Journey of a swallowed wooden stick to the liver

Laboratory tests showed: elevated amount of white blood cells and CRP (Leu : 24,64 x 109/l, CRP 139 mg/l), elevated hepatal enzymes (GMT 7,28 ukat/l, ALP 2,85 ukat/l ) nd slightly elevated renal parameters.

Patient was medicated, he received antipyretics, cephalosporines, chinolones and metronidazole without cultivation finding. Conservative treatment had only temporary effect, patient was without febrility for few days. Because of the septic shock with elevated amount of procalcitonin and low blood pressure, patient was admitted to the internal intensive care unit and treated with vasopressor support.

Patient was examinated by stomatologist - without finding of infectious focus, paranasal sinuses were without pathological finding, too.

Plain X-ray showed elevated diaphragm without any fluidothorax, accented bronchovascular tissue, and thicker pleura l. sin.

Urine sediment was negative despite of renal parameters elevation, ultrasound of kidneys showed bilateral lipoid changes of kidneys.

Echo cardiogram described hypertrophic cardiomyopathy of the left chamber.

Ultrasound of abdomen showed hypoechogenic tumour (size: 63x58 mm) with bubbles of the air in the right hypochondrium. Based on ultrasound finding we decided to send him to CT because of suspection of subphrenic abscess.

CT imaged enlargement of liver (craniocaudal diameter was 15,5 cm). In VIII. segment of the liver was found expansion with unclear borders (size: 6,9 cm) with thick wall (7 mm). There was a collection of fluid and air inside - abscess. Based on this finding patient was discharged from hospital in Medzilaborce and admitted to the first surgical department of UNLP.

An exploratory laparotomy was undertaken in the day of hospitalisation. Subcostal incision in the right hypochondrium was performed and revision showed that the whole abdominal cavity was without any fluid or ascites. Revision of the liver in VIII. segment revealed a big abscess with volume of 200 ml of pus. Pus was smelling and looked like skim. Sample from fluid was sent to microbiology for cultivation. During palpation surgeon found a slim wooden stick with cotton on the end. A stick was broken in the middle. The length of the stick was 15 cm (Figure 1). Abscess of the cavity was sucked away and cavity was repeatedly cleaned with Betadine and after toilette, drainage of this cavity was done. Revision of stomach and duodenum didn´t show any perforation, or fistula, through the foreign body could pass in the liver.

Surgeon asked the patient after anaesthesia how could get the wooden stick in this body. Patient told, that half an year ago he swallowed this stick during cleaning his tonsils. Patient after this incident visited a family doctor, who sent him to gastroscopy, where was not found stick in the stomach and duodenum. He recommended him to wait until this foreign material will not pass by natural way from his body and he told him, that he doesn´t need surgery. Since this accident patient had a trouble with fever sometimes, dyspesia, a losing weight. Last week before admission he suffered from persistently fever. During retrospective description of CT finding, surgeon revealed the wooden stick on CT in the abscess cavity, which was really hardly recognised on CT scan (Figure 2).

Patient in postoperative period was treated with antibiotics and chemotherapeutic drugs (Edicin, Gentamycin, Metronidazole) based on cultivation finding: Enterococcus faecalis, Streptococcus viridans a E. coli. Patient had rinsing drain placed in abscess cavity for next 17 days, Betadine and Pamycon was instilated inside this cavity through the drain to clean the site of infection. Patient was realimented, without fever and he was discharged after 19 days of hospital stay.

The ingestion of a foreign body and lost instruments during operation is the most frequent way of getting foreign material in the patient´s body. Most ingested foreign bodies pass (80-90 %) through the gastrointestinal tract spontaneously without necessitating any treatment during one week; however, about 20% require endoscopic or surgical removal. Symptoms occur because of gastrointestinal obstruction usually. Perforation and further infection is n less than 1 % of all cases, and the most frequent affected area is ileocoecal , rectosigmoid colon, duodenum or pylorus.

The most frequent foreign bodies, which perforate gastrointestinal tract are fish bones, chicken bones, needles, tooth picks or pens. Place of enter are mouths, anus, urogenital tract or by percutaneous way. Abscess in the liver because of penetration of foreign body is very rare, too.

Typical triad of symptoms in the case of liver abscess is: fever, pain, jaundice is rare. Most of the patients have non specific signs - vomitus, anorexia, loosing of weight, fever - it is a systematic immune response to infection and inflammation. Laboratory tests are non-specific, too. There is leucocytosis, elevated bilirubin, ALP and CRP frequently seen in serum.

Left lobe of liver is affected usually with abscess. Microorganisms, which are isolated from pus have origin from normal flora of oropharynx.

X ray examination can be helpful in the case of metal foreign material, plastic and wooden things are not contrast for X ray beam, and can be seen only with the help of ultrasound or CT. Endoscopy is helpful only in early detection, when the material didn´t start to migrate through the wall of gastrointestinal tract.

Migration to the liver, mesentery or abdominal wall is extremely rare. The loop of small intestine can rotate around foreign body and get necrotic. Between presentation of symptoms and perforation of gastrointestinal tract can be different duration - it can take months or even years.

Prognosis depends of diagnostic and treatment. Treatment remains controversial, it involves antibiotic treatment, percutaneous drainage , or laparoscopic or opened surgical revision. If the abscess cavity is smaller than 5 cm, conservative treatment is the most suitable. Patients with worse finding are mostly treated by percutaneous drainage. Surgery should underwent patients with multilocular abscess, with concomitant problems with biliary tree, with rupture of abscess cavity, or in the case of suspection of perforated gastrointestinal tract.