Attached
Introduction
The presence of foreign bodies in the liver is rare.
Usually foreign bodies migrate to liver after perforating
the upper gastro intestinal tract and cause an abscess or
a granuloma. We report a foreign body in the liver mimicking
a malignant neoplasm on imaging.
Case report
A 58-year old woman was seen for vague episodic
right upper abdominal pain and loss of appetite. She had
lost 2-3 kg of weight over two months. Physical examination
was unremarkable. She has had a single episode of high
fever with chills and rigors, three months previously. The fever was associated with vague right hypochondrial pain.
She had not noted any features of obstructive jaundice
and her bowel habits had been normal. As the symptoms
settled within a day she had not sought medical advice.
Blood tests including liver profile were normal except
for an elevated CRP of 30 mg/1. Ultrasound scan of
abdomen showed a suspicious irregular lesion in the left
lobe of the liver. Plain X-ray of abdomen showed no
abnormality. Contrast enhanced computed tomography
(CECT) of abdomen showed an irregular, heterogeneous
lesion of intermediate density occupying segments II and
III of the liver.The appearance was similar to that of an
intrahepatic cholangiocarcinoma. There were prominent
para-aortic lymph nodes (Figure 1).
Figure 1. C E C T image of abdomen.
Tumour marker (CA 19-9 and AFP) levels were
normal. In a multi-disciplinary meeting, several radiologists
suggested that the possibility of a cholangiocarcinoma
could not be excluded. The differential diagnosis was a
chronic inflammatory lesion of the liver. Finally, it was
decided to treat the lesion as an intrahepatic cholangiocarcinoma. The surgical team agreed on left lobectomy
with lymphnode clearance and intra-operative imprint
cytology of resection margins and lymph nodes.
During surgery when the left lobe of the liver was
retracted to expose the posterior surface, it was noted that
the lesser curvature of the stomach was adherent to the
liver by an area of fibrosis. Careful dissection of the
postero-inferior surface of the liver revealed a fibrotic area
with a hard notch. A pointed object embedded in the notch
was easily extracted from the liver tissue with no bleeding
or drainage of pus. It resembled a fish bone about 3.5 cm in
length (Figure 2). The foreign body was sent for analysis.
Imprint cytology of the abnormal area on liver revealed
granulomatous inflammation. Intra-operative ultrasonography excluded the possibility of any other lesions of
the liver. Hepatic resection was abandoned.Post-operative
period was uneventful, and the analysis of the foreign
body confirmed it as a fish bone. The patient was symptom
free three months after surgery.
Figure 2. Fish bone retrieved from the liver.
D is c u s s io n
Presence of a foreign body in the liver after upper
gut perforation is rare [ 1 ]. Such perforation occurs mainly
around the stomach and duodenum and can be induced
by sharp foreign bodies like fish bones, chicken bones,
needles and toothpicks [2]. Most of these perforations
do not cause significant symptoms. Probable time of
perforation may be assumed by retrospective speculation.
Most patients do not recall a particular incident out of
the ordinary and may remain silent until an abscess is
formed [2].
According to a Swiss study that reviewed 59 cases
of foreign body migration, computed tomography
demonstration of a thickened gastrointestinal wall in
continuity with the abscess was suggestive of foreign
body migration [3]. But CECT of our patient showed a
prominent liver lesion similar to an intrahepatic cholangiocarcinoma, with misleadingly prominent paraaortic lymph
nodes. An unknown foreign body mimicking colorectal
liver metastases has been reported [4], According to two
previous case reports, a foreign body could simulate
carcinoma in the head of pancreas [5,6], Except for those
instances most patients had features of a liver abscess. As
pre-operative diagnosis by biopsy is not favoured by many
hepatobiliary surgeons, foreign body in liver mimicking a
neoplasm could remain a diagnostic dilemma.
E th ics
The patient gave informed, written consent for
publication of this article including pictures.
C o n flicts o f interests
There are no conflicts of interest
