A case of liver abscesses and porto-enteric fistula caused by an ingested toothpick: A review of the distinctive clinical and imaging features

Abstract

Though foreign body (FB) ingestions are a relatively common occurrence in the bustling emergency department, particularly among children, the vast majority of FBs either pass uneventfully or can be retrieved endoscopically. Only a small percentage of patients will experience complications such as bowel obstruction, ischemia, or perforation that may progress to abscess, septic thrombophlebitis, peritonitis, or shock. Depending on their composition, small FBs can be very difficult to detect on computed tomography (CT). However, a delay in definitive treatment resulting from the failure to clinically or radiologically recognize that a FB may be responsible for the acute presentation can lead to substantial morbidity and mortality. We present a case of unresolving hepatic abscess and recurrent sepsis caused by a toothpick-induced porto-enteric fistula in which the FB was not initially identified, thereby leading to multiple treatment failures and readmissions. This is followed by a literature review with comprehensive discussion of the distinctive clinical and imaging features of migrated FB-induced liver abscesses.

Keywords: Abscess; Foreign body; Hepatic; Liver; Portoenteric fistula; Toothpick.

Fig. 1

Noncontrast CT abdomen/pelvis. a. Axial image with standard windowing (C:35.0, W:350) at the level of the pyloroduodenal junction demonstrates a punctate hyperdense foreign body (yellow arrow) within the posterior pyloric wall. Note the reactive eccentric gastric wall thickening surrounding the foreign body (green arrows), which had increased compared to initial the CT 1 month prior (not shown). b. Coronal image with narrow windows (C:35, W:100) demonstrates a 4.6 cm linear hyperdense foreign body (yellow arrows) extending from the pyloroduodenal junction (green arrow) directly into the distal left portal vein (blue arrow). a. & b. Low attenuation areas in the liver parenchyma represent incompletely resolved abscess cavities (red arrow). (Color version of figure is available online.)

Fig. 2

Hepatic Doppler ultrasound with targeted assessment of foreign body. a. Sagittal oblique sonographic image at the level of the pyloroduodenal junction (green arrow) showing long-axis view of a linear hyperechoic foreign body (yellow arrow) that penetrates the full thickness of the gastric wall and extents directly into the left portal vein (blue arrow). b. Transaxial color Doppler sonographic image at the level of the left portal vein shows short-axis view of the foreign body (yellow arrow) within the lumen of the left portal vein and absent intraluminal color Doppler signal consistent with thrombosis. (Color version of figure is available online.)

Fig. 3

Surgical specimen. A 4.5 cm long wooden toothpick retrieved from exploratory laparotomy, corresponding to foreign body seen on preoperative US and CT.