Large hepatic abscess caused by fish bone

S perforation by ingested fish bone resulting in hepatic abscess is very rare with few case reports in the literature. They present with nonspecific features of an acute abdomen and with less severe clinical features than those perforations present in other parts of the gastrointestinal tract (GIT). The clinical diagnosis is challenging without a definitive history of fish bone ingestion. The main stay of diagnosis is CT scan of the abdomen carried out for evaluation of acute abdomen. We hereby report a rare case of large hepatic abscess caused by fish bone perforating the lesser curvature of the stomach with gastrohepatic fistula. A 69-year-old male presented with history of high-grade fever and abdominal pain for 5 days. On examination, tenderness was present in the right upper quadrant without jaundice. Laboratory data revealed leukocytosis (14x109/L [normal range [NR]: 11x109/L]). The liver function test revealed elevated total serum bilirubin (36 umol/L [NR: 2-18 umol/L]) and abnormal liver enzymes with increased elevation of alkaline phosphatase (131 U/L [NR: 30-120 U/L]), alanine transaminase (41 U/L [NR: 10-40 U/L]) and aspartate transaminase (55 U/L [NR: 14-20 U/L]). The total serum protein (57 G/L [NR: 64-83 G/L]) and serum albumin (23 G/L [NR: 35-50 G/L]) were decreased. Clinical diagnosis of intra-abdominal sepsis with cholangitis was carried out, and further evaluation with a CT scan of the abdomen was requested. It revealed a multiloculated rim enhancing fluid collection in segments II, III, and IVa (Figure 1) measuring 9.4 x 6.1 x 5.3 cm in size. In addition, a linear radio-density was present in the left lobe of liver extending from the inferior subcapsular region into the collection. Also, there was a short tract bridging the affected liver surface superiorly and the lesser curvature of the stomach inferiorly. Imaging diagnosis of large liver abscess secondary to a foreign body, likely a fish bone perforating the lesser curvature of the stomach and migrating into the liver with bridging fistulous tract between the stomach and liver was made. There was no dilatation of the intra or extrahepatic biliary ducts. The findings were confirmed by open laparotomy; wedge resection of segment II/III abscess with Cavitron ultrasonic surgical aspirator and diathermy were performed. The gastrohepatic fistula was resected. The tiny perforation of the lesser curvature of the stomach was repaired with 2 layers of Vicryl sutures, and the fish bone measuring 1.4 cm was removed. He had a history of ischemic heart disease and developed fast atrial fibrillation on the first postoperative day. He was started on intravenous amiodarone and subsequently converted to sinus rhythm. The fluid culture of abscess returned growing Klebsiella, Proteus vulgaris, Citrobacter freundii, and Alpha hemolytic streptococcus. He was started on intravenous ceftriaxone and metronidazole for one week. At the time of discharge on the eighth postoperative day, he was stable and was put on oral levofloxacin for 2 weeks. He was readmitted after one year from discharge with small bowel obstruction due to extensive adhesion of a small segment of jejunum and transverse colon on the undersurface of the previous incision. Open surgical laparotomy, adhesiolysis, and wedge resection of small bowel were subsequently performed. Fish bone is one of the most commonly ingested foreign bodies. Some studies report they represent up Clinical Note