Interintestinal and subdiaphragmatic abscesses

In essence, limited forms of purulent peritonitis refer to extragenital foci of purulent inflammation.

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Causes of interintestinal abscesses

In patients with purulent formations of the uterine appendages, especially with a long-term recurrent course, microperforations may occur with the next activation (exacerbation) of the process. In rare cases, diffuse peritonitis develops (according to our data, no more than 1.9% of all perforations). More often, the purulent process is limited, which is due to a number of reasons: firstly, due to the enormous absorption, exudative and plastic properties of the peritoneum, capable of neutralizing some microorganisms; secondly, as a result of fibrin loss and the development of adhesions and, thirdly, due to the "sanitary" role of the omentum, which performs, in addition to bactericidal and phagocytic, also "limiting" functions.

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Symptoms of interintestinal abscesses

1. Patients have anamnesis and all clinical signs of purulent inflammation of the pelvic organs, but it is necessary to remember that during remission of the purulent-infiltrative process and especially when using palliative drainage operations, palpation data during a gynecological examination may be scanty, which does not at all mean that the gynecological nature of the interintestinal abscess is excluded. In such cases, a thorough collection of anamnesis is crucial for establishing the genesis of the disease.
2. In the remission stage, interintestinal abscesses are characterized by weakness, a tendency to constipation and symptoms of prolonged purulent chronic intoxication.
3. In the acute stage, patients are bothered by pain localized mainly in the mesogastric parts of the abdominal cavity and accompanied by transient intestinal paresis or partial intestinal obstruction, as well as an increase in temperature and other phenomena of purulent intoxication.

During a gynecological examination, patients are usually found to have a single conglomerate occupying the small pelvis and part of the abdominal cavity. The size of the conglomerate can reach 25-30 cm in diameter. During the examination, limited mobility or, more often, complete immobility of the formation, the absence of clear contours, uneven consistency (from dense to hard-elastic) and its sensitivity are determined. During an exacerbation, the size of the infiltrate increases, and sharp local pain appears.

Symptoms of a subphrenic abscess

1. Patients have a history and all the clinical signs of complicated purulent inflammatory process in the pelvic cavity.
2. In patients with unilateral purulent tubo-ovarian formations of the appendages, a subdiaphragmatic abscess always forms on the affected side.
3. Here, chest pains appear, caused by reactive pleurisy. The intensity of the pain varies, most often they have a pulling character, radiate to the neck, shoulder blade, shoulder area, and increase with inhalation and movement.
4. In case of a subdiaphragmatic abscess, the patient is forced to take a position on her back or side (on the affected side) with the upper part of her body raised.
5. A characteristic feature is Duchenne's sign, or paradoxical breathing syndrome, when the abdominal wall in the epigastric region is drawn in during inhalation and protrudes during exhalation.
6. When taking a deep breath, patients experience pain in the area of the costal arch (IX, X, XI ribs), as well as retraction of the intercostal spaces in these areas (Litten's symptom).
7. In some cases, pain appears in the neck - in the area of the projection of the phrenic nerve (Mussi's symptom).

Diagnosis of interintestinal abscesses

During echography, abdominal infiltrates without abscess formation have the following echographic characteristics: echo-positive formations of irregular shape without a clear capsule with reduced echogenicity in relation to surrounding tissues due to increased hydrophilicity; intestinal loops, pathological purulent structures of various localizations and foreign bodies can be identified in the infiltrates.

During abscission, the structure of the infiltrates themselves becomes heterogeneous (against the background of the main echo-positive structures, one or more cystic formations with a clear capsule and heterogeneous fluid contents, reflecting the accumulation of purulent exudate, are determined).

Echographic signs of interintestinal abscesses are the presence in the corresponding projection (area of intestinal loops) of encapsulated echo-negative formations with an echo-positive capsule and liquid heterogeneous contents.

CG, NMR are highly informative diagnostic methods that should be used in complex cases. The informativeness of CT for a single interintestinal abscess is 94.4%, for multiple abscesses - 94.7%.

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Diagnosis of subphrenic abscess

The echographic criterion of subdiaphragmatic abscess is the presence of an encapsulated echo-negative formation with an echo-positive capsule and liquid heterogeneous contents, localized in the corresponding projection (subdiaphragmatic region). An extensive adhesive process is observed in the abdominal cavity, additional identification of purulent appendage formations helps differential diagnostics.

X-ray examination is of primary importance for establishing the correct diagnosis. In the presence of a subdiaphragmatic abscess, a high position of the diaphragm is revealed, and complete immobility of the diaphragm dome on the affected side is noted. In some cases, paradoxical movement of the diaphragm is observed: it rises during a deep inhalation and falls during exhalation. Sometimes, when the patient is in an upright position, a gas bubble of varying size can be detected under the diaphragm, located above the horizontal level of the fluid. When the woman changes position or bends to the side, the horizontal level of the fluid is maintained. In the case of left-sided localization, X-ray diagnostics of a subdiaphragmatic abscess is more difficult due to the presence of a gas bubble in the stomach. In these cases, it is advisable to conduct a study with a large amount of barium sulfate administered orally.

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Features of performing operations for interintestinal abscesses

1. It is advisable to extend the incision of the anterior abdominal wall.
2. Adhesions between loops of the small intestine must be separated only by sharp means, in which case the abscesses are emptied. A thorough revision of the walls of the abscess cavity is required, i.e. determining the degree of destructive changes in the intestinal wall and its mesentery.
3. Small defects of the serous and muscular layers of the intestine are eliminated by applying converging serous-serous or serous-muscular sutures in the transverse direction with vicryl No. 000 on an atraumatic intestinal needle. In the presence of an extensive defect or complete destruction of the intestinal wall, including the mucous membrane, resection of the intestine within healthy areas with the application of a side-to-side or end-to-side anastomosis is indicated.
4. To prevent intestinal obstruction, improve evacuation and reparation conditions, and in case of extensive adhesions between small intestinal loops, transnasal intubation of the small intestine with a probe should be performed at the end of the operation. In case of intestinal resection, this procedure with the introduction of a probe beyond the anastomosis area is mandatory.
5. In addition to transvaginal drainage, additional 8 mm diameter drains are inserted transabdominally through counter-openings in the mesogastric regions to perform APD.
6. In order to regulate the motor function of the intestine in the postoperative period, long-term epidural anesthesia is used.

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Features of performing operations in patients with subdiaphragmatic abscesses

1. It is advisable to further extend the incision of the anterior abdominal wall.
2. For complete removal of the abscess, it is necessary to perform not only palpation, but also a thorough visual revision of the subdiaphragmatic space.
3. In addition to transvaginal, transabdominal drainage on the affected side is inserted through counter-openings in the meso- and epigastric regions to perform APD.

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