Hepatic inflammation granuloma secondary to fish bone ingestion: a case description and literature analysis

Introduction

Penetration of the liver by a gastrointestinal foreign body is exceedingly rare, occurring in less than 1% of cases, and typically presents as liver abscess or acute abdomen. To our knowledge, this is the first reported case of hepatic inflammatory granuloma caused by a foreign body with the longest documented history (5 years), which was successfully diagnosed using computed tomography (CT) after being initially misdiagnosed as cholangiocarcinoma on magnetic resonance imaging (MRI). The foreign body and its migration pathway were clearly depicted on CT with three-dimensional (3D) reconstruction, were confirmed by laparoscopy. We present this case in accordance with the CARE guidelines to underscore the utility of CT in the diagnostic workup of such ambiguous presentations.

Case presentation

A 64-year-old female presented with epigastric pain for the last 1 month without other symptoms. Physical examination showed mild epigastric tenderness without rebound tenderness or palpable mass. Laboratory tests revealed elevated platelet count (352×10⁹/L), high-sensitivity C-reactive protein (15.0 mg/L) and hepatic enzymes, normal tumor markers [carbohydrate antigen 19-9 (CA19-9), carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP)].

MRI findings and misdiagnosis: abdominal MRI identified a 21 mm × 18 mm mass in segment III of the liver, with atrophy of the left hepatic lobe and dilated left intrahepatic duct (Figure 1A-1D). Gadoxetate-enhanced MRI revealed mild and persistent enhancement of the mass, which appeared hypointense in the hepatobiliary phase. The mass was initially interpreted as a mass-forming cholangiocarcinoma (Figure 1E-1J).

Figure 1 Hepatic inflammation granuloma secondary to fish bone ingestion. (A-I) Axial unenhanced MRI showed a mass (white arrow) were hypointense on T1-weighted image (A), mild hyperintensity on T2-weighted image (B), restricted diffusion on DWI (C,D), with atrophy of the left liver and perihepatic space blurred (arrowhead) (E). Using gadoxetate-enhanced MRI, the mass showed mild enhancement in the arterial phase (F), persistent enhancement in portal venous phase (G) and equilibrium phase (H), hypointense in the hepatobiliary phase (I). (J) Coronal MRI shows enhancement of thickened gastric wall (black star) was similar to the liver. (K-M) Axial CT images showed a short linear hyperdensity (black arrow) within the mass (white arrow). (N) MPR, (O) MIP and (P) VR demonstrated a long linear foreign body and its migration tract (black arrow). (Q) The fish bone was measured 43 mm × 1 mm in size. (L,M) Contrast-enhanced CT images were similar to MRI (white arrow). (R) Histopathology showed lymphoplasmacytic infiltration and fibrosis (H&E,10×). (S) Three-month follow-up CT revealed complete resection of the hepatogastric lesions. CT, computed tomography; DWI, diffusion-weighted imaging; MIP, maximum intensity projection; MPR, multi-planar reconstruction; MRI, magnetic resonance imaging; VR, volume rendering.

CT imaging and correct diagnosis: CT shows a linear hyperdense structure [CT value: 283 Hounsfield units (HU)] traversing the center of the hepatic mass vertically, crossing the gastric lesser curvature and the left lobe of the liver (Figure 1K-1N). Multi-planar reconstruction (MPR), maximum intensity projection (MIP) (Figure 1O), and volume rendering (VR) (Figure 1P) clearly delineated the trajectory of the foreign body (lesser curvature of stomach → left hepatic lobe).

The patient recalled fish bone ingestion five years ago, which cause transient choking and discomfort. The diagnosis has been revised to foreign body-induced chronic hepatic inflammation.

Surgery, pathology, and follow-up: abdominal laparotomy was performed, confirming preoperative imaging findings: the hepatic mass was densely adherent to the gastric antral wall, and a fish bone measuring 44 mm × 1 mm (Figure 1Q) stabbed into liver and stomach and was wrapped in inflammation granuloma. Pathological examination revealed chronic hepatic inflammatory granuloma with dense inflammatory cell infiltration and fibrosis, consistent with a foreign body reaction. No tumor cells were identified (Figure 1R). After removing the fish bone, the patient was discharged on the 9th postoperative day favorably. Three-month postoperative CT showed no residual lesion (Figure 1S).

Ethical considerations

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

The incidence of sharp foreign bodies (e.g., fish bones) perforating the gastrointestinal wall is less than 1% (1). We report a rare case of “stomach-to-liver “penetration pattern, distinguished by its chronic course (5 years) and insidious symptoms (dull epigastric pain) factors that contributed to diagnostic uncertainty and initial misinterpretation as cholangiocarcinoma on MRI.

Hepatic penetration by foreign body typically manifests as liver abscess or acute abdomen (2-4). In contrast, this case presented with an inflammatory granuloma, reflecting a chronic inflammatory response to a retained fish bone. Fish bones are the most commonly reported gastrointestinal foreign bodies, followed by toothpicks and chicken bones (5). Due to their size and sharpness, these bones can easily penetrate the gastrointestinal tract and migration to the liver. Due to anatomical proximity of the stomach and duodenum to the liver, foreign bodies may migrate via peristaltic activity and be embedded in the liver parenchyma, which is the most frequently involved solid organ in such cases (6). Because most patients cannot recall the ingestion event and present with non-specific symptoms, the foreign body may remain undetected, ultimately forming a chronic inflammatory focus.

MRI offers superior soft tissue resolution compared to CT, but is inferior for visualizing foreign body. In this case, the left hepatic lesion was initially misdiagnosed as cholangiocarcinoma on MRI. In contrast, CT (especially with 3D reconstruction techniques like MIP, VR, and MPR) clearly delineated the morphology, location, and relationship of the foreign body to adjacent structures, with imaging findings closely correlating to intraoperative findings (7). In our patient, 3D CT reconstruction vividly showed the fish bone’s migration route, and attenuation of 283 HU confirmed its osseous nature—providing direct diagnostic evidence. This highlights that CT may be considered a preferred screening tool for hepatic inflammatory lesions, to avoid missing slender foreign bodies.

Inadequate clinical history taking also contributed to the initial misdiagnosis, emphasizing that clinical history taking remains the cornerstone of accurate diagnosis. A detailed inquiry regarding possible foreign body ingestion should be routinely pursued in patients with unexplained hepatic lesions. A literature review (6) of 178 cases of liver abscess caused by gastrointestinal foreign bodies found that only 19% of patients recalled the ingestion event, and 88% of diagnoses were confirmed via imaging (80% by CT, 6% by ultrasound, and 2% by abdominal X-ray). These findings reinforce the need for heightened awareness and proficiency in imaging techniques to improve diagnostic accuracy for foreign body-related hepatic complications. We reviewed the literature from the past two decades (7-13) and identified eight representative cases of hepatic inflammatory lesions caused by migrated foreign bodies (Table 1). The cohort included five males and three females (mean age: 54 years), with symptom duration ranging from 2 days to 2 months. Abdominal pain was the most common symptom (6/8), while other symptoms included chills with back pain, and fatigue with poor appetite. Preoperative imaging (ultrasound, CT, MRI) identified foreign bodies in six cases (CT: 5, ultrasound: 1). In the remaining two cases, wooden toothpicks were discovered intraoperatively within hepatic lesions located in the left and right lobes, respectively. All hyperdense foreign bodies identified on CT (four fish bones and two chicken/rabbit bones) were associated with intrahepatic inflammatory lesions. All eight patients were successfully treated with surgery or antibiotic therapy. Notably, our case is the first to document an exceptionally prolonged clinical course (5 years) and to demonstrate the diagnostic utility of CT with 3D reconstruction in this setting.

This study has inherent limitations to its design as a single-case report from a single institution, which limits the generalizability of our findings. Additionally, reliance on retrospective patient recall for the history of foreign body ingestion may introduce reporting bias. Future prospective, multicenter studies are needed to validate the diagnostic pathway suggested herein.

Conclusions

Hepatic inflammatory granulomas may result from the penetration of gastrointestinal foreign bodies. Clinicians should consider foreign body migration in the differential diagnosis of a hepatic mass accompanied by chronic inflammation. The recommended diagnostic approach includes: (I) thorough history-taking regarding possible foreign body ingestion; (II) CT with 3D reconstruction to identify the foreign body. Therefore, strengthening multidisciplinary collaboration among radiology, surgery, and gastroenterology, as well as implementing standardized and individualized diagnostic pathways, is essential for improving diagnostic accuracy in such cases.

Acknowledgments

None.

Footnote

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-aw-2328/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Horii K, Yamazaki O, Matsuyama M, Higaki I, Kawai S, Sakaue Y. Successful treatment of a hepatic abscess that formed secondary to fish bone penetration by percutaneous transhepatic removal of the foreign body: report of a case. Surg Today 1999;29:922-6. [Crossref] [PubMed]
2. Abel RM, Fischer JE, Hendren WH. Penetration of the alimentary tract by a foreign body with migration to the liver. Arch Surg 1971;102:227-8. [Crossref] [PubMed]
3. Pinero Madrona A, Fernández Hernández JA, Carrasco Prats M, Riquelme Riquelme J, Parrila Paricio P. Intestinal perforation by foreign bodies. Eur J Surg 2000;166:307-9. [Crossref] [PubMed]
4. Ammari I, Longueira Suárez R, Lamas Ferreiro JL, Iribarren Díaz M, Toscano Novella A, Martínez Vázquez C. Foreign body: an uncommon cause of liver abscess. Gastroenterol Hepatol 2009;32:179-80. [Crossref] [PubMed]
5. Xu BX, Lu JD, Mao XP, et al. MSCT Diagnosis and Clinical Application Value of Abdominal Puncture-like Gastrointestinal Foreign Bodies. Journal of Clinical Radiology 2017;36:1663-6.
6. Suenghataiphorn T, Tribuddharat N, Danpanichkul P, Kulthamrongsri N. Hepatic Abscess from Ingested Foreign Body: Clinical Features and Diagnostic Challenges-A Systematic Review of Current Reported Cases. J Clin Exp Hepatol 2025;15:102586. [Crossref] [PubMed]
7. Perera MT, Wijesuriya SR, Kumarage SK, Ariyaratne MH, Deen KI. Inflammatory pseudotumour of the liver caused by a migrated fish bone. Ceylon Med J 2007;52:141-2. [Crossref] [PubMed]
8. Badea R, Chiorean L, Matei D, Seicean A, Andreica V, Botan E. Accidentally ingested foreign body associated with liver actinomycosis: the diagnostic value of imaging. J Gastrointestin Liver Dis 2013;22:209-12. [PubMed]
9. Tallón Aguilar L, Bernal Moreno DA, López Porras M, Marín Gómez LM, Pareja Ciuró F. Foreign bodies as infrequent cause of liver abscess. Rev Esp Enferm Dig 2011;103:334-5. [Crossref] [PubMed]
10. Graça L, Viamonte B, Carvalho C, Sarmento A. Hepatic abscess secondary to gastric perforation. BMJ Case Rep 2019;12:e230452. [Crossref] [PubMed]
11. Zhou X, Mou Y, Zheng J, Liu Q. Hepatic inflammatory pseudotumor secondary to a foreign body at right lobe of liver. Asian J Surg 2020;43:866-7. [Crossref] [PubMed]
12. Chen J, Wang C, Zhuo J, Wen X, Ling Q, Liu Z, Guo H, Xu X, Zheng S. Laparoscopic management of enterohepatic migrated fish bone mimicking liver neoplasm: A case report and literature review. Medicine (Baltimore) 2019;98:e14705. [Crossref] [PubMed]
13. Del Fabbro D, Torzilli G, Gambetti A, Leoni P, Gendarini A, Olivari N. Liver inflammatory pseudotumor due to an intrahepatic wooden toothpick. J Hepatol 2004;41:498. [Crossref] [PubMed]