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Subphrenic abscess is a rare complication of amebic liver abscess, its diagnosis and treatment are problematic. We present one patient with a right subphrenic abscess secondary to amebiasis. Treatment with chloramphenicol and percutaneous drainage had good response. Radiological intervention is an option in treatment of this kind of complication.
Subphrenic abscess is reported in two patients, one previously operated on for pancreatic carcinoma and the other for clear cell carcinoma of the left kidney. The subphrenic abscess presented with cachexia and low grade fever six months and one year after surgery. Metastatic carcinoma was erroneously diagnosed in both patients. Despite massive antibiotic treatment, both patients succumbed to sepsis. Because of the inherent diagnostic challenge, delineation of a subphrenic abscess in cancer patients without clear-cut evidence of a metastatic spread is crucial.
Although extraserous drainage of subphrenic abscesses has gained wide acceptance, there is some renewed enthusiasm for the more frequent use of a transperitoneal operation because it affords the opportunity to discover unsuspected pathologic conditions, particularly heterotopic abscess. In 44 patients with postoperative subphrenic abscesses, the approach to drainage was selected on the basis of the clinical circumstances. Among 28 patients whose abscesses were drained extraserously, the incidence of heteroptic and recurrent abscesses was low. No serious complications of peritoneal or wound soilage occurred after transperitoneal drainage in 16 patients, yet the problems of inadequate drainage and heteroptic abscess were not eliminated. Celiotomy prior to definitive abscess localization was required for 13 patients. Five patients died. The operative approach should be based on the clinical assessment of the patient and particularly on the probability that multicentric intra-abdominal pathologic conditions exist.
Four septic patients with suspected subphrenic abscess were evaluated with gallium-67 citrate and technetium-99m labeled radiopharmaceuticals. Gallium-67 scintigraphs proved instrumental in correctly diagnosing and localizing one left and three right subphrenic abscesses. Gallium-67 scintigraphy can be a useful noninvasive technique for evaluating patients with suspected subphrenic abscess.
Main symptoms and causes of subphrenic abscess are described. Localization is possible using Gallium 67 scanning. Prophylaxis and surgical approach are illustrated. In 75 patients of the surgical clinic of the University of Hamburg, the subphrenic abscess was drained by an anterolateral extrapleural incision through the diaphragm. Positive identification and localization are necessary to prevent contamination of the peritoneal cavity. Scintigraphic Gallium 67 scanning is also useful to identify synchronous subphrenic (bilateral) abscesses.
Nineteen consecutive cases of subphrenic abscess which were treated in the Royal Hospital for Sick Children, Glasgow, from 1962 to 1972 are analyzed. This complication of intra-abdominal suppuration of surgery still carries a grave prognosis. Four of the patients died (21 per cent); 2 deaths were related to the subphrenic abscess while the remaining 2 were not directly related to the abscess. The mean hospital stay of the survivors was 59 days (range 30-122 days). The changing patterns of aetiology and presentation which have recently been emphasized in general surgical practice are not reflected in this paediatric series.
The clinical picture of subphrenic abscess taking place against the background of the treatment with modern antibacterial drugs has changed essentially, which requires a complex solution of the problem of the timely abscess diagnosis. The antistaphylococcal plasma and gamma globulin applied together with other methods of intense therapy proved to be the most effective after the dissection of the abscess.
Diagnosis of a left subphrenic abscess after splenectomy is often difficult. C.T. scanning was used to establish the diagnosis in 5 patients with subphrenic abscesses. The examination is simple and gives valid results. Needle aspirations, controlled by scanning, can confirm the diagnosis or be used for drainage of the abscess.
Recent changes in the etiology, topography, and bacteriology of subphrenic abscess are identified in 93 patients treated between 1955 and 1975. Gastric and biliary tract operation account for 52% of abscesses. Appendicitis is now responsible for only 8% of subphrenic infections, in contrast with the 40% of previous reports. Colonic surgery (19%) and trauma (8%) are increasing in importance. Left-sided abscesses occur in 40%, and multiple space abscesses in 20% of patients. The bacterial flora consists of multiple strains of aerobic and anaerobic organisms. Since 1970, the aerobes have been Escherichia coli (96%), Klebsiella (21%), and Proteus (38%); anaerobes include Bacteroides (83%), cocci (50%), and clostridia (50%). The mean interval from the preceding operation until drainage of the subphrenic abscess was 5.5 weeks. Overall mortality was 31%, with higher mortalities for multiple space involvement (39%) and for abscesses developing after emergency procedures (35%). Recommendations based on this data are: (1) antibiotics selected should be effective against anaerobes, and (2) transperitoneal drainage is frequently indicated because of the increase in multiple abscesses and the need to evaluate the first operation.
We have collected 62 cases of post-operative subphrenic abscess. Two thirds of these patients were sent to us by another unit for post-operative complications. Subphrenic asbcess is still very dangerous as the mortality is still 38%. They occurred after a gastro-duodenal operation (26 times), spleno-pancreatic operation (21 times), intestinal operation (15 times), hepato-bilary operation (11 times) appendicectomy (twice). They were situated usually on the right, but 11 patients had a double subphrenic abscess and 14 an associated submesocolic abscess. Gram negative bacteria were usually the cause. These abscesses often started early. They occurred in 80% of cases in patients operated under the antibiotic cover. Chest X-ray was the best method of detection, but experience is necessary to read them. The abscesses were drained by the abdominal route in order to verify th whole peritoneal cavity. 22 patients died. 11 from septicemia. 21 out of 22 had a digestive fistula. Among the factors in prognosis, the most obvious were age, type of operation, the notion of reoperation, multiple abscess, and finally the delay in starting treatment.
A series of 241 patients with subphrenic abscess was analysed to seek reasons for the continuing mortality. Aspects of pathology, clinical presentation, special investigations and management were affected by therapy with broad spectrum antibiotics to make diagnosis more difficult, particularly in relation to left subphrenic abscesses. When transperitoneal exploration and drainage were employed, high morbidity and mortality resulted. Satisfactory results followed extraserous drainage. The introduction of parenteral hyperalimentation promised control fistulas associated with abscesses, a situation hitherto associated with a poor prognosis.
This report of a case of chronic subphrenic abscess, with a brief review and recommendations for diagnosis and prevention, draws attention to this clinical entity as a potential cause of chronic ill health. The clinical presentation and laboratory findings in this case were unremarkable. It is clear that the condition can be easily missed and the patient may be exposed unnecessarily to prolonged illness and to inappropriate investigation and therapy.
A 75-year-old female was admitted to our hospital with complaints of fever, cough and left hypochondralgia. She had been operated for cholecystectomy ten years ago. Chest roentgenogram indicated bilateral pleural effusion. Tube drainage was done to the left thorax and empyema was caused by Bacteroides fragilis and Escherichia coli (E. coli). Though antibiotic therapy was already being conducted, the left hypochondralgia persisted. A CT scan and MRI demonstrated local subphrenic abscess around the spleen due to E. coli. Tube drainage was conducted to the subphrenic abscess under ultrasound control and and the symptoms disappeared rapidly. The present results show that examination of the abdomen is necessary for empyema with complication of compromised host. The past history of abdominal surgery and disturbance in the biliary tract should also be considered.
A 52-year-old man was complicated with a left subphrenic abscess after total pancreatectomy and gastrectomy for advanced pancreatic cancer. A left subphrenic silicon tube penetrated the diaphragm and the bottom of the left lung as well, causing a bronchial fistula with bilateral aspiration pneumonia. Then bronchoscopically, the fistula was successfully treated by packing a few pieces of oxidized cellulose into the affected bronchus. One month later the patient died of sepsis due to multiple liver abscess. On autopsy, the bronchial fistula and any active inflammation were not recognized in the left lower lung area.
To assess the value of liver-lung scanning in the diagnosis of right subphrenic abscess, 148 scans were reviewed against corresponding charts. Of 91 scans with adequate clinical data, overall scanning error was 19.3% with 14 false positive and 3 false negative scans. Among 49 scans (of the initial group of 91 studies) with presence or absence of actual pathology proved by surgery and/or autopsy, there were 3 true positive, 12 false positive, 29 true negative, and 3 false negative scans. Analysis of data indicated (1) lower accuracy of scan interpretations than generally reported, (2) low specificity for positive scans and high specificity for negative scans, (3) correlations of false interpretations with atypical degrees of liver-lung separation and with scanning defects in liver and lung, and (4) failure of rereading significantly to improve accuracy of interpretation.
This paper is a study of the evolution of the management of subphrenic abscess from the earliest reports to the present day. Its purpose is to compare and contrast the attitudes and practices established during the earlier years with those of the present, in particular in relation to changes consequent on the introduction of antibiotics.
The authors describe the slow development of an abscess in the left subphrenic space in a patient with acute myeloid leukaemia. The patient suffered several months before the diagnosis was established from pain in the left subcostal region and was on account of this pain examined repeatedly by clinical methods and sonography. During the last sonographic examination in this area a hypoechogenic formation was detected. The diagnosis was than established more accurately by computer tomography by visualization of the abscess cavity. The case-history and relatively thick wall of the cavity suggested a long-term process. The abscess cavity was evacuated surgically, however, the patient suffered a relapse later and died from septicaemia. In the discussion the authors analyze the problem of development of metastatic abscesses in leukopenic patients, early diagnosis and treatment.