess cavity, turned out to be a fish-bone (Fig. 1D), which corresponded with the findings of the postdrainage CT-Scan referred to above. Her post-operative course was uneventful and the patient is doing well after her follow-ups 6 years later. Two years later a second female patient, 69-years-old, was referred to our Unit with a postcholecystectomy liver abscess. She had already undergone a laparoscopic cholecystectomy one month before for an “acute cholecystitis”. The CT-Scan that prompted her admission clearly showed a hepatic abscess in segment III with a high-density linear image that communicated with the hepatic abscess area (Fig. 2). Because of our previous experience with patient number one, we could quickly identify the origin of the disease, and make a preoperative diagnosis of a hepatic abscess due to a fish-bone. The patient was operated again, and an abscess drainage and the removal of the fish-bone were performed. The patient was satisfactorily discharged on the 8th post-operative day. She is doing well after her follow-ups 4 years later.

Fig. 1.

Patient no. 1. (A) Admission CT Scan showing a huge left hepatic lobe abscess of unknown origin. (B) Postdrainage control CT Scan showing an atrophic left hepatic lobe with the residual hepatic abscess and a high-density linear lesion inside (arrow). (C) Laparoscopic view of the fish bone (arrow). (D) Corresponding gross specimen of the resected left lateral segment of the liver. The fish bone (arrow) is shown horizontally having migrated into the liver, and the hepatic abscess can be observed. Color version.

(0.4MB).
Fig. 2.

Patient no. 2. Postlaparoscopic cholecystectomy CT Scan. A hepatic abscess in segment III with a high-density linear image that communicated with the hepatic abscess area is clearly shown (arrow). An endoclip can also be seen (circle).

(0.07MB).

We have been able to collect, including our two patients presented here, at least 53 well-described identified cases of fish bone-related intra-hepatic abscesses. In our literature review only 4 papers have been published by Spanish groups.4–7 We found a mortality of 9.4% (5 deceased patients out of the 53 cases studied). The treatment of choice in the literature remains an aggressive approach. It involves the mandatory drainage of the abscess and removal of the fish-bone, and a careful search for the source of perforation. Recently, some reports have shed some light on the role of minimally invasive treatments for this condition. The treatment consists of a non-operative ultrasonographic-guided abscess drainage, the interventional percutaneous or endoscopic removal of the foreign body, and the systemic administration of appropriate antibiotics.8–10 Our cases and the review of the literature illustrate the difficulty in making the preoperative diagnosis, and alert that such etiologic source should be included in the differential diagnoses in patients with liver abscesses of unknown origin. The more familiar with this pathology surgeons, gastroenterologists and hepatologists are, the more patients will be diagnosed and treated properly.

References
[1]
K.D. Paraskeva, R.W. Bury, P. Isaacs.
Streptococcus milleri liver abscesses: an unusual complication after colonoscopic removal of an impacted fish bone.
Gastrointest Endosc, 51 (2000), pp. 357-358
[2]
Y.M. Kim, T.H. Lee, S.H. Jung, S.M. Kim, E.H. Im, K.C. Huh, et al.
Hepatic abscess that formed secondary to fish bone and had a fistula with the ascending colon.
Dig Dis Sci, 52 (2007), pp. 3515-3518
[3]
S.A. Santos, S.C. Alberto, E. Cruz, E. Pires, T. Figueira, E. Coimbra, et al.
Hepatic abscess induced by foreign body: case report and literature review.
World J Gastroenterol, 13 (2007), pp. 1466-1470
[4]
J.G. Gonzalez, R.R. Gonzalez, J.V. Patiño, A.T. Garcia, C.P. Alvarez, C.S.A. Pedrosa.
CT findings in gastrointestinal perforation by ingested fish bones.
J Comput Assist Tomogr, 12 (1988), pp. 88-90
[5]
M. De la Vega, J. Rivero, L. Ruiz, S. Suarez.
A fish bone in the liver.
Lancet, 358 (2001), pp. 982
[6]
A. Álvarez, P. Redondo, G. Anes, N. Fernández.
Absceso hepático secundario a perforación por cuerpo extraño.
[7]
M. Jiménez-Fuertes, A. Moreno-Posadas, J. Ruíz-Tovar Polo, M. Durán-Poveda.
Liver abscess secondary to duodenal perforation by fishbone: report of a case.
Rev Esp Enferm Dig, 108 (2016), pp. 42
[8]
A. Panebianco, R.C. Lozito, A. Prestera, P. Ialongo, A. Volpi, G. Carbotta, et al.
Unusual liver abscess secondary to ingested foreign body: laparoscopic management.
G Chir, 36 (2015), pp. 74-75
[9]
C.H. Tan, S.Y. Chang, Y.L. Cheah.
Laparoscopic removal of intrahepatic foreign body: a novel technique for management of an unusual cause of liver abscess – fish bone migration.
J Laparoendosc Adv Surg Tech A, 26 (2016), pp. 47-50
[10]
C.W. Lau, K.M. Wong, A. Gogna.
Image-guided percutaneous transhepatic removal of fish bone from liver abscess.
J Radiol Case Rep, 11 (2017), pp. 1-7

Please cite this article as: Gómez Portilla A, Ezurmendia B, Martín E, López de Heredia E, Muriel López J. Absceso intrahepático por espina de pescado. ¿Una condición pasada por alto infradiagnosticada? Cir Esp. 2019;97:116–118.

Copyright © 2018. AEC
Article options
Tools
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos

es en pt
Política de cookies Cookies policy Política de cookies
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.