Ann Hepatobiliary Pancreat Surg.  2020 Aug;24(3):362-365. 10.14701/ahbps.2020.24.3.362.

Toothpick in the porta: Recurrent liver abscesses secondary to transgastric migration of a toothpick with successful surgical exploration retrieval

• Kishawi S
• Anderson MJ
• Chavin Case K

• KMID: 2505352
• DOI: http://doi.org/10.14701/ahbps.2020.24.3.362

Abstract

We present a rare case of a 72-year-old man with recurrent hepatic abscesses secondary to transgastric migration of a toothpick into the liver parenchyma and left portal venous branch. Prior to identification of the foreign body, the patient received multiple courses of antibiotics and underwent image-guided catheter placement without resolution of infection. Given his refractory abdominal pain, fevers, and chills, a repeat abdominal CT was obtained and demonstrated a radio-opaque object extending through the prepyloric gastric submucosa into the liver parenchyma and left portal vein. EGD confirmed a pre-pyloric fistula tract with purulent discharge. The patient subsequently underwent exploratory laparotomy, cholecystectomy, porta hepatis exploration, removal of foreign body, and ligation of porto-enteric fistula tract. A wooden toothpick was removed in its entirety. Interval CT demonstrated resolution of hepatic abscesses and no evidence of persistent porto-enteric fistula. This exceptional case demonstrates the value of multidisciplinary care, hypervigilance for patients with refractory pyogenic liver abscesses of unknown origin, and the importance of careful preoperative planning.

Keyword

Toothpick; Liver abscess; Porto-enteric fistula; Foreign body; Surgery

Figure

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  Fig. 1 CT demonstrated persistent liver abscess with IR drain in appropriate position (A). Coronal images (B) demonstrated linear, radio-opaque object extending from gastric wall to liver parenchyma and left portal venous branch. Post-operative imaging demonstrated resolution of hepatic abscess (C) and no evidence of persistent portoenteric fistula (D).

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  Fig. 2 Endoscopy revealed purulent output (A) from pinpoint fistulous tract (B) in pre-pyloric gastric mucosa.

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  Fig. 3 Intra-operative imaging demonstrating careful dissection of porta hepatis (A) which revealed foreign body (B). A toothpick was carefully isolated (C) and retrieved (D) from the fistula tract without significant hemorrhage.

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