Introduction
In the first place, a subphrenic abscess develops in the subphrenic space. In like manner, there is a space between the diaphragm, which separates the chest cavities from the abdominal cavity, and the transverse colon. Of course, this is the “subphrenic space”. There is a right and a left chest cavity. This is the reason why two clinical entities exist, a right-sided and a left-sided subphrenic abscess.
First of all, in about 50% of the cases there is a right-sided subphrenic abscess. Furthermore, in 25% there is a left-sided subphrenic abscess. And finally, in the other 25% there is a bilateral subphrenic abscess. Typically this develops 3 to 6 weeks following surgery in the abdomen. It happens especially after surgeries like biliary surgery, appendix surgery or surgery on the stomach or duodenum.
Additionally, any anastomosis leakage or other wound contamination tends to lead 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 abdomen into the subphrenic space and with it travel any bacteria that might be present, which certainly facilitates abscess formation.
Symptoms
Most noteworthy, patients are often elderly. Symptoms can be very subtle and start perhaps with a fever and a loss of appetite approximately 1 month after the surgery. There might be a dry cough due to an atelectasis in the lung of the affected side. Alternatively there may be a pleural effusion (fluid in the chest cavity) on that side. Upper abdominal pain on the affected side is common. This can be severe on deep palpation by the physician. Blood tests show a leukocytosis, which means too many white blood cells. The test may also show a lack of red blood cells (anemia).
First, plain abdominal X-ray films may show the abscess cavity with gas in it from gas producing bacteria. Second, chest X-rays often show abnormalities in the lungs (atelectases, lower lobe pneumonia). Even pleural effusions as well as an immobile diaphragm may be there. Another test is useful, such as an ultrasound for a right-sided subphrenic abscess. In case of a left-sided subphrenic abscess a CT scan is reasonable (hepar=liver; abscessus=abscess; a subphrenic abscess is between the diaphragm and the liver) . It can be rather difficult to come to a diagnosis, so int this case radioactive isotope scanning such as an indium-111-labeled leukocyte scan can sometimes be useful in detecting a hidden intraabdominal or subphrenic abscess.
Treatment
To emphasize, like with any other abscess in the body, the physician needs to drain the abscess and treat the infection with appropriate antibiotics. This can be a complex undertaking with a subphrenic abscess.
If there is an intraabdominal breakdown of an anastomosis, the surgeon has to fix this defect. In addition the surgeon also needs to drain the abscess. In another presentation it may be possible to drain the abscess through a percutaneous (meaning by perforating the skin) drainage catheter. Parallel to the clinical condition the physician needs to watch the patient’s nutritional status as these patients often are malnourished and may need to receive intravenous feeding. If the nutritional status is not attended to the patients may not heal properly and cannot fight the infection with their weakened immune system.
Other complications can be clots in the leg veins or the portal system veins, which may have to be treated with heparin and Coumadin. The overall mortality rate is about 35% despite the best therapy.
References
1. DM Thompson: The 46th Annual St. Paul’s Hospital CME Conference for Primary Physicians, Nov. 14-17, 2000, Vancouver/B.C./Canada
2. C Ritenbaugh Curr Oncol Rep 2000 May 2(3): 225-233.
3. PA Totten et al. J Infect Dis 2001 Jan 183(2): 269-276.
4. M Ohkawa et al. Br J Urol 1993 Dec 72(6):918-921.
5. Textbook of Primary Care Medicine, 3rd ed., Copyright © 2001 Mosby, Inc., pages 976-983: “Chapter 107 – Acute Abdomen and Common Surgical Abdominal Problems”.
6. Marx: Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th ed., Copyright © 2002 Mosby, Inc. , p. 185:”Abdominal pain”.
7. Feldman: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease, 7th ed., Copyright © 2002 Elsevier, p. 71: “Chapter 4 – Abdominal Pain, Including the Acute Abdomen”.
8. Ferri: Ferri’s Clinical Advisor: Instant Diagnosis and Treatment, 2004 ed., Copyright © 2004 Mosby, Inc.
9. Suzanne Somers: “Breakthrough” Eight Steps to Wellness– Life-altering Secrets from Today’s Cutting-edge Doctors”, Crown Publishers, 2008
