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Liver abscess caused by foreign body obstruction of the intrahepatic bile duct

A 58-year-old woman presented with fever and right upper abdominal pain. She had cholecystectomy and choledochoenterostomy as a result of biliary stone disease 15 years ago. Laboratory findings showed WBC 20 910/mm, ALP 191 IU/L [45-129], ALT 261 IU/L [5-35], Total Bilirubin 3.7 mg/dl and CA19-9 11.3 U/ml. Abdominal computed tomography (CT) showed a 6.5 9 5.2 cm irregular mass with peripheral rim enhancement. No definite calcified stone or stricture was noted at choledochoenterostomy site (Fig. 1). Under a diagnosis of liver abscess, empirical antibiotics were started and endoscopic retrograde cholangiopancreatography (ERCP) was performed to rule out radiolucent biliary stone, hidden stricture or malignancy. Cholangiography revealed an ill-defined filling defect in the right posterior segmental duct, and endoscopic image showed a brownish stone looking object (Fig. 2). On removal, it was a conical tip of dried pepper (Fig. 3) and the patient improved dramatically without percutaneous drainage. When a liver mass develops in patients with history of choledochoenterostomy, abscess or cholangiocarcinoma should be considered (1). Liver abscesses are usually caused by stricture with or without biliary stone. Theoretically, it is unlikely that any foreign body could be impacted in bile duct because of continuous bile flow, although sump syndrome by reflux of gastrointestinal content has been reported (2, 3). In our case, cone shape of the foreign body might explain why it entered and remained in the bile duct. When liver abscess develops in a patient with choledochoenterostomy, ERCP should be considered even if the CT shows no evidence of stricture or biliary stone.