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

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.