Subphrenic abscess

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The space between the diaphragm, which separates the chest cavities from the abdominal cavity, and the transverse colon is called the "subphrenic space". If there is an abscess developing in this space, this is called a subphrenic abscess. As there is a right and a left chest cavity, there can be from an anatomical point of view a right-sided and a left-sided subphrenic abscess.

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Nội dung Text: Subphrenic abscess

Subphrenic abscess 1. Introduction The space between the diaphragm, which separates the chest cavities from the abdominal cavity, and the transverse colon is called the "subphrenic space". If there is an abscess developing in this space, this is called a subphrenic abscess. As there is a right and a left chest cavity, there can be from an anatomical point of view a right-sided and a left-sided subphrenic abscess.
2. Aetiology
Subphrenic abscesses are localised collections of pus, usually underneath the right or left hemi- diaphragm. Other sites include the lesser sac - beneath the liver - and in the hepato-renal pouch. They are usually the result of a breach in the integrity of the peritoneum. Subphrenic abscesses are the commonest intra-abdominal abscess. 3.Subphrenic abscesses may occur as the result of generalised peritonitis following • acute appendicitis • perforated peptic ulcer • perforated gallbladder, producing a right-sided subphrenic abscess, and biliary surgery • bowel surgery and subsequent peritoneal faecal contamina tion Other causes include infection of a haematoma, for example, after splenectomy. 4. Clinical features The clinical picture of a subphrenic abscess is one of a patient who develops features of toxicity 2 to 21 days after making an initial recovery from a n episode of peritonitis or an operation; these features are:
• swinging fever • malaise, nausea, weight loss • there may also be upper abdominal pain that radiates to shoulder tip • there may also be breathlessness, due to lower lobe lung collapse or deve lopment of a pleural effusion On examination: • swinging pyrexia • sometimes abdominal tenderness in the subcostal region and/or signs of a pleural effusion 5. Diagnosis The diagnosis of a subphrenic abscess is by: • ultrasound or abdominal CT: localises collections of pus • white cell count: often a leucocytosis of around 20,000 • chest X-ray: o high diaphragm on the affected side
o may be gas and fluid beneath the diaphragm o if there is a pleural effusion then this is seen on chest X -ray 6. Treatments Surgical drainage of abscess and dead tissue removal, chloramphenicol, metronidazole, gentamycin, tobramycin, amkiacin, clindamycin