- Email: [email protected]
Liver inflammatory pseudotumor due to an intrahepatic wooden toothpick
Journal of Hepatology 41 (2004) 498 www.elsevier.com/locate/jhep
Images in Hepatology Associate Editor: Dominique Charles Valla
Liver inflammatory pseudotumor due to an intrahepatic wooden toothpick
Ingestion of foreign bodies is a common clinical problem. However, intrahepatic migration is an exceptional occurrence: it has caused a hepatic abscesses which did not heal with percutaneous drainage, and caused patient death because of sepsis [1]. Clinical history is not helpful and only 50% of ingested toothpicks are radio-opaque [2]. A 63-year-old man was admitted in our department because of a typical episode of cholangitis with upper right abdominal pain, fever and jaundice. Ultrasonography (US) revealed a 6.5 cm in diameter, hypoechoic hepatic mass in the left lobe, which showed undefined margins, and caused a slight dilation of the intrahepatic bile ducts of segments 2 and 3. Helical CT scan confirmed the presence of the lesion located mainly in segment 3 and extended to segment 2: the lesion showed delayed peripheral enhancement (arrows in left panel; UP, umbilical portion) and was interpreted as a mass-forming type cholagiocellular carcinoma (MFCCC). Magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP) confirmed this diagnosis. The serum level of AFP, CEA and Ca 19-9 were normal. The patient underwent surgery. An inverted T-shaped incision was accomplished and a palpable sticky mass was noted on the inferior surface of the left lobe with a thickened hepato-gastric ligament possible expression of a previous gastrointestinal perforation. At intra-operative US a linear high echogenic mass within the liver tumour was identified; vessels running through the tumor without dislodgement were also disclosed. A left hepatic lobectomy was performed and a 4 cm wooden toothpick was extracted from the resected liver (right panel). At histology the liver mass proved to be an inflammatory granuloma. Postoperative outcome was uneventful and patient was discharged at eighth postoperative day. Daniele Del Fabbro, Guido Torzilli, Andrea Gambetti, Piera Leoni, Adele Gendarini, Natale Olivari Hepatobiliary Surgery Unit, 1st Department of Surgery, Hospital of Lodi, Lodi, Italy References [1] Dugger K, Leby T, Brus M, Sahgal S, Leikin JB. Hepatic abscess resulting from gastric perforation of a foreign object. Am J Emerg Med 1990;8:323 –325. [2] Rioux M, Langis P. Sonographic detection of clinically unsuspected swallowed toothpicks and their gastrointestinal complications. J Clin Ultrasound 1994;22:483 –490.
0168-8278/$30.00 q 2004 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.jhep.2004.02.035
Images in Hepatology Associate Editor: Dominique Charles Valla
Liver inflammatory pseudotumor due to an intrahepatic wooden toothpick
Ingestion of foreign bodies is a common clinical problem. However, intrahepatic migration is an exceptional occurrence: it has caused a hepatic abscesses which did not heal with percutaneous drainage, and caused patient death because of sepsis [1]. Clinical history is not helpful and only 50% of ingested toothpicks are radio-opaque [2]. A 63-year-old man was admitted in our department because of a typical episode of cholangitis with upper right abdominal pain, fever and jaundice. Ultrasonography (US) revealed a 6.5 cm in diameter, hypoechoic hepatic mass in the left lobe, which showed undefined margins, and caused a slight dilation of the intrahepatic bile ducts of segments 2 and 3. Helical CT scan confirmed the presence of the lesion located mainly in segment 3 and extended to segment 2: the lesion showed delayed peripheral enhancement (arrows in left panel; UP, umbilical portion) and was interpreted as a mass-forming type cholagiocellular carcinoma (MFCCC). Magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP) confirmed this diagnosis. The serum level of AFP, CEA and Ca 19-9 were normal. The patient underwent surgery. An inverted T-shaped incision was accomplished and a palpable sticky mass was noted on the inferior surface of the left lobe with a thickened hepato-gastric ligament possible expression of a previous gastrointestinal perforation. At intra-operative US a linear high echogenic mass within the liver tumour was identified; vessels running through the tumor without dislodgement were also disclosed. A left hepatic lobectomy was performed and a 4 cm wooden toothpick was extracted from the resected liver (right panel). At histology the liver mass proved to be an inflammatory granuloma. Postoperative outcome was uneventful and patient was discharged at eighth postoperative day. Daniele Del Fabbro, Guido Torzilli, Andrea Gambetti, Piera Leoni, Adele Gendarini, Natale Olivari Hepatobiliary Surgery Unit, 1st Department of Surgery, Hospital of Lodi, Lodi, Italy References [1] Dugger K, Leby T, Brus M, Sahgal S, Leikin JB. Hepatic abscess resulting from gastric perforation of a foreign object. Am J Emerg Med 1990;8:323 –325. [2] Rioux M, Langis P. Sonographic detection of clinically unsuspected swallowed toothpicks and their gastrointestinal complications. J Clin Ultrasound 1994;22:483 –490.
0168-8278/$30.00 q 2004 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.jhep.2004.02.035