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A 75-year-old man with diabetic end-stage renal disease requiring hemodialysis presented with 1 week of progressive abdominal pain and fever. Laboratory examination showed an alkaline phosphatase level of 140 IU/L and white blood cell count of 15.7 × 109/L. Noncontrast abdominal CT revealed a 2.9-cm × 3.3-cm air/fluid collection in the left hepatic lobe with a linear foreign body extending from the collection into the duodenum (Fig. 1). An upper endoscopy was performed and was notable for 2 pustular lesions and edema in the second portion of the duodenum (Fig. 2).
Figure 1Noncontrast abdominal CT demonstrating a 2.9-cm × 3.3-cm air/fluid collection in the left hepatic lobe with a linear foreign body extending from the collection into the duodenum.
He was referred to our center for further evaluation and management (Video 1, available online at www.VideoGIE.org). An outpatient EUS was performed. A loculated fluid collection within the left hepatic lobe was seen. After transgastric puncture and contrast injection, a linear foreign body could be seen radiographically within the cavity (Fig. 3). A 0.025-in × 450-cm–long guidewire was coiled within the cavity, and a 6-mm biliary balloon dilator was used to dilate the tract. A 4-cm × 10-mm fully covered self-expandable metal transgastric stent and 7F double stent were placed into the cavity for abscess drainage and to allow a fistula to form for subsequent endoscopic retrieval of the foreign body (Fig. 4). The patient was discharged home from the procedure suite on oral antibiotics.
Figure 3Fluoroscopic view after transgastric puncture and contrast injection demonstrating a linear foreign body within the liver.
Figure 4Fluoroscopic view after 4-cm × 10-mm fully covered self-expandable metal transgastric stent and 7F double placement into the cavity for abscess drainage.
Four weeks later, repeat endoscopy was performed. A standard upper endoscope was used to remove the indwelling stents, and the tract was dilated with a 15-mm through-the-scope balloon dilator. The endoscope was advanced into the cavity, where a segment of wood was grasped and retrieved (Fig. 5). After removal, it was noted that the foreign object was a toothpick, but it had not been removed intact; a snare was used to grasp the remaining portion of the object for complete retrieval. The patient remained an outpatient without the need for hospitalization during our care because there were no procedure-related adverse events. A follow-up CT 3 months later showed no abnormalities (Fig. 6).
Figure 5Endoscopic view after grasping the embedded toothpick.
Our patient reported a frequent habit of chewing toothpicks, one of which likely was inadvertently ingested and lodged in the duodenum before eventually eroding into the liver. As with all infections, prompt recognition, administration of antibiotics, and source control are critical for managing foreign bodies in the liver parenchyma.
EUS-guided abscess drainage followed by endoscopic retrieval via natural orifice transluminal endoscopic surgery is a feasible nonsurgical option in some cases of intrahepatic foreign bodies.
Disclosure
Dr Baron is a consultant and speaker for Boston Scientific, W.L. Gore, Cook Endoscopy, and Olympus America. Dr James receives research and training support by a grant from the National Institutes of Health (T32DK007634). All other authors disclosed no financial relationships.
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