Saturday, April 30, 2011

Abscesses - Subphrenic abscess is a pus filled cavity and misdiagnosis lead sepsis and death


SUBPHRENIC ABSCESS 
 
There are a number of spaces below the diaphragm in relation to the liver which may become the site of abscess formation ( a subphrenic abscess ).Abscess may arise from such lesions as perforated peptic ulcer ,perforated appendicitis ,or perforated diverticulitis .Only two of the spaces are in fact directly subphrenic , the other two being subhepatic.The right and left subphrenic spaces lie between the diaphragm and the liver and are separated from one another by the falciform ligament. The right subphrenic space ( pouch of Rutherford Morrison ) is bounded by the posterior abdominal wall behind and by the liver above.The gall bladder, duodenum and right kidney are immediate relations. 

The left subphrenic space is the lesser sac itself.It may distend with fluid as a result of a perforated posterior gastric ulcer or as a result of acute pancreaitis ( pseudocyct of the pancrease ).At the present time most subphrenic abscess are drained percutaneously under the ultrasound control . However , the occasional one still requires open surgery and may be accessed if they are posteriorly placed by an incision below or through the bed of the twelfth rib. If they are placed anteriorly they can be drained through an incision below and parallel to the costal margin.

Any anastomosis leakage or another harm contamination tends to advance to a subphrenic abscess. The pressures from the diaphragmatic movements with respirations are such that there is a movement of the ascitic fluid of the cavum into the subphrenic space and with it travel any bacteria that strength be present, which facilitates abscess formation.

Patients are ofttimes elderly. Symptoms can be very impalpable and start perhaps with a fever and a loss of appetite approximately 1 month after the surgery. There might be a non-productive cough due to an atelectasis in the lung of the strained side or a pleural effusion (fluid in the chest cavity) on that side. Abdominal pain on the strained side in the upper cavum is common, which is severe on deep palpation by the physician. Blood tests exhibit a leukocytosis, there haw also be a lack of red blood cells (anemia).
 
Plain abdominal X-ray films haw exhibit the abscess decay with gas in it from gas producing bacteria. Chest X-rays ofttimes exhibit abnormalities in the lungs (atelectases, lower lobe pneumonia) and pleural effusions as well as an immobile diaphragm. Other tests are useful much as an ultrasound for a right- sided subphrenic abscess and a CT scan for a left-sided subphrenic abscess. The unification here shows a subphrenic abscess before (upper image) and after (lower image) drainage. Because it can be rather arduous to become to a diagnosis, hot isotope scanning much as an indium-111-labeled leukocyte scan could be useful in sleuthing a hidden intra-abdominal or subphrenic abscess.

 
TREATMENT

PERCUTANEOUS DRAINAGE insert a percutaneous drainage tube blindly, under combined ultrasonic and fluroscopic control. Same tube can be used to instill antibiotic solutions into abscess cavity.

SURGICAL DRAINAGE
INCISION if a swelling can be detected , incision is made over the site of maximum tenderness , or over any area where edema or redness is present. If no swelling is apparent , subphrenic spaces should be explored either by anterior subcostal approach or from behind after removal of outer part of 12th rib.

CLEANSING AND DRAINAGE When the cavity is reached ,all the fibrinous loculi must be broken down with finger .One or two drains or drainage tubes must be fully inserted.Drains are withdrawn gradually during next 10 days and closure of the cavity checked by x-ray sinograms.


X-ray shows sub-phrenic abscess

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