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Subdiaphragmatic abscess

 

When the internal infectious inflammation of the tissues, accompanied by their destruction and purulent fusion, is classified as a subdiaphragmatic abscess, this means that the abscess (limited by a pus accumulation capsule) is located in the hypodermic area of the abdominal cavity - in the space between the dividing thoracic and abdominal cavity diaphragm and the upper part of such abdominal organs like the liver, spleen, stomach and transverse colon.

Epidemiology

According to statistics, in more than 83% of cases the formation of subdiaphragmatic abscesses is directly associated with acute forms of diseases of the abdominal cavity; and in two thirds of cases it is the result of surgical intervention in these diseases.

In 20-30% of patients, a subdiaphragmatic abscess is formed after removal of perforated purulent appendicitis; 50% - after operations related to the stomach, duodenum, gall bladder and biliary tract; almost in 26% - with purulent inflammation of the pancreas.

In less than 5% of cases, a subdiaphragmatic abscess develops without predisposing circumstances.

Right-sided subdiaphragmatic abscesses are diagnosed 3-5 times more often than left-sided abscesses; the share of bilateral foci of suppuration does not exceed 4-5% of cases.

Causes of the subdiaphragmatic abscess

According to the data of clinical surgery, in most cases, the causes of the subdiaphragmatic abscess are associated with operations: for perforated ulcers of the stomach or duodenum; acute perforated appendicitis; removal of cysts or gall bladder (cholecystectomy); removal of bile duct stones (choledocholithotomy) or reconstruction of ducts; splenectomy (removal of the spleen) or liver resection. The formation of a subdiaphragmatic abscess is an extremely dangerous complication of such operations.

Also, a subdiaphragmatic abscess can cause combined trauma of thoracoabdominal localization; acute inflammation of the gallbladder, bile ducts or pancreas ( purulent pancreatitis ). The abscess of this localization can be the result of a breakthrough in the intrahepatic pyogenic or amoeba abscess or purulent echinococcal cyst. In rare cases, the suppuration is caused by parainfritis or generalized septicopyemia.

As a rule, the abscess in the subdiaphragmatic zone is formed inside the abdominal cavity in the form of anterior, upper, posterior, pre-gastric, superhepatic or near-abscesses abscesses. They can also be middle, right and left (more often - right-handed, that is, over the liver).

There is an arrangement of the abscess behind the peritoneum - in the cellulose of the retroperitoneal space, which takes place below the diaphragm until the pelvic organs located below. This retroperitoneal subdiaphragmatic abscess arises from an infection that comes here with a current of lymph or blood in a purulent inflammation of the appendix, pancreas, adrenal gland, kidneys or intestines.

Risk factors

Risk factors for the development of postoperative subdiaphragmatic abscess, as well as other infectious complications in surgery, include the presence of patients with diabetes mellitus or serious renal dysfunction; a large loss of blood, children and the elderly, as well as taking glucocorticosteroids or cytostatics that reduce overall immunity. Chronic syndrome is more common in patients who have previously taken antibiotics.

Pathogenesis

The pathogenesis of subfunctional abscess formation consists of an inflammatory reaction induced by a combination of aerobic and anaerobic bacteria (Staphylococcus spp., Streptococcus spp., Escherichia coli, Pseudomonas aeruginosa, Klebsiella spp., Bacteroides fragilis, etc.) present in the inflamed organ, for bacterial contamination - infection of the zone of operative intervention with nosocomial microbes.

As a result of activation of macrophages and other immunocompetent cells at the site of introduction of bacteria - around the pyogenic cavity with dead cells and leukocytes - a connective tissue capsule separating the zone of suppuration from healthy tissues and constantly replenished with purulent exudate is formed.

Symptoms of the subdiaphragmatic abscess

Doctors pay attention to the fact that the symptoms of the subdiaphragmatic abscess are typical for intracavitary inflammatory processes with purulent exudation, but their intensity depends on the course of the etiologically related disease and the localization of suppuration. And the clinical features of the manifestation of this pathology can range from severe acute illness to an insidious chronic process with intermittent fever, loss of appetite and weight, anemia and nonspecific symptoms.

The first signs are manifested by malaise and a state of general weakness. Very quickly, a sharp increase in body temperature (up to + 38.5-40 ° C) in the daytime with a slight decrease at night, that is, there is a prolonged fever with chills and nighttime hyperhidrosis.

The symptomatology of the subdiaphragmatic abscess also includes: pain under the costal arch, over 8-11 ribs (with palpation of the abdomen - muscle tension and pain in the upper right quadrant), pains give up the shoulder and under the scapula and intensify with deep breathing; cough, frequent and shallow breathing (often the epigastric region inhales on inspiration); hiccough, eructation, bad smell from the mouth, nausea and vomiting. Many patients take forced semisid position.

On the part of the blood, there is an increase in the number of leukocytes (leukocytosis) and the acceleration of erythrocyte sedimentation (ESR). At radiography approximately in 80% of patients pleural fluid is found, and at the third of them - gas bubbles above a liquid.

Complications and consequences

Consequences and complications of the subdiaphragmatic abscess: the perforation of the pyogenous capsule through the diaphragm and the entry of purulent exudate into the lungs and the pleural cavity (pulmonary empyema, pyotorax, reactive pleurisy), peritoneal cavity or pericardial bag (pericardium), and into the intestinal lumen. In the absence of treatment or an erroneous diagnosis, the consequences of a subdiaphragmatic abscess are peritonitis, sepsis, septic shock, and death.

Diagnostics of the subdiaphragmatic abscess

To diagnose the sub-diaphragmatic abscess in a timely manner, there is a rule in surgery: any patient with a fever of unknown origin who had a hollow operation (even if the operation was performed several months earlier) should be suspected of a chronic intra-abdominal, primarily subdiaphragmatic abscess.

The examination necessarily includes blood tests, and instrumental diagnosis - radiographic examination (in two projections), ultrasound examination and a computer tomogram of the abdominal cavity and the area of the diaphragm.

What do need to examine?

Differential diagnosis

Very important is the differential diagnosis - due to the localization of suppuration in the intrathoracic part of the abdominal cavity. Existing diagnostic criteria (on the composition of blood and instrumental visualization) contribute to the correct detection of this type of purulent-inflammatory process.

Treatment of the subdiaphragmatic abscess

Treatment of a subdiaphragmatic abscess is an operative treatment that is performed in a hospital.

Transthoracic (transpleural) or transabdominal opening of the sub-diaphragmatic abscess and removal of pus from its cavity (by means of suction) are performed. Then the cavity is washed with antiseptic means and drainages are established with suturing the wound.

After this, drug treatment continues, and here the main drugs are antibiotics. First of all, by parenteral administration, preparations of the cephalosporins group are used: Cefotaxime, Cefazolin, Ceftriaxone, etc., which are administered either intramuscularly or intravenously (dropwise) - 0.25-0.5 g every 8 hours (in severe cases, 1 -2 g).

Flukloxacillin, Trimethoprim-sulfamethoxazole (Biseptol, Bactrim, Co-trimoxazole, Septrim and other trade names), Clindamycin (Dalacin, Klindachin, Klitsimin) are also used.

Antibiotic-lincosamide Clindamycin is prescribed in the form of injections - 2.5-2.8 g per day. Among its contraindications, only the presence of enteritis or colitis are noted. However, like all antibacterial drugs, this medicine can give side effects (changes in blood, urticaria, lowering blood pressure, abdominal pain, nausea, diarrhea, intestinal dysbiosis).

Prevention

To date, the prevention of subfunctional abscess development after surgical interventions is carried out by the introduction of antibiotics for an hour or two before the operation and within the first 24 hours after it.

Forecast

The prognosis of the outcome of the intra-abdominal abscess in the subdiaphragmatic area - with its average mortality rate of 10-20% - is determined by specialists with several factors. And a key condition for safety for patients' life is the timely opening of the sub-diaphragmatic abscess and adequate follow-up therapy.

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