Definition
A subphrenic abscess is any abscess located in the pancreas between the diaphragm and colon.
The subdiaphragmatic space is a section of the upper abdomen, bounded above, behind and sides by the diaphragm, below by the liver and spleen, the splenic flexure of the colon, in front by the anterior abdominal wall.
Spine and lig. falciforme divide the subphrenic space into two halves (right and left). There are intraperitoneal and extraperitoneal subphrenic spaces.
Causes
The source of infection and the route of its spread in a particular case cannot always be determined. The most common sources are purulent processes in the abdominal area.
The most common sources are perforated ulcers of the stomach and duodenum, acute appendicitis, suppuration of the liver and gall bladder. Other sources may be the spleen, pancreas, paranephritic abscess, uterine appendages, colon, rib osteomyelitis. In newer statistics, indications predominate of the postoperative origin of the subdiaphragmatic abscess - mainly due to operations on the organs of the pancreas (stomach, duodenum, gallbladder, liver, pancreas).
Direct (open trauma), lymphogenous (pulmonary abscess, gangrene, bronchiectasis) and hematogenous infections of the subphrenic space are also possible.
The transfer of infection to the subdiaphragmatic space is favored by such factors as: movements of the diaphragm synchronous with breathing with fluctuations in pressure and the creation of a pumping effect to the subdiaphragmatic space, outflow of exudate from abdominal cavity in a lying position, according to the laws of hydraulics.
The use of antibiotics and sulfonamides masks the clinical picture, but does not prevent the occurrence of an abscess.
Most often, coli bacteria, streptococci and staphylococci are found in this abscess. Other pathogens, including anaerobic bacteria, are also less common.
Intraperitoneal subdiaphragmatic abscesses are more common than extraperitoneal ones. More often they are right-sided. Bilateral subphrenic abscesses are rare.
Typical localizations of subphrenic abscesses are:
- between the right dome of the diaphragm and the convexity of the right lobe of the liver. Localization can be anterior or posterior;
- the space under the left dome of the diaphragm and the upper surface of the left lobe of the liver and the fundus of the stomach;
- the space between the left dome of the diaphragm, the spleen and the splenic flexure of the colon.
Subphrenic abscesses can reach significant sizes. They increase sharply when gases are formed. Under the tension of pus, displacement of adjacent organs occurs. So, for example, the diaphragm moves upward, the mediastinum - to the opposite side.
Symptoms
The symptoms of subphrenic abscess are complex. It combines general phenomena local symptoms and symptoms of the underlying disease. Most often, at present, a subdiaphragmatic abscess is a complication after surgery. Thus, its symptoms are superimposed on the phenomena of the postoperative period, and even a protracted one in this case. Treatment with antibiotics greatly obscures the clinical picture. Therefore, one cannot expect violent manifestations of classical signs - chills, high temperature, high leukocytosis, etc. But, despite the fact that the symptoms are not very pronounced, still general state severe, pulse is rapid, tachypnea is also evident. The expected postoperative resolution of the abdominal status is delayed. The abdomen is distended, the intestines are paretic, palpation pain is noted in the hypochondrium and sometimes in the epigastric region, where the abdominal wall can be stable. The skin in the areas of projection of the subphrenic abscess is often doughy soft. These areas are painful when percussed.
Intercostal spaces are smoothed. Breathing on the appropriate side chest is a little behind. One of early symptoms is persistent vomiting. The third symptom complex is the clinical picture of the disease, a complication of which is a subphrenic abscess. Data laboratory research are an indicator not only of the presence of a subphrenic abscess, but also of the underlying disease. There is usually high leukocytosis, a shift to the left, lymphopenia, accelerated ROE, hypoproteinemia, and a greatly shortened Veltman strip.
Clinical picture often complicated by accompanying pleural effusion.
Diagnostics
Diagnosis of subdiaphragmatic abscess is difficult. The most important thing to think about is the possibility of such a complication. And a subphrenic abscess should always be considered when, after an acute inflammatory process in the abdomen and postoperative period after abdominal surgery, there is a slowdown in the recovery of the general condition, when it is inexplicable why intoxication occurs, when septic temperatures and pain or a feeling of heaviness appear in the subdiaphragmatic area. These symptoms suggest the presence of a subphrenic abscess. They are not pathognostic. X-ray data are also indirect signs. There is a high position of the diaphragm and restriction of its movement, and with the content of gases in the abscess - a water-air shadow. Reactive exudate is usually found in the pleural sinus. For smaller abscesses, a tomographic examination is necessary.
Proof of the correctness of the diagnosis can only be the evacuation of pus from the subphrenic space through a diagnostic puncture. It is permissible only if you are ready to carry out the immediate operation. Carrying out a puncture with evacuation of pus and administration of antibiotics as an independent therapeutic method, is associated with dangers and unreliability of the therapeutic result.
Complications of subdiaphragmatic abscesses are most often directed to chest cavity(pleural empyema, pneumonia, abscess pneumonia, bronchial fistula, breakthrough of pus into the pleura, into the pericardium) and, less often, to the abdominal cavity (breakthrough of pus into the free abdominal cavity, causing peritonitis, etc.).
At differential diagnosis should be kept in mind: pleural empyema, pneumonia, liver abscess, paranephritis and typical abscesses in the epigastric region.
Subdiaphragmatic abscess is usually an acute disease, but it should be borne in mind that it can also occur chronically.
Prevention
Treatment of subphrenic abscess is surgical. It consists of opening the abscess and draining it. It is carried out through three classical approaches: 1. Abdominal transperitoneal or abdominal extraperitoneal; 2. Transpleural; 3. Posterior retroperitoneal.
The best opportunity for viewing is created by a transpleural approach. Due to the danger of pleural infection, it is necessary, in the absence of adhesions, to conduct a preliminary pleuroscopy - suturing the diaphragm to the parietal pleura. The safest are extrapleural and extraperitoneal approaches. It is advisable to associate drainage of large abscesses with a suction system. In the postoperative period, antibiotics are used for general and local treatment according to the antibiogram.
Pus with a subphrenic abscess is localized in natural pockets of the peritoneum, called the subdiaphragmatic space, which is located in top floor the abdominal cavity and is limited above, behind by the diaphragm, in front and on the sides - by the diaphragm and the anterior abdominal wall, below - by the upper and posterior surface of the liver and its supporting ligaments.
In the subdiaphragmatic space, intraperitoneal and retroperitoneal parts are distinguished. The intraperitoneal part is divided into right and left sections by the falciform ligament of the liver and the spine. In the right section, anterosuperior and posterosuperior areas are distinguished. The anterior-superior region is limited medially by the falciform ligament of the liver, behind by the upper layer of the coronary ligament, above by the diaphragm, below by the diaphragmatic surface of the right lobe of the liver, in front by the costal part of the diaphragm and the anterior abdominal wall. The posterosuperior region is limited in front by the posterior surface of the liver, in the back by the parietal peritoneum covering the posterior abdominal wall, and above by the lower layer of the coronary and right triangular ligaments of the liver (Figure 1). Both of the above areas communicate with the subhepatic space and the abdominal cavity. The left-sided subphrenic space has a slit-like shape and is located between the left dome of the diaphragm above and the left lobe of the liver to the left of the falciform ligament of the liver, the spleen and its ligaments and the anterior outer surface of the stomach.
The retroperitoneal part of the subdiaphragmatic space has a diamond shape and is limited above and below by the leaves of the coronary and triangular ligaments of the liver, in front by the posterior surface of the extraperitoneal part of the left and right lobes of the liver, behind by the posterior surface of the diaphragm, the posterior abdominal wall and passes into the retroperitoneal tissue.
Most often, a subphrenic abscess occurs in the intraperitoneal part of the subphrenic space.
The etiology is quite diverse and is caused by infection entering the subphrenic space from local and distant foci.
Most common reasons Subphrenic abscess: 1) direct (contact) spread of infection from neighboring areas: a) with a perforated gastric ulcer and duodenum, destructive appendicitis, purulent cholecystitis and liver abscess, b) with limited and diffuse peritonitis of various origins, c) with postoperative complications after various operations on the abdominal organs, d) with a suppurating hematoma due to closed and open injuries to parenchymal organs, e) with purulent diseases lungs and pleura, e) with inflammation of the retroperitoneal tissue as a result of purulent paranephritis, kidney carbuncle, paracolitis, destructive pancreatitis and others; 2) lymphogenous spread of infection from the abdominal organs and retroperitoneal tissue; 3) hematogenous dissemination of infection from various purulent foci along blood vessels for furunculosis, osteomyelitis, sore throat and others; 4) often Subphrenic abscess occurs with thoracoabdominal wounds, especially gunshot wounds.
The microbial flora of the subphrenic abscess is diverse.
The penetration of infection into the subdiaphragmatic space is facilitated by negative pressure in it, resulting from the respiratory excursion of the diaphragm.
The clinical picture is characterized by significant polymorphism. It's connected with different localization ulcers, their size, the presence or absence of gas in them and is often due to the symptoms of the disease or complication against which the Subdiaphragmatic abscess developed. The use of antibiotics, especially wide range actions due to which many symptoms become erased, and the course often becomes atypical. In 90-95% of cases, the subphrenic abscess is located intraperitoneally, and right-sided localization is observed, according to Wolf (W. Wolf, 1975), in 70.1%, left-sided - 26.5%, and bilaterally - in 3.4% of cases.
Despite the variety of forms and variants of the course of subdiaphragmatic abscess, the clinical picture is dominated by symptoms of an acute or subacute purulent-septic condition. With intraperitoneal right-sided subdiaphragmatic ulcers after a previous, usually recent, acute illness abdominal organs or in the immediate postoperative period after abdominal operations, general weakness, an increase in temperature to 37-39° occur, often with chills and sweating, tachycardia, an increase in leukocytosis with a shift in the leukocyte formula to the left, as well as hypoproteinemia and anemia of the patient. Many patients complain of pain of varying intensity and nature in the lower parts of the chest on the right, in the back, in the right half of the abdomen or in the right hypochondrium. The pain usually intensifies with deep breathing, coughing, sneezing, and also with body movement. Sometimes there is irradiation of pain to the right shoulder, scapula, shoulder girdle, and the right half of the neck. A common symptom is shortness of breath and pain with deep inspiration on the side. Subdiaphragmatic abscess. Some patients experience a dry cough and pain with deep breathing (Troyanov's symptom). When examining patients, a forced semi-sitting position and pallor are noted. skin, sometimes subicteric sclera. You can observe, especially with large abscesses, smoothing of the intercostal spaces in the lower half of the chest, thickening of the skin fold, pastiness, and rarely hyperemia on the affected side.
Retroperitoneal Subphrenic abscess in initial stage differ in a blurred clinical picture and manifest as dull or throbbing pain in the lumbar region, often on the right, elevated temperature(37-38°), leukocytosis and local pain in the abscess area. Subsequently, pastiness or swelling appears in the lumbar region and the region of the lower ribs, thickening of the skin fold, and, less often, hyperemia. At the same time, the picture of purulent intoxication increases.
Diagnosis. With anterior superior abscesses, there is often a lag in breathing of the anterior abdominal wall, tension and pain in the right hypochondrium and epigastric regions, which is associated with inflammation of the areas of the peritoneum adjacent to the subphrenic abscess. Palpation of the IX - XI ribs on the right, especially in the area of their confluence at the costal arch, is accompanied by pain (Kryukov's symptom).
The results of physical examinations for subdiaphragmatic abscess largely depend on the size and location of the abscess, as well as on changes in the topography of the organs of the thoracic and abdominal cavities adjacent to it. In the initial stage and with small accumulations of pus, percussion provides little information. As the abscess increases, the diaphragm shifts upward and the liver is pushed downward, as a result of which the upper border of the diaphragm can rise on the right to the level of the III-IV ribs in front and compress the lung. In many cases, the boundaries of hepatic dullness increase. In case of right-sided subdiaphragmatic abscess, percussion of the chest in a sitting position of the patient often reveals dullness of the pulmonary sound in its lower parts, the boundaries of which run along an arcuate line with the apex located along the midclavicular and parasternal lines. Compression of the lung tissue in this localization of the subdiaphragmatic abscess is observed mainly from front to back and laterally due to the high position of the dome of the diaphragm, and therefore, with percussion, it is sometimes possible to detect a section of pulmonary sound in the interval between the subdiaphragmatic abscess laterally and cardiac dullness medially (Trivus symptom).
G. G. Yaure (1921) described a symptom for subdiaphragmatic abscess, which consists in the fact that when tapping with one hand on back surface chest, the second hand, located on the abdominal wall, experiences jerking movements in the liver area. Right-sided gas-containing subdiaphragmatic abscess in some cases may be accompanied by so-called percussion three-layeredness. A clear sound over the lung turns into a tympanic sound in the area where the gas is localized and into a dull sound over the abscess and liver (Barlow phenomenon).
Tympanitis in the area of Traube's semilunar space (see full body of knowledge: Traube's space) complicates percussion recognition of left-sided subphrenic abscess, detected in most cases only with large accumulations of pus.
Auscultation for small subdiaphragmatic abscess does not give results. With a large abscess, high standing of the diaphragm, the presence of concomitant pleurisy, significant compression of the lung, weakened vesicular breathing, sometimes with a bronchial tint, which is usually not detected above the site of the abscess, can be heard, especially on the right above the chest. When the patient shakes in this area, it is occasionally possible to hear the sound of splashing.
X-ray examination for suspected subdiaphragmatic abscess includes transillumination and radiography with the patient's body in an upright position, and, if necessary, in a position on the side, as well as on the back (see full body of knowledge: Polypositional examination).
The X-ray picture of a subdiaphragmatic abscess consists of an image of the abscess itself, displacement of adjacent organs and signs of acute diaphragmatitis (see full body of knowledge: Diaphragm). With a subdiaphragmatic abscess of traumatic origin, this may be accompanied by x-ray signs of damage to the chest and organs of the thoracic and abdominal cavities, as well as the shadow of foreign bodies.
X-ray diagnostics is most effective in the case of gas-containing subdiaphragmatic abscess. When fluoroscopy and radiography are performed in a vertical position of the patient (in severe condition of patients - in the later position), a cavity with a horizontal level of liquid is determined under the dome of the diaphragm (Figure 2). When the position of the patient’s body changes, the liquid moves into the cavity, and its level remains horizontal and changes little in size, which distinguishes a subdiaphragmatic abscess from the accumulation of gas and liquid in the stomach or intestinal loop. Images in different projections make it possible to clarify the size of the cavity and topography. Subdiaphragmatic abscess Most often it is located in the right part of the intraperitoneal part of the subphrenic space, occupying all of this space or only its anterior, posterior or lateral sections. With left-sided localization, it is possible to distinguish between a perisplenic subdiaphragmatic abscess and ulcers formed above or below the left lobe of the liver. In some cases, not one, but two or three cavities are observed (Figure 3).
The right-sided subdiaphragmatic abscess, which does not contain gas, does not provide an independent image on ordinary photographs; the left-sided one causes intense darkening, visible against the background of gas in the stomach and intestines. Differential diagnosis of subphrenic abscess and intrathoracic pathological process in such cases, the symptom of deformation and pushing down the vault of the stomach and the left (splenic) flexure of the colon helps. For greater confidence, the patient is given two or three sips of an aqueous suspension of barium sulfate. If at the same time a depression is detected on the vault of the stomach, this means that the infiltrate is located under the diaphragm. In the case of a subdiaphragmatic abscess, which developed due to insufficiency of the anastomotic sutures after gastrectomy, the contrast mass sometimes passes from the stomach into the cavity of the subdiaphragmatic abscess
New opportunities in recognizing subdiaphragmatic abscess have been opened by computed tomography (see full body of knowledge: Computer tomography), ultrasound diagnostics (see full body of knowledge) and angiography (see full body of knowledge). Computed tomograms provide a direct image of a subdiaphragmatic abscess. In this case, the exact localization of the abscess is established, including the distinction between intraperitoneal and extraperitoneal subdiaphragmatic abscess located between the layers of the coronary ligament or above the upper pole of the kidney. Aortography (see full body of knowledge) in combination with celiacography (see full body of knowledge) makes it possible to determine the position and condition of the phrenic and hepatic arteries. Along with ultrasound scanning data, this facilitates the sometimes difficult task of differentiating a subphrenic abscess from a liver abscess.
Subdiaphragmatic abscess, according to M. M. Vikker (1946), V. I. Sobolev (1952), is of great importance in X-ray diagnostics, and has a syndrome of acute diaphragmatitis. It is expressed in deformation and high position of the affected half of the diaphragm or part of it, in a sharp weakening, absence or paradoxical nature of its movements during breathing, in thickening and blurring of the contours of the diaphragm due to its edema and inflammatory infiltration. The costophrenic sinuses are reduced due to infiltration of fiber and reactive effusion. As a rule, this is accompanied by small atelectasis and foci of lobular pneumonia at the base of the lung and effusion in pleural cavity. However, acute diaphragmatitis syndrome with damage to the right half of the diaphragm can be caused by liver abscess (see full body of knowledge). Therefore, for the final conclusion, it is very important to compare clinical symptoms, symptoms and results of x-ray, radionuclide and ultrasound examinations.
With a subdiaphragmatic abscess of medial localization, thickening of the legs of the diaphragm and the disappearance of their outlines are observed. In the case of a retroperitoneal adrenal subdiaphragmatic abscess, the images show blurred or absent outlines of the upper pole of the kidney, and with a large abscess, a downward displacement of the kidney is noted.
In the case of diagnostic puncture of an abscess, some surgeons and radiologists consider it advisable to replace part of the removed pus with gas or high-atomic tri-iodinated contrast agent. This provides a complete picture of the position and size of the purulent cavity and usually facilitates differential diagnosis Subphrenic abscess with liver abscess.
With subdiaphragmatic abscess as a result gunshot wound the development of an external purulent fistula is possible (B.V. Petrovsky). In this case, they resort to fistulography (see full body of knowledge) to study the direction and extent of the fistula tract, identify purulent leaks, establish the connection of the fistula with the abscess cavity, foci of destruction in damaged bones, with foreign bodies.
Treatment. Conservative treatment Subphrenic abscess is usually performed when there is doubt about the diagnosis or for the purpose of preoperative preparation. It consists of prescribing antibacterial and detoxification therapy and treating the underlying disease that served as the source of the Subdiaphragmatic abscess. A diagnosed Subdiaphragmatic abscess is subject to mandatory opening and drainage.
The surgical approach and the nature of the surgical intervention largely depend on the location of the subdiaphragmatic abscess and associated complications.
Transpleural access was first described by Roser in 1864. It consists of thoracotomy (see full body of knowledge) in the area of projection of the abscess, dissection of the diaphragm, opening and drainage. Subphrenic abscess The method is quite simple, but as a result of infection of the pleural cavity, empyema often occurs, flowing heavily.
To prevent this complication, F. Trendelenburg (1885) developed the following method. An incision is made along the X rib on the side between the posterior and anterior axillary lines on the right or posteriorly between the paravertebral and middle axillary lines, depending on the location of the subphrenic abscess, and then its subperiosteal resection (Figure 4). After careful dissection of the periosteum, without opening the pleura, it is sutured to the diaphragm with continuous sutures in the form of an oval to isolate the pleural cavity. The subphrenic abscess is opened with a longitudinal incision between the sutures through the pleura and the diaphragm.
Many surgeons prefer to use the extrapleural access developed by A.V. Melnikov in 1921. With this access, the diaphragm is exposed and the subdiaphragmatic abscess is opened through the so-called parapleural space after the costophrenic sinus is displaced upward, as a result of which the pleural cavity remains intact. The skin incision is planned depending on the location of the subphrenic abscess in the anterior or posterior part of the subphrenic space and extends 2-3 transverse fingers above the edge of the costal arch. After subperiosteal resection of one or two ribs (most often IX - X) for several centimeters, the periosteum is dissected and peeled away from the pleural sinus, which is separated from the chest wall and move up. Along the wound, the diaphragm is dissected to the parietal peritoneum and carefully peeled off. The cranial edge of the transected diaphragm is sutured to the muscles of the chest wall along the upper perimeter of the wound (Figure 5).
The extrapleural and extraperitoneal method of opening a subphrenic abscess includes retroperitoneal access, which is more often used for right-sided posterosuperior abscesses. This operation is based on the fact that pleural sinus on the right it almost never descends below the spinous process of the first lumbar vertebra. The operation is performed with the patient positioned on the left side. The incision is made along the XII rib with subperiosteal resection. A transverse incision at the level of the spinous process of the first lumbar vertebra is used to dissect the posterior layer of the periosteum, the adjacent intercostal and serratus posterior muscles and expose the diaphragm near its attachment. The latter is opened and the peritoneum covering the lower surface of the diaphragm is peeled off, the Subphrenic abscess is found (Figure 6) and it is opened.
To open the right anterior superior subdiaphragmatic abscess, most surgeons use a very convenient extraperitoneal subcostal approach (Figure 7), proposed by P. Clairmont in 1946. The incision is parallel and immediately below the costal arch. The muscular aponeurotic layers of the anterior abdominal wall are dissected layer by layer to the parietal peritoneum, which is bluntly peeled off from the inner surface of the diaphragm to the subphrenic abscess. The latter is opened and drained.
Mortality with subdiaphragmatic abscess depends on the nature of the underlying disease, the location of the abscess, the age of the patient, concomitant diseases, duration of the disease, timeliness of recognition and timing of surgical intervention. According to Wang and Wilson (S. Wang, S. Wilson, 1977), the mortality rate for subdiaphragmatic abscess that occurred after emergency operations was 35%, after planned operations - 26%, and overall mortality - 31%.
Clinic, diagnosis and treatment of subdiaphragmatic abscess in children do not differ from those of subdiaphragmatic abscess in adults.
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Subphrenic abscess
Subphrenic abscess(lat. abscessus subdiaphragmaticus; synonyms: subphrenic abscess, infraphrenic abscess) - accumulation of pus under the diaphragm (in the subphrenic space).
Most often occurs as a complication of acute inflammatory diseases abdominal organs, in particular: acute appendicitis, acute cholecystitis, perforation of a hollow organ, peritonitis.
Clinical picture
Subphrenic abscesses are characterized by a polymorphic clinical picture. It depends on:
- localization of the abscess,
- its size,
- the presence of gas in the abscess cavity,
- symptoms of the disease against which the subdiaphragmatic abscess occurred,
- the use of antibiotics (against the background of which many symptoms often become erased, and the course becomes atypical).
The intraperitoneal location of the subphrenic abscess is observed in 90-95% of cases. According to W. Wolf (1975), in 70.1% of cases, abscesses were located in the right part of the intraperitoneal part of the subdiaphragmatic space, in 26.5% - in the left part, and in 3.4% of cases, bilateral localization was observed.
Symptoms of acute or subacute purulent-septic process predominate; in particular, high fever with chills, corresponding localization of pain, is possible. It is possible to detect sympathetic effusion in the pleural cavity on the corresponding side.
Diagnostics
In addition to the clinical picture and changes in laboratory parameters characteristic of inflammation, imaging studies have diagnostic value. Most informative method is computed tomography of the diaphragm area, since this method allows you to clearly determine anatomical features location of the abscess and choose the correct access. Ultrasonography allows you to identify the liquid contents in the abscess cavity. At x-ray examination note limited mobility of the diaphragm on the corresponding side, effusion in the corresponding pleural sinus.
Treatment
Conservative treatment (prescription of antibiotics, detoxification therapy, treatment of the disease that caused the abscess) is carried out either if there is doubt about the diagnosis or as preoperative preparation. After a confident diagnosis, the subdiaphragmatic abscess should be opened and drained. The approach used to open an abscess is largely determined by its location and the presence of associated complications.
Extraserous approaches
If available, the optimal choice is the extraserous (i.e., extrapleural and extraperitoneal approach). According to a number of authors (published in works from 1938 to 1955), mortality with extraserous access ranged from 11 to 20.8%, and with transserous (that is, transpleural or transperitoneal) - from 25 to 35.8%.
Anterior extraserous subcostal approach
Anterior extraperitoneal subcostal access was proposed by P. Clairmont and is used to open anterosuperior right-sided subdiaphragmatic abscesses. With this approach, the incision is made just below the costal arch parallel to it, starting from the lateral border of the rectus abdominis muscle, to a width that allows insertion of the arm. The tissue is dissected layer by layer to the parietal peritoneum, after which it is bluntly peeled off from the inner surface of the diaphragm in search of an abscess. An abscess is characterized by a dense wall; After its detection, it is opened and drained.
Transpleural approaches
Transperitoneal approaches
Percutaneous puncture drainage under visualization control
Notes
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See what “Subphrenic abscess” is in other dictionaries:
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Subphrenic abscesses include abscesses localized between the diaphragm and the mesentery of the colon, both in contact with the diaphragm and located under the liver, since their etiology and pathogenesis are common and in some cases they occur simultaneously.
Subphrenic abscess occurs on the right 7 times more often than on the left.
Etiology
The cause of subphrenic abscesses are primarily complications of acute surgical diseases of the abdominal organs: perforated ulcer of the stomach and duodenum, acute destructive appendicitis, pancreatitis, as well as failure of the sutures of the duodenal stump or its damage due to injuries, suppurating hematoma due to liver injuries, purulent pleurisy and etc.
Clinic and diagnosis.
Subphrenic abscess is always accompanied by severe clinical course. Body temperature rises to 38 - 39° and is accompanied by chills, intoxication symptoms increase, general condition worsens, leukocytosis increases with a shift in the formula to the left. In this case, pain is often observed in the lower parts of the chest, often radiating to the right shoulder blade and shoulder; pressure on the 9th - 11th ribs causes intense pain.
Fluoroscopy reveals limited mobility of the diaphragm, sometimes its high position. Often, effusion is detected in the pleural cavity, which can be mistakenly interpreted as pleurisy. Often the abscess contains some gas, which can be detected by x-ray examination (as a result of specular reflection)
Treatment.
When a diagnosis of subdiaphragmatic abscess is made, the latter must be widely opened and drained. You cannot delay opening the abscess, as it can pierce into the abdominal cavity and cause peritonitis. In addition, prolonged presence of an abscess causes intoxication of the body with all the negative consequences.
The abscess should be opened extraperitoneally and extrapleurally, if possible, to prevent the occurrence of peritonitis or pleural empyema, which pose a great threat to the patient’s life.
To open a subdiaphragmatic abscess, an access is used depending on the location of the abscess.
The right-sided suprahepatic posterosuperior abscess is opened using a posterior approach (but with Melnikov).
The patient is placed on the left side with a bolster under the lower back. Under endotracheal anesthesia (danger of right-sided pneumothorax), an incision up to 10 cm long is made along the XII rib and resected, preserving the periosteum. At the level of the spinous process of the 1st lumbar vertebra, the bed of the right XII rib is crossed laterally. To the right of the rib are the fibers of the intercostal muscle, and to the left are the inferior serratus posterior muscle. Below them is part of the diaphragm, which is crossed along the cut line. After this, the renal fascia is visible in the lower corner of the wound, and the liver is located under it in the upper corner of the wound. By moving the index finger upward carefully behind the kidney and liver, the posterior parietal peritoneum is separated from the inner surface of the diaphragm and, when palpated, the abscess is punctured and then opened. A forceps is inserted into the wound, the opening is widened with jaws and the contents of the abscess are removed. Rubber drains are inserted into the abscess cavity, the wound is sutured in layers until the drains are removed.
If the abscess is located anteriorly, between the diaphragm and the liver, an anterior approach is used to open it. The patient is also placed on the left side with a bolster under the lower back. An incision up to 10 cm long is made 1.5 cm below the costal arch and parallel to it on the right to the peritoneum. The peritoneum above the liver is carefully separated with a tupper from the diaphragm to the abscess. When you feel it with your finger, the abscess is punctured and when pus is obtained, it is opened. The contents are removed by suction, the cavity is washed with antiseptics, drained with gauze swabs and rubber drainage tubes, the wound is sutured in layers until drainage occurs.
In the postoperative period, antibiotics are used, first with a broad spectrum of action, and then taking into account the sensitivity of the microbial flora. Conduct intensive detoxification and restorative therapy
A subphrenic abscess is an encysted collection of pus between the lower surface of the diaphragm and the upper surface of the liver (right) or the gastric vault and spleen (left). Right-sided subphrenic abscess is more common. The source of a subphrenic abscess is foci of purulent inflammation of the abdominal organs (perforated and duodenal ulcers, inflammation biliary tract and pancreas, liver abscess, acute appendicitis, amoebic dysentery, suppurating echinococcal cyst), sometimes lungs and. The cause of the formation of a subphrenic abscess can also be open and closed injury abdomen and thoraco-abdominal wounds. Most often, the subphrenic abscess is located intraperitoneally.
The clinical picture of a subphrenic abscess is often blurred, since it usually appears against the background of a serious illness. The most typical symptoms are prolonged fever, chills, appetite, weakness, and mental depression. The patient takes a forced semi-sitting position. Breathing is gentle. With the abdomen, muscle tension and pain in the right hypochondrium, with an increase in the borders of the liver. In the blood leukocytosis, acceleration. In more severe cases, the symptoms of a subphrenic abscess are pain in the right hypochondrium, aggravated by deep breathing, coughing, sudden movements, radiating to the shoulder girdle, right collarbone, scapula, fever, leukocytosis. with a subphrenic abscess plays a decisive role (the dome of the diaphragm is raised, motionless; underneath there is gas and a horizontal liquid level).
Complications of subphrenic abscess: reactive, breakthrough of pus into the pleural or abdominal cavity, into the pericardium. serious, without surgery usually ends in death.
The main treatment method for subphrenic abscess is surgery. A diagnostic puncture is only permissible so that when pus is obtained from the subdiaphragmatic space, the operation can be started immediately. Access to the subphrenic abscess through the chest is transpleural and extrapleural. After the abscess is emptied, the cavity is drained and tampons with Vishnevsky ointment and rubber drains are inserted. Tampons are changed for the first time on the 5-7th day.
In the postoperative period, the use of antibiotics, vitamins, control of the chest and abdominal cavity is indicated. It is necessary to change dressings, which may become wet due to purulent discharge, as well as skin care: lubrication with sterile Vaseline, Lassara paste.
Subphrenic abscess (subphrenic abscess) is a limited accumulation of pus in the subphrenic space between the diaphragm and the organs adjacent to its lower surface, mainly the liver on the right, stomach and spleen on the left.
The subphrenic space above the liver is divided by the suspensory ligament of the liver (lig. suspensorium hepatis) into a larger right and smaller left halves isolated from each other.
The coronary ligament of the liver (lig. coronarium hepatis) delimits the subphrenic fissure from the back, and two triangular ligaments (lig. triaagulare dext. et sin.) - from the sides. Normally, under the left dome of the diaphragm there is also a gap between the diaphragm and the stomach and spleen adjacent to its lower surface. These slits communicate with the abdominal cavity, essentially representing a part of it; and only during the inflammatory process in some area of the subdiaphragmatic space adhesions are formed very early, with which the area of inflammation is quickly delimited from the free abdominal cavity. The described areas of the subphrenic space do not communicate with each other, and therefore the suppurative process in one of them usually does not spread to the others.
The following localizations of subdiaphragmatic abscess are distinguished: right upper anterior; right superoposterior; left upper-posterior. In addition, extrahepatic subdiaphragmatic abscesses are identified. In the upper floor of the abdominal cavity above the transverse colon and mesocolon: right lower hepatic; left inferoanterior (pregastric); left infero-posterior (retrogastric). A subdiaphragmatic abscess develops predominantly in the right subphrenic space, with about half of all abscesses located in the right superior aad space. This is explained by the fact that during an inflammatory process in one of the abdominal organs, the lymph, and along with it the infection, rush to the centrum tendineum diaphragmatis and the right subphrenic space is primarily infected.
Subdiaphragmatic abscess is usually observed at 30-50 years of age, 3 times more often in men than in women. However, a subphrenic abscess can develop in childhood and old age, but much less frequently.
Subphrenic abscess, as a rule, is a complication of inflammatory processes in the abdominal organs: perforated appendicitis, perforated gastric and duodenal ulcers, severe forms acute cholecystitis and cholangitis. Less commonly, a subphrenic abscess develops with paranephritis, and even less often with general purulent processes and pyaemia. Finally, a subphrenic abscess can develop as a result of a rupture of an intrahepatic abscess, with liver injuries, or after thoracoabdominal injuries.
