Treatment of subphrenic abscess. Subdiaphragmatic abscess - errors in the diagnosis and treatment of acute diseases and injuries of the abdomen. Postoperative management of patients

Subphrenic abscess is a rare but extremely serious complication of purulent processes in the abdominal cavity. Included in the ICD classification, the pathology is assigned code K65-K67 as a consequence of diseases of the peritoneum and acute peritonitis. A subphrenic abscess is found in the area inside the peritoneum - under the diaphragm next to adjacent organs.

Etiology of subphrenic abscess

The pathology most often occurs in men, although women also suffer from this disorder. The age of patients is from 30 to 50 years. Among the reasons are:

• perforated ulcers in the gastrointestinal tract;
• acute appendicitis;
• inflammation of the gallbladder;
• purulent and inflammatory processes around the esophagus;
• suppuration in the pelvic area;
• pathology of the prostate gland.

If pus spreads in the area of ​​the lower abdominal wall, the disease mechanism involves the lymphatic system. Less common disorders include: lung abscess, purulent diseases of the respiratory tract, and pleurisy.

The least common diseases are liver disease, purulent inflammation of the transverse colon, lesions of the lower ribs and osteomyelitis. Even more rarely, an abscess is provoked by closed liver injuries.

The disorder is diagnosed mainly under the right dome of the diaphragm: pus is located between the upper right lobe of the liver, to the right of the ligament that holds the organ. The most severe form is bilateral subphrenic abscess. In the area of ​​suppuration during surgery, traces of gases are almost always found that penetrate into the cavity from the organs or become a consequence of the activity of pathogenic microflora.

Identifying the causes of a subphrenic abscess is not the most difficult task for doctors. This is due to the fact that first of all the original source of purulent inflammation is removed and the harmful factor is eliminated. During the procedure, a complication in the form of an abscess is discovered.

Clinical signs of pathology

The first symptoms of a subphrenic abscess can be detected by the following external signs:

• painful sensations that become stronger when inhaling, and also radiate to the shoulder blade;
• pain in the chest area, localized on the right;
• if the abscess is located near the anterior abdominal wall, the symptoms intensify;
• severe, often recurrent hiccups, loss of appetite and nausea;
• forced stay on the back or side, as the pain on the stomach becomes unbearable;
• the patient suffers from fever, chills, sweating;
• if the abscess lasts for a long time, a seal may appear in the 9-11 intercostal space;
• shortness of breath and tachycardia are often diagnosed;
• upon palpation, rigidity of the muscles of the upper abdominal wall is observed, and severe pain is observed between the ribs.

Surgeons or nurses may suspect a disorder in most patients in the early stages.

Diagnosis of an abscess

After identifying signs of the disease, it is necessary to undergo a detailed examination. To do this, they use ultrasound, CT, take tests from the patient and prescribe x-rays. But the main diagnostic method is palpation.

Among the instrumental methods, chest X-ray is the most informative. Images in this case will indicate changes in the area of ​​the legs of the diaphragm (its dome is located higher in the area of ​​pus formation).

Pathology treatment methods

The only way to combat a subphrenic abscess is surgery. Surgeons use invasive and minimally invasive methods:

• a wide incision in the area of ​​the abscess is used for severe forms and large spread of pus;
• the contents are removed using a large needle, and then the affected area is washed for small tumors.

Prognosis and prevention

The prognosis for any subphrenic abscess is quite serious. If the pathology is ignored, in a short period of time the pus penetrates the organs and leads to death in 90% of cases. If the abscess is detected and opened surgically, the mortality rate is reduced to 10-15%.

Possible complications that may occur even after surgery include:

• relapse of purulent inflammation;
• bleeding;
• intestinal obstruction;
• lung diseases, including pneumonia;
• sepsis as one of the most severe consequences;
• multiple organ failure.

If there is no operation, the abscess is opened and the contents are poured into the abdominal cavity.

An abscess and its consequences can only be prevented if the pathology is detected in a timely manner. It is important to immediately treat inflammation of the abdominal cavity and prevent complications of these pathologies. There are no specific methods of prevention.

Subphrenic abscess is a severe purulent inflammation, which is characterized by very high mortality in the absence of surgical treatment. However, if the pathology is detected in time, it can be successfully treated.

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Subphrenic abscesses are serious complications that occur after surgery on the abdominal organs.

The subdiaphragmatic region is the most common location of postoperative ALP. A subdiaphragmatic abscess is any accumulation of pus in the upper floor of the abdominal cavity, limited on either side by the diaphragm. The frequency of subphrenic abscesses is 0.3-0.8% [B.A. Gulevsky et al., 1988; A.S. Lavrov et al., 1988; S.K. Malkova, 1989]. Being a secondary disease, it represents part of the common surgical infections that spread from other organs and differ in the complexity of pathogenesis, as evidenced by the breadth of variations in the primary source of the disease.

Subdiaphragmatic abscesses often form after surgery for appendicitis, perforated gastroduodenal ulcers, trauma, diseases of the hepatobiliary-pancreatic zone, proximal and subtotal gastrectomy, gastrectomy, resection of OC due to malignant neoplasms [D.P. Chukhrienko, 1977; DI. Krivitsky et al., 1990]. The development of a subdiaphragmatic abscess is associated primarily with infection of the abdominal cavity or with insufficient efficiency of drainages.

Subdiaphragmatic abscess is especially common in patients with malignant diseases of the stomach, pancreas and left half of the gastrointestinal tract [S.K. Malkova, 1989]. Their frequent development in cancer patients (“risk group”) is due to the nature of the disease, accompanied by suppressed immunity. Removal of the spleen also plays an important role, which leads not only to the elimination of an important barrier to infection, but also to disruption of leukopoiesis. It would seem that drainage of the subdiaphragmatic space and massive antibacterial therapy should prevent the formation of a subphrenic abscess. However, as experience shows, despite adequate drainage with a silicone tube, this dangerous complication cannot be avoided. In the development of subphrenic abscess, a certain role is played by technical difficulties associated with the nature of the pathological process, the time factor and the traumatic nature of the operation [S.K. Malkova, 1989].

The reasons for the formation of a subdiaphragmatic abscess are often errors in hemostasis technique, inadequate toilet, irrational drainage of the abdominal cavity, high virulence of the infection and reduced reactivity of the body. Due to the difficulty of diagnosis, these abscesses are often detected late, which leads to a delay in surgical intervention, causing a high mortality rate of 16.5-25.4% [V.M. Belogorodsky, 1964; M.I. Kuzin, 1976; S.K. Malkova, 1984]. Difficulties in diagnosis are partly due to the deep location of the abscesses. Subdiaphragmatic abscess is distinguished by the paucity of symptoms indicating the presence of inflammation.

Subphrenic abscess is often localized (in relation to the liver and diaphragm) in the right postero-superior, right anterosuperior, left superior, right inferior, left posteroinferior, left anterior-inferior spaces [V.Sh. Sapozhnikov, 1976] (Figure 14). Most often (up to 70% of cases) they are localized in the right anterior and posterosuperior spaces [D.P. Chukhrienko and Ya.S. Bereznitsky, 1977].

Figure 14. Division of the subdiaphragmatic space by the coronary ligament (a) and typical localization of subphrenic abscesses (b):
1 - diaphragm; 2—liver; 3 - superoposterior space; 4 - upper anterior space; 5 - kidney; 6 — subhepatic abscesses; 7 - suprahepatic abscesses

Figure 15. Right-sided subphrenic abscess under the dome of the diaphragm

Bilateral (right and left) subdiaphragmatic abscesses are very rarely observed. According to O. B. Milonov et al. (1990), their frequency is 0.8%. You should always remember about the possibility of a multi-chamber structure of a subdiaphragmatic abscess [B.V. Petrovsky et al., 1966]. Sometimes, under the influence of adhesions, surgery, or in cases where pus, pushing apart the tissues, finds new containers, an indefinite, atypical location of the subdiaphragmatic abscess is observed.

A “median subdiaphragmatic abscess” is identified, which develops after resection of the stomach and borders on the right and back with the left lobe of the liver, with the stump of the stomach, below with the mesentery of the transverse OK and in front with the anterior abdominal wall. There is also a retroperitoneal subphrenic abscess, in which pus accumulates very high, between the extra-abdominal part of the liver and the diaphragm, as well as between the layers of the coronary ligament of the liver, forming the so-called extraperitoneal central subphrenic abscess; they make up from 2 to 18% of the number of all subphrenic abscesses, differing in their unique clinical picture [D.P. Chukhrienko and Ya.S. Bereznitsky, 1976].

The frequent right-sided localization of subphrenic abscess is explained by more favorable anatomical and topographic conditions for delimiting the suppurative process in this particular part of the abdominal cavity, as well as the location on the right of the organs in which pathological processes most often lead to the development of this postoperative complication. The direction of OK peristalsis is also important, especially the circulation of intra-abdominal fluid, its entry into the gap between the liver and the diaphragm during respiratory movements [O.B. Milonov et al, 1990].

The ratio of right-sided and left-sided localizations is 3:1 [V.S. Shapkin, Zh.L. Grinenko, 1981; A. Viburt et al, 1968]. In recent years, left-sided subdiaphragmatic abscesses have become noticeably more frequent. This is explained by a change in the nature of surgical interventions on the stomach and an increase in their number, as well as the frequency of acute postoperative pancreatitis [M.I. Kuzin et al., 1976, etc.]. According to V.I. Belogorodsky (1973), this figure is 0.07%, according to O.B. Milonova et al. (1990) - 0.12%.

Data on the frequency of subdiaphragmatic abscess are directly dependent on the profile of the medical institution, the composition of patients, the volume of surgical interventions, the proportion of emergency pathology and oncological diseases. For example, if the data of M.I. Kuzina et al. consider differentiatedly, it turns out that after oncological operations on the stomach, a subdiaphragmatic abscess occurs in 2.2% of patients, after gastric resection for gastric ulcer - in 0.9%, after surgery on the biliary tract - in 0.2%, after allendectomy - in 0.1% of patients.

Mortality with subdiaphragmatic abscess varies within a fairly wide range - 10.5-54.5% [v.M. Sapozhnikov, 1976; V. Halliday, 1976]. It depends on a timely diagnosis, type of surgical intervention, intensity of anti-inflammatory and antibacterial therapy. Of course, one cannot ignore the surgeon’s experience in treating this very serious postoperative complication [M.I. Kuzin et al., 1976; I'M WITH. Bereznitsky, 1986].

In reducing mortality, the following is of great importance:
1) timely, before the development of secondary complications, clinical and radiological diagnosis of abscesses, which allows for early surgery;
2) the use of predominantly non-serous methods of drainage of purulent cavities;
3) transition from open management of opened abscesses under tampons to closed management, allowing flow-aspiration washing of purulent cavities;
4) application of a set of measures for the prevention and treatment of combined and secondary thoracoabdominal complications.

Etiopathogenesis. In most cases (81.7% of patients), a subdiaphragmatic abscess occurs after operations for diseases of the esophagus, stomach, duodenum, pancreas, gallbladder and extrahepatic bile ducts (Ya.S. Bereznitsky, 1986; O.B. Milonov et al, 1990 ] Less commonly, subphrenic abscess develops after surgery on the intestines (6.1%), as well as those performed for abdominal trauma (6.6%) and other diseases (5.6%).

Subdiaphragmatic abscess often occurs after operations for destructive forms of appendicitis, cholecystitis, perforated gastroduodenal ulcers, acute purulent and hemorrhagic pancreatitis [CD. Toskin and V.V. Zhebrovsky, 1986]

Complications are equally common in both sexes. Among the patients, elderly and senile people predominate. Predisposing factors for abscess formation are considered to be neglect of acute surgical diseases of the abdominal organs and complicated long-term course of chronic diseases [K.D. Toskin and V.V. Zhebrovsky, 1986; I'M WITH. Bereznitsky, 1986]. The most important factor predisposing to the development of subdiaphragmatic abscess should be considered inhibition of systemic and immunological reactivity [Ya.S. Bereznitsky, 1986].

Very rarely, a subdiaphragmatic abscess occurs as a result of hematogenous or lymphogenous spread of infection from any individual focus. Even more rarely, the suppurative process spreads into the subphrenic space from the pleural cavity.

A bacteriological study of the microflora of pus reveals various types of microorganisms and their associations, most often Escherichia coli, Staphylococcus aureus and white staphylococcus, anaerobic flora [O.B. Milonov et al., 1990].

In our opinion, in a significant proportion of cases, a subdiaphragmatic abscess develops, passing through the stage of subdiaphragmatic peritonitis. During operations on the stomach, gastrointestinal tract, and perforations of these organs, infection of the peritoneum within the subphrenic space occurs at varying rates. As a result, limited widespread subdiaphragmatic peritonitis often develops, which in the future may have a different course and different outcome [A.K. Shilov, 1969].

Subdiaphragmatic peritonitis can be serous, end in recovery, or go to the next stage - become fibrinous-purulent, which, in turn, can develop into a septic focus and form into a subdiaphragmatic abscess.

The walls of neighboring organs, areas of the diaphragm adjacent to the abscess, and the greater omentum take part in the formation of the inflammatory infiltrate during a subphrenic abscess. The formed abscess usually has a connective tissue capsule. About 15-35% of subphrenic abscesses contain gas [D.P. Chukhrienko, Ya.S. Bereznitsky, 1976, 1986]. A subphrenic abscess can cause a number of intra-abdominal complications. These include: perforation into the abdominal cavity, diffuse peritonitis, perforation through the abdominal wall to the outside, etc.

The high frequency of intrathoracic complications (pleurisy, pleural empyema, bronchopulmonary fistula (Figure 16), pericarditis, mediastinal abscess, pneumonia, pneumothorax, lung abscess) allows us to consider subphrenic abscess a thoracoabdominal pathology [Ya.S. Bereenitsky, 1986; ABOUT. Milonov et al., 1990].

Figure 16. Anastomosis between the abscess cavity and the bronchial tree

The symptomatology of subphrenic abscess is very diverse. It is characterized by two groups of symptoms - general and local. This complication develops acutely (usually within 3-10 days) and is accompanied by pronounced general phenomena or, as they also call it, early signs: general weakness, loss of strength, fatigue, deterioration of condition, tachycardia, shortness of breath, persistent increase in temperature, increased breathing, change blood pictures (leukocytosis, shift of the leukocyte formula to the left). Later, scleral hysteria, effusion in the pleural cavity, and icteric coloration of the skin appear. The latter has more prognostic than diagnostic value. Typically, symptoms depend mainly on intoxication of the body. A very constant symptom is increased heart rate up to 120 beats/min. This indicates a high degree of intoxication, representing a formidable phenomenon.

The initial stage often manifests itself as a clinical picture of pleurisy or lower lobe pneumonia.
Local symptoms are characterized by pain in the upper abdomen and lower chest, constant pain in the hypochondrium, aggravated by deep breathing, bloating, high fever with chills.

Body temperature can be of three types: constantly high, hectic and intermittent. A constantly high temperature (38-40 °C) indicates the most severe course of the abscess, which is large in size and not sufficiently limited by the capsule. Often this temperature is periodically accompanied by chills. At the hectic temperature, which is observed most often, the daily temperature range reaches 2 °C [M.I. Kuzin et al, 1976].

Some patients experience intermittent fever, in which low-grade fever alternates with a higher temperature. This is usually observed in cases where, against the background of massive antibacterial and multidrug therapy, the complication develops very slowly and covertly. The temperature reaction is absent mainly in severely weakened patients receiving large doses of antibiotics and corticosteroids [O.B. Milonov et al., 1990]. The pulse usually corresponds to the temperature.

The pain is non-localized, and therefore the leading symptom is persistent postoperative intestinal paresis, which is interpreted as early adhesive NK. Abdominal pain (usually moderate) radiates to the shoulder girdle, scapula and collarbone, sometimes, depending on the location of the abscess, to the lower back and costal arch [D.P. Chukhrienko, 1976]. The abdominal wall, especially its upper sections (epigastric region), does not participate in respiratory movements.

Increases and fluctuations in temperature are inconsistent symptoms. However, there is usually no very high temperature with a subdiaphragmatic abscess. More often, it fluctuates within 37.5-38.5 "C. A rather early and pathognomonic sign is a change in breathing. With a subphrenic abscess, excursion of the diaphragm is painful; breathing is shallow, the patient, as if for fear of causing an excursion of the diaphragm, tries to hold his breath , therefore, there is a lag of the affected half of the chest during respiratory movements.The detection of the frenicus symptom of pain with pressure between the legs of the sternocleidomastoid muscle is also characteristic.

There is pain along the IX-XI intercostal spaces. One of the early symptoms of a subphrenic abscess is hiccups caused by irritation of the branches of the phrenic nerve. If the diaphragm is immobile and the process is limited, vomiting and belching are possible. For this reason, some patients develop moderate respiratory failure. The temperature later becomes hectic. Sometimes patients complain of nagging pain in the right half of the chest and epigastric region, radiating to the neck. The pain intensifies when changing position. Gradually all the signs of a catastrophe appear in the upper floor of the abdominal cavity.

Signs of severe intoxication are revealed: pale skin, pointed facial features and feverish shine in the eyes. Consciousness is usually preserved, as with any purulent infection, agitation, delirium, and hallucinations may be observed. This complication develops gradually. On days 3-10 after surgery, instead of the expected improvement in general condition, deterioration occurs. The patient complains of general weakness, malaise, constant pain in the upper abdomen, a feeling of pressure or heaviness, and fever. The pain intensifies with movement or coughing (cough symptom) and radiates to the shoulder and shoulder blade. The pain in the shoulder joint in some patients is so intense that it deprives them of sleep. Often the onset of development of a subdiaphragmatic abscess is masked by the symptoms of the underlying disease.

Postoperative subphrenic abscess develops slowly and is therefore diagnosed late. The expected improvement in the patients' condition does not occur. The temperature does not decrease, sometimes, on the contrary, it even increases. The pulse quickens, the pain in the lower chest intensifies. Deterioration is often mistaken for a pulmonary complication (especially since reactive pleurisy is often observed with RI).

When the abscess is localized in the anterioinferior space, symptoms characteristic of damage to the abdominal organs predominate, and in the area of ​​the dome of the diaphragm - the thoracic one. The general condition of the patients is different. With prolonged formation of a subdiaphragmatic abscess, the patient usually experiences increasing weakness, sleep and appetite are disturbed. The temperature, as a rule, rises, acquiring a hectic character.

When examined, the patient is usually inactive, trying to lie on his back or on the side where the abscess is located, with his hips adducted. The patient takes this forced position due to increased pain with physical exertion and deep breathing. Patients avoid unnecessary movements. When examining the chest, smoothness of the intercostal spaces, expansion of the intercostal spaces and their protrusion at the site of the abscess are noted, which is observed with a significant accumulation of pus. However, this rare symptom, first described by Lezhar, is observed only in very advanced cases, with large accumulations of pus in the subphrenic space [B.V. Petrovsky et al, 1965). Sometimes, when examining the chest in thin subjects, one can see retraction of the intercostal spaces during deep inspiration (Litgen's sign).

Note that the lower parts of the chest and upper parts of the abdomen on the affected side lag behind when breathing. During examination of the abdomen (especially with subhepatic abscesses), characteristic symptoms are observed: swelling in the hypochondrium, paradoxical movement (“paradoxical breathing”) of the abdominal wall (the epigastric region, unlike the norm, retracts when inhaling and, conversely, protrudes when exhaling - a symptom Duchenne). On palpation of the abdominal wall and lower half of the chest, pain is noted and, accordingly, localization of the abscess and muscle tension. Palpation from behind reveals pain in the area of ​​the costal arch (IX-XI ribs) and intercostal spaces.

Note that a valuable sign is point pain in the intercostal space at the edge of the costal arch, and this symptom can be considered the leading one, especially with regard to the localization of the inflammatory focus.
Valuable instructions are given by hiccups - the result of a reflex of the inflamed peritoneum. It usually begins on the first or second, sometimes on the third day after surgery. This symptom is one of the earliest in cases of slowly developing postoperative subphrenic abscess.

Chest symptoms are more often observed when the abscess is located directly under the diaphragm. The first and important symptom of a subdiaphragmatic abscess is pain along the edge of the costal arch (usually on the right), ribs and intercostal area (Kryukov’s symptom) upon palpation and pressure. An area of ​​pain in the neck, scapula, and shoulder joint, an area of ​​hyperesthesia in the area of ​​the right shoulder girdle (Belogorodsky’s symptom), percussion accumulation of gas (Deve’s symptom), the presence of fluid in the pleural cavity (reactive pleurisy—Grekhov-Overholt symptom), a dry painful cough ( Troyanov's symptom), an area of ​​clear pulmonary sound along the right edge of the sternum (Trivus's symptom), Bokuradze's symptom (pain on palpation of the smoothed intercostal spaces on the affected side), displacement of the border of the heart.

It is necessary to be able to identify liver balloting (Jaure's symptom). The surgeon places one hand on the area of ​​the right hypochondrium, the other makes jerking movements in the subscapular area. In some patients, a clear asymmetry of the chest (Langenbuch's symptom) and a tilt of the torso forward and towards the affected side (Senator's symptom) are detected. Also characteristic is a shortening of the percussion sound under the lower edge of the lung at the upper limit of dullness on inspiration (Leiden's symptom).

Abdominal symptoms are more often observed with low localizations of the subphrenic abscess: pain and limited tension in the muscles of the anterior abdominal wall, palpable or visible protrusion in the hypochondrium and upper abdomen. On the affected side, the presence in the wall of the right half of the abdomen of a transverse shaft of a thickened edge of a descending abscess, bloating, and dyspeptic disorders are noted. If the abscess is located under the diaphragm, the abdomen is usually soft upon palpation, but the liver is displaced downwards. Noticeable tension in the muscles of the abdominal wall and sharp pain are constant signs of subhepatic abscesses.

If the phenomena of local peritonitis are not pronounced, then palpation often reveals a dense painful infiltrate. On percussion, the classic symptom of a gas-containing subdiaphragmatic abscess complicated by exudative pleurisy is Barlow's phenomenon, in which a clear pulmonary sound heard upward along the midaxillary line is successively replaced downward by zones of dull tympanic sound (Figure 17). This phenomenon has diagnostic value only for large gas-containing abscesses [O.B. Milonov et al., 1990].

Figure 17. Alternation of percussion sound in a patient with subdiaphragmatic abscess (scheme according to B.L. Ospovat)

Auscultation in the initial stages of pleurisy can listen to the friction noise of the pleura, which, when fluid appears in the costophrenic sinus, is replaced by the absence of respiratory sounds in the lower parts of the lung. In the remaining sections, harsh breathing occurs with increased vocal tremors and varied wheezing.
It must be remembered that all of the above symptoms are not pathognomonic for a subphrenic abscess. Each of them separately can be observed in various diseases of the chest and abdominal organs. Only when they are combined, as well as based on the results of additional studies, should a correct diagnosis be made.

We distinguish between early and late signs of subphrenic abscess. Early symptoms include: fever, persistent intestinal paresis, difficulty breathing, fatigue, changes in white blood (leukocytosis, shift of the leukocyte formula to the left), the appearance of effusion in the pleural cavity; to late - swelling of the subcutaneous tissue of the lumbar region, positive Kryukov and Barlow's sign.

Late diagnosis of subdiaphragmatic abscess leads to a delay in surgical intervention and is the cause of high mortality, which is 10.5-15.4% [V.M. Belogorodsky, 1964; M.I. Kuzin et al, 1976].

The clinical picture of the complication can sometimes be atypical and smoothed. The pain can be non-localized; in this regard, the leading symptom is persistent postoperative intestinal paresis, interpreted as early adhesive NK. Delayed diagnosis is facilitated, as already noted, by the small number of reliable clinical signs, sometimes their masking in a complex clinical picture.

However, based on such signs as pain on palpation in the epigastric region and in the hypochondrium, tension of the abdominal wall in these areas in the absence of it in other parts of the abdominal cavity, point tenderness in the intercostal space at the edge of the arch, painful load on the lower ribs, pain when coughing, fever, pleurisy, decreased breathing, increased heart rate, leukocytosis, increased ESR, hiccups, etc., in most cases a diagnosis can be made.

Diagnosis is also helped by blood LI data, which always reveals pronounced leukocytosis with a shift of the leukocyte formula to the left and toxic granularity of leukocytes. Most patients experience hylochromic anemia due to a decrease in the number of red blood cells and a decrease in hemoglobin. There are also pronounced disturbances in biochemical processes, manifested in changes in the activity of enzyme systems, the main of which are changes in indicators characterizing the proteolytic activity of the blood (trypsin and its inhibitors), lysosomal enzymes (cathepsin D, acid phosphatase), enzymes characterizing the aerobic and anaerobic pathways of transformation glucose [O.B. Milonov et al., 1990].

The main research method in the diagnosis of subdiaphragmatic abscess is x-ray. The direct radiological signs of a subdiaphragmatic abscess, which are of decisive importance, include the presence of gas above a horizontal fluctuating liquid level. However, it should be remembered that ulcers do not always contain gas; in addition, the presence of gas under the diaphragm after laparotomy can be a source of diagnostic error.

When an abscess is localized on the left, the doctor may be misled by a gas bubble in the stomach or its stump. In this case, a sip of barium sulfate helps to correctly assess this sign [O.B. Milonov et al, 1990]. When interposition of the OK between the liver and the abdominal wall, gas is also observed under the diaphragm, which may cause an erroneous conclusion. A subphrenic abscess that does not contain gas is characterized by an enlarged liver shadow and blurred contours. For these reasons, these signs make it possible to determine a subdiaphragmatic abscess in some patients (25-30%) [G.N. Zakharova et al., 1985].

If the clinical picture of a subdiaphragmatic abscess is erased, a complex of x-ray examinations is carried out in horizontal and vertical positions of the patient, and, if necessary, x-rays in the later position with contrast of the stomach and duodenum.

Despite the serious condition of the patient, RI should be performed in a vertical position, since photographs taken in a horizontal position are usually less informative. However, if the patient’s condition still does not allow the study to be performed in a vertical position, it must be carried out in a horizontal position, both in direct projection and in later positions. Note that the effectiveness of RI increases with repeated polypositional examination of the chest and abdominal cavities until the cause of the complicated course of the postoperative period is established. RI often has to be repeated several times.

With a non-gas subdiaphragmatic abscess, indirect radiological signs are noted on the radiograph, such as thickening, blurred contours of the dome of the diaphragm, as well as high standing, sharp limitation or almost complete immobility of its affected side, sympathetic (reactive) effusion pleurisy, “cellularity” of the subdiaphragmatic space, atelectasis of the basal segments, discoid collapse of the lungs, lower lobe pneumonia, enlargement of the liver shadow with a downward displacement of the transverse OC, an area of ​​continuous darkening under the diaphragm, changes in the position of neighboring organs, flatulence [I.L. Rabkin et al, 1973].

To detect subphrenic abscess, especially in the early stage, radioisotope radionuclide methods, scintigraphic examination, and simultaneous scanning of the liver and lungs are used. For this purpose, macroaggregate albumin labeled with 131 J is used [V.N. Baranchuk, 1975], 67 Ca citrate [N. Cattee et al., 1977], and leukocytes labeled with 111 J [B. Colleman et al, 1960].

In this case, an isotope-free zone appears between these organs [V.P. Kryshin, 1980; R. White, 1972]. An increase in the distance between them suggests the presence of an abscess under the liver, although the same picture is observed with lower lobe pneumonia, exudative pleurisy and other diseases.

For diagnostic purposes, sonographic, infrared thermographic, laparoscopic, and angiographic research methods are widely used. CT is very effective in identifying subphrenic abscess, especially in early diagnosis [EL. Berseneva, 1984; E.L. Bazhenov, 1986; R. Kochler, 1980; M.L. Meyers, 1981]. It provides especially useful information in cases where it is impossible to confidently exclude a purulent complication based on available indirect radiological signs and data from other research methods (ultrasound); if necessary, a detailed description of the abscess identified using traditional RI, its exact localization, relationship with neighboring organs, as well as determining the optimal surgical access; to exclude possible multiplicity of lesions. CT, being a very effective method, allows you to identify both small abscesses and large gasless subdiaphragmatic abscesses that are not recognized using traditional X-ray, as well as establish the exact location, size, relationship of the abscess with vital organs, which is of serious importance when determining tactics surgical treatment.

On CT, a subdiaphragmatic abscess is defined as soft tissue, in most cases inhomogeneous formations in the upper sections, in which irregularly shaped gas bubbles are visible.

When the infiltrate or abscess is localized in the right postero-superior and anterosuperior and left upper parts of the subdiaphragmatic space, characteristic changes are noted in the adjacent zone between the abdominal and thoracic cavities, in the tissue, muscles, as well as in the liver and kidney of the corresponding side [D.I. Krivitsky et al, 1990].
Ultrasound detection of acute subdiaphragmatic abscess is associated with certain difficulties. The thin wall of the abscess is not clearly differentiated from the surrounding tissue. The thickened and compacted wall of a chronic abscess is more echogenic. Clear identification of gas in the abscess cavity is difficult due to the uniform echogenicity of the intestinal gas layering on this area.

Infrared thermography reveals a focus of sharply increased infrared radiation with clear boundaries and a homogeneous structure, corresponding to the projection of the inflammatory focus.

The use of liquid crystal thermography in dynamics reveals “hot” zones of blue luminescence of the inflammatory-infiltrative process; a green-violet glow on a red-brown background characterizes abscess formation; a “cold” zone in the projection of an encysted abscess indicates the formation of a limited cavity.

To clarify the diagnosis of “subphrenic abscess,” hepatoangiography is performed. In this case, the “avascular zone” of the gap between the liver and the diaphragm or the infiltrated lobe of the lung is determined [V.S. Shapkin, JA. Grienko, 1981].

During laparoscopy, the condition of the liver, subhepatic space, the presence or absence of adhesions between the upper surface of the liver and the diaphragm, the presence and nature of effusion or its absence are assessed.
The final diagnostic method when there are difficulties in diagnosing a subdiaphragmatic abscess is its targeted puncture. It is carried out under the control of fluoroscopy, CT or ultrasound. The puncture is made with a thick needle in the tenth intercostal space along the mid-axillary line from below towards the vertebral bodies, taking the necessary precautions, since there is a risk of damage to the lung, liver, spleen or other organs.

The presence of an abscess is indicated by pus. If it is absent, the patient should be placed in an inclined position, while measuring the ratio of pus and gas bubble. After obtaining pus, the abscess is opened without removing the needle. If there is no pus, then the needle is removed with constant discharge in the syringe (risk of infection of the pleural cavity).

During puncture, two main conditions are observed:
1) be ready for immediate surgery;
2) based on sufficient experience in performing a puncture, the surgeon must clearly understand all possible dangers [B.V. Petrovsky, 1976].

Prevention of the development of subdiaphragmatic abscess consists of gentle surgery, good hemostasis, timing of the operation, and correct implementation of surgical techniques during surgical interventions on the abdominal organs. Rough handling of tissues should be avoided, leading to disruption of the peritoneal endothelium, leaving blood clots, hematomas as a good breeding ground for microorganisms, thorough treatment of the abdominal cavity, and intensive antibacterial therapy.

Treatment of postoperative subdiaphragmatic abscess is sometimes carried out with multiple punctures under the control of ultrasound echography and CT. Repeated punctures of abscesses allow, in addition to therapeutic measures (evacuation of pus, washing of the abscess cavity with solutions of antiseptics and antibiotics, drainage of the abscess cavity with silicone tubes) to also conduct a bacteriological examination of the pus [F.I. Todua, M.Yu. Vilyavin, 1986, etc.].

For small abscesses with a diameter of up to 3-4 cm, microdrainage is used according to the Seldinger method. For large subphrenic abscesses, transthoracic Monaldi drainage is used with the introduction of silicone drains with an outer diameter of 5-10 mm into the abscess cavity. In some cases, drainage followed by sanitation of the abscess cavity and rational antibacterial therapy can achieve a cure for patients. However, it should be noted that during puncture there is a high risk of infection of the pleural cavity. In addition, there is no confidence in complete evacuation of pus.

Sometimes the abscess cavity has a rather complex structure, part of it can be laced off with adhesions, and then some reduction in intoxication under the influence of punctures and antibacterial therapy can be regarded as a positive effect of treatment. Some prospects for conservative therapy appeared after the Kanshin method began to be used in the treatment of closed abscesses (Figure 18), the principle of which is to combine constant irrigation of the abscess cavity with antibacterial agents with constant active aspiration. Only the surgical method is recommended for a wide range of practical surgeons.

Figure 18. Drainage of ulcers according to H.H. Kanshin

The prognosis of this complication, in addition to the timeliness of diagnosis, also depends on rational surgical access, the correct choice of drainage method, complete antibacterial, desensitizing, detoxification and restorative therapy [Ya.S. Bereznitsky, 1986]. The operation is performed under endotracheal anesthesia (the patient must lie on the healthy side with a bolster under the lumbar region so that “scoliosis” of the lower part of the thoracic and lumbar spine is formed).

Surgical approaches to subphrenic abscess are determined by their location. All proposed approaches can be divided into four groups: transpleural, extrapleural, extrapleural-extraperitoneal and transperitoneal. Most authors prefer the intra-abdominal Lauenstein-Clermont approach, especially in cases where there are multiple abdominal abscesses, when the midline location of the abscess is noted (Figure 19).

Figure 19. Drainage of subphrenic abscesses according to Lauenstein-Clermont:
1 - cut line; 2 - abscess cavity; 3 - liver; 4 - fascia; 5 - parietal peritoneum

Figure 20. Lumbar extraserous approach to the subphrenic abscess according to Melnikov:
a — dissection of the periosteum above the XII rib: b, c — mobilization of the rib; d — subperiosteal resection of the rib

Figure 21. Transpleurodiaphragmatic approach:
a — subphrenic abscess is localized between the diaphragm and the dome of the liver; b - wound after resection of the OS of the rib, suturing of the pleural layers and drainage

Through the bed of the 11th rib, access to these abscesses is quite difficult and may be less effective for postoperative drainage. After resection of the ribs, a puncture of the subphrenic space is performed with a thick needle and, after obtaining pus, without removing the needle, the abscess is opened using the needle. If the costophrenic sinus of the pleura interferes with the dissection of the diaphragm, the surgeon bluntly mobilizes it upward.

After evacuation of the pus with an electric suction, the abscess cavity is examined with a finger, washed with a furatsilin solution and drained with a double-lumen tube.

If this fails or the sinus is damaged, then the layers of the costal and diaphragmatic pleura should be sutured above the future incision of the diaphragm. Then, in the center of the ellipse formed by the sutures, the pleura and diaphragm are dissected. In cases where the sinus can be mobilized upward or is completely obliterated, the diaphragm is incised without preliminary suturing. The diaphragm is carefully dissected to the peritoneum.

Before opening the abscess, the upper edge of the crossed diaphragm is sutured to the muscles of the upper edge of the chest wound, which makes it possible to further isolate the pleural cavity and restore the attachment of the damaged diaphragm. Next, the abscess is opened along the entire length of the wound. When opening an abscess, lavage of the abdominal cavity is performed from the upper-median laparotomy access.

If necessary, a counter-aperture is made at the lowest level of the abscess, departing from the first incision by 5-6 cm or more along the costal arch towards the axillary line. The presence of a counter-aperture significantly improves the outflow of content. Extrapleural approaches are well tolerated by patients, as they are not accompanied by breathing problems.

Abscesses located in the right anterosuperior, right lower, left anterior-inferior and left upper sections under the diaphragm can also be drained through the anterior abdominal wall; an incision is made 3 cm above the costal edge and parallel to it through the abdominal muscles and transverse fascia to the anterior parietal peritoneum. The parietal peritoneum is separated from the lower surface of the diaphragm. The peritoneum is mobilized until the abscess cavity is reached. The cavity is opened extraperitoneally and drained with tubes.

Peritoneal surgical access to abscesses of the upper half of the abdomen is used mainly in cases of unclear localization, when they are multiple and accidentally detected during radiotherapy for other complications.

Cleaning the abscess cavity from pus and necrotic masses is performed with caution so as not to cause severe capillary bleeding. Since several abscesses may form in the subdiaphragmatic space, it is necessary to conduct an intraoperative examination. Sometimes these abscesses communicate with each other, so it is appropriate to perform “abscessography” on the operating table after removing the pus.

Often, an x-ray can reveal the presence of other communicating cavities, which dictates the need for additional drainage through a counter-aperture, followed by rinsing with antibacterial solutions. After opening the abscess, pus or exudate should be collected for bacteriological examination. To wash the abscess cavity, first use a 3% solution of hydrogen peroxide, then other antiseptic liquids. In the fight against both aerobic and anaerobic non-clostridial infection, solutions of furatsilin, furagin, chlorhexidine, dioxidine are considered the most effective [A.T. Tyshko et al, 1984].

It is advisable to drain the abscess cavity with 2-3 polyethylene tubes. It is better to introduce drainage through small counter-apertures. The main laparotomy incision is sutured tightly for prophylactic purposes, to avoid suppuration of the postoperative wound and the possibility of eventration. Drains are replaced 6-7 days after surgery; covered with mucus, they come out easily. Drainage of the cavity should be carried out until complete obliteration, achieving its completion by granulation from the depths (open method). With a closed method of treatment, the purulent cavity is drained with two- or single-channel tubes that can provide flow-aspiration sanitation. The tubes are removed through separate punctures outside the wound, which is sutured tightly.

If, in addition to the subdiaphragmatic abscess, patients also have abscesses of other localization, RL is performed and the abscess cavity is drained through an incision and counter-aperture made below the costal arch along the posterior axillary line. In this case, the tube is located at the coronary ligament of the liver (the most sloping place when the patient is lying down). In the postoperative period, the abscess cavity is washed with a solution of antibiotics and nitrafuran drugs.

When abscesses with bilateral localization develop simultaneously, first of all, an abscess of large size or, as a rule, containing gas is detected. If, after opening the abscess on one side, the patient continues to have a fever, leukocytosis persists, and the leukocyte count shifts to the left, this forces one to look for another source of intoxication and leads to the recognition of an abscess of another location. In the postoperative period, multicomponent treatment is carried out: antibacterial therapy, restorative treatment, administration of low-molecular dextrons, vitamins, heart medications, protein drugs, detoxification (hemodesis, polydesis) of glucose with insulin and correction of immunity.

- a local abscess formed between the dome of the diaphragm and the adjacent organs of the upper abdominal cavity (liver, stomach and spleen). Subphrenic abscess is manifested by hyperthermia, weakness, intense pain in the epigastrium and hypochondrium, shortness of breath, and cough. Examination of the patient, fluoroscopy data, ultrasound, CT, and general blood test are of diagnostic importance. To completely cure a subdiaphragmatic abscess, surgical opening and drainage of the abscess is performed, and antibacterial therapy is prescribed.

Subphrenic abscess is a relatively rare, but very serious complication of purulent-inflammatory processes in the abdominal cavity. The subphrenic abscess is located mainly intraperitoneally (between the diaphragmatic layer of the peritoneum and adjacent organs), rarely in the retroperitoneal space (between the diaphragm and the diaphragmatic peritoneum). Depending on the location of the abscess, subphrenic abscesses are divided into right-sided, left-sided and median. The most common are right-sided subdiaphragmatic abscesses with anterosuperior localization.

The shape of a subdiaphragmatic abscess can be different: more often - round, when it is compressed by organs adjacent to the diaphragm - flat. The contents of the subdiaphragmatic abscess are pus, sometimes mixed with gas, less often gallstones, sand, and feces.

A subphrenic abscess is often accompanied by the formation of pleural effusion; when large, it exerts pressure to varying degrees and disrupts the functions of the diaphragm and neighboring organs. Subphrenic abscess usually occurs in 30-50 year old patients, with men being 3 times more likely than women.

Causes of subphrenic abscess

The main role in the occurrence of subphrenic abscess belongs to aerobic (staphylococcus, streptococcus, Escherichia coli) and anaerobic non-clostridial microflora. The cause of most cases of subdiaphragmatic abscess is postoperative peritonitis (local or diffuse), which developed after gastrectomy, gastrectomy, suturing of a perforated gastric ulcer, splenectomy, pancreatic resection. The development of a subdiaphragmatic abscess is facilitated by the occurrence of extensive surgical tissue trauma, disruption of the anatomical connections of the organs of the subdiaphragmatic space, anastomotic failure, bleeding, and immunosuppression.

Subphrenic abscesses can occur as a result of thoracoabdominal injuries: open (gunshot, stab or cut wounds) and closed (bruises, compression). Hematomas, an accumulation of leaked blood and bile formed after such injuries, suppurate, encysted and lead to the development of a subdiaphragmatic abscess.

Among the diseases that cause the formation of a subphrenic abscess, the leading role is played by inflammatory processes of the abdominal organs (abscesses of the liver, spleen, acute cholecystitis and cholangitis, pancreatic necrosis). Less commonly, a subphrenic abscess complicates the course of destructive appendicitis, salpingo-oophoritis, purulent paranephritis, prostatitis, festering echinococcal cyst, retroperitoneal phlegmon. The development of a subphrenic abscess is possible with purulent processes in the lungs and pleura (empyema of the pleura, lung abscess), osteomyelitis of the lower ribs and vertebrae.

The spread of purulent infection from foci of the abdominal cavity into the subdiaphragmatic space is facilitated by negative pressure under the dome of the diaphragm, which creates a suction effect, intestinal motility, and lymph flow.

Symptoms of subphrenic abscess

In the initial stage of a subdiaphragmatic abscess, general symptoms may be observed: weakness, sweating, chills, remitting or intermittent fever, which are also characteristic of other abdominal abscesses (interintestinal, appendicular, abscess of the pouch of Douglas, etc.)

A subphrenic abscess is characterized by a feeling of heaviness and pain in the hypochondrium and lower part of the chest on the affected side. The pain can have varying intensity - from moderate to acute, intensifies with active movement, deep breathing and coughing, and radiates to the shoulder, scapula and collarbone. Hiccups, shortness of breath, and a painful dry cough also appear. Breathing is rapid and shallow, the chest on the side of the abscess lags behind when breathing. A patient with a subphrenic abscess is forced to take a semi-sitting position.

Diagnosis of subphrenic abscess

Detection of a subdiaphragmatic abscess becomes easier after it has fully matured. For the purpose of diagnosis, data from the patient's history and examination, the results of X-ray, ultrasound, laboratory tests, and CT are used.

Palpation of the upper abdomen with a subphrenic abscess shows pain and muscle tension of the abdominal wall in the epigastric region or in the hypochondrium. Smoothness and widening of the intercostal spaces, protrusion of the subcostal region are revealed, and with a right-sided abscess - enlargement of the liver.

If the subphrenic abscess does not contain gas, chest percussion reveals dullness of sound above the border of the liver, decreased or absent mobility of the lower edge of the lung. When gas accumulates in the cavity of the subphrenic abscess, areas of different tones (“percussion rainbow”) are revealed. On auscultation, a change in breathing is observed (from weakened vesicular to bronchial) and a sudden disappearance of breathing sounds at the border of the abscess.

Laboratory blood tests show changes characteristic of any purulent processes: anemia, neutrophilic leukocytosis with a shift in the leukocyte formula to the left, an increase in ESR, the presence of C-reactive protein, dysproteinemia.

The main importance in the diagnosis of subdiaphragmatic abscess is given to radiography and fluoroscopy of the chest. A subdiaphragmatic abscess is characterized by changes in the area of ​​the legs of the diaphragm, a higher position of the dome of the diaphragm on the affected side and limitation of its mobility (from minimal passive mobility to complete immobility). The accumulation of pus in gasless subdiaphragmatic abscesses is visible as a darkening above the line of the diaphragm, the presence of gas is visible as a clearing strip with a lower horizontal level between the abscess and the diaphragm. There is effusion in the pleural cavity (reactive pleurisy), a decrease in the airiness of the lower parts of the lung.

MSCT and ultrasound of the abdominal cavity can confirm the presence of fluid, pus and gas in the abdominal or pleural cavity, changes in the position and condition of adjacent internal organs (for example, deformation of the stomach, displacement of the longitudinal axis of the heart, etc.). Diagnostic puncture of an abscess is permissible only during surgery.

Subphrenic abscess is differentiated from gastric ulcer, peptic ulcer 12p. intestines, purulent appendicitis, diseases of the liver and biliary tract, festering echinococcus of the liver.

Treatment of subphrenic abscess

The main method of treating subphrenic abscess in operative gastroenterology is surgical opening and drainage of the abscess.

Surgery for subphrenic abscess is performed via transthoracic or transabdominal access, which allows for adequate conditions for drainage. The main incision is sometimes supplemented with a counter-aperture. The subphrenic abscess is slowly emptied and its cavity is inspected. To quickly cleanse a subdiaphragmatic abscess, the method of supply-aspiration drainage with double-lumen silicone drains is used.

The complex treatment of subphrenic abscess includes antibacterial, detoxification, symptomatic and restorative therapy.

Forecast and prevention of subphrenic abscess

The prognosis of a subphrenic abscess is very serious: the abscess can break into the abdominal and pleural cavities, the pericardium, break out, and be complicated by sepsis. Without timely surgery, complications in 90% of cases lead to the death of the patient.

The formation of a subphrenic abscess can be prevented by timely recognition and treatment of inflammatory pathology of the abdominal cavity, exclusion of intraoperative injuries, thorough sanitation of the abdominal cavity during destructive processes, peritonitis, hemoperitoneum, etc.

A subphrenic abscess is an abscess that forms in the subdiaphragmatic space, which is located in the upper abdominal cavity, on the right - between the lower surface of the diaphragm and the upper surface of the liver, and on the left - between the lower surface of the diaphragm, the stomach and the spleen.

Essentially, a subphrenic abscess is one of the types of limited or encysted peritonitis, i.e., it is a secondary disease that complicates the course of a primary disease, most often located in the abdominal cavity. In most cases, right-sided subphrenic abscesses are observed.

Subphrenic abscess causes. The cause of these abscesses is the spread of a purulent-infectious process into the subdiaphragmatic space from neighboring organs: the stomach (with a perforated ulcer), the vermiform appendix (with appendicitis), the liver (with an abscess), the bile ducts (with cholecystitis), the spleen (with its abscesses) , with purulent pleurisy, some penetrating wounds of the abdominal cavity or operations on its organs.

The spread of the purulent process occurs either directly through the flow of pus from the primary focus, or through the lymphogenous route. It should be borne in mind that one of the most common causes of the appearance of a subdiaphragmatic abscess is acute appendicitis, and in these cases the subdiaphragmatic abscess usually appears 2-3 weeks after the onset of appendicitis. When an abscess develops in the subphrenic space, pus gradually pushes the diaphragm upward and the liver downward.

Subphrenic abscess signs and symptoms: pain and a feeling of pressure in the right (or left) half of the upper abdomen or lower chest, often hiccups, high temperature with large fluctuations, chills and sweats, sometimes a general severe condition, leukocytosis. However, in many cases, the onset of abscess formation and its course may be less acute and with less noticeable signs.

With large subphrenic abscesses, shortness of breath, smoothing of the intercostal spaces and lag of the affected side when breathing, and some downward displacement of the liver are observed. When tapping in the lower part of the chest, dullness is detected, and when listening - weakened or bronchial breathing, sometimes pleural friction noise. There is no vocal tremor in the area of ​​dullness.

If there is gas in the abscess cavity, a tympanic sound is heard when tapping. When there is pressure on the lower ribs, on the intercostal spaces or on the edge of the liver, pain may be detected. Fluid may also appear in the pleural cavity. If the abscess is located close to the peritoneum, signs of irritation may occur: nausea, vomiting, bloating and slight tension in the abdominal wall. X-ray examination of the patient can provide valuable data for diagnosis.

It is difficult to recognize a subphrenic abscess and should be distinguished from purulent pleurisy and lung abscess. Whenever after surgery, for example for a perforated gastric ulcer, appendicitis, cholecystitis, or when there is damage to the right hypochondrium, a high persistent temperature, leukocytosis, etc. occurs, you should think about the possibility of a subdiaphragmatic abscess.

Subphrenic abscess complications: opening of an abscess into the abdominal cavity with the occurrence of general purulent peritonitis or opening it through the diaphragm into the pleural cavity with the development of purulent pleurisy; sometimes there is an opening of an abscess into the lung with its emptying through the bronchus. The development of sepsis is also possible.

Subphrenic abscess emergency care. At the slightest suspicion of a subphrenic abscess, the patient must be immediately hospitalized in the surgical department of the hospital. Transport in a supine position.

Subphrenic abscess

Subphrenic abscess is a local abscess formed between the dome of the diaphragm and the adjacent organs of the upper abdominal cavity (liver, stomach, spleen, kidneys, intestines, greater omentum).

They can be primary (very rare) and secondary, as a complication of other diseases (cholecystitis, perforated gastric ulcer, pancreatitis, etc.) or after operations on the abdominal organs.

The location of the abscess may vary; in the abdominal cavity and in the retroperitoneal space. Most often, the abscess is located under the right dome of the diaphragm above the liver.

Symptoms

Patients complain of pain in the upper abdomen - right and left hypochondrium, epigastric region (under the stomach). The pain is constant, worsening with movement. Worries about dry cough, weakness, shortness of breath, fatigue, hiccups. The temperature rises to 41.C, chills. The general condition is grave, the forced semi-sitting position. Noteworthy is the lag of the chest when breathing on the affected side.

Breathing is rapid and shallow. When palpating the lower parts of the chest in the upper abdomen, pain is noted on the sore side. Percussion reveals a high position of the diaphragm and its immobility. Decreased breathing in the lower parts of the lungs on the affected side, pleural friction noise (if the pleura is involved in the process), increased vocal tremors.

Symptoms of a subdiaphragmatic abscess at first do not present any particularities and recognition of an abscess is usually possible only when an abscess has formed. Based on the medical history, it is sometimes possible to assume gastric or duodenal ulcers, appendicitis, liver disease, and biliary tract diseases. It is often possible to establish that some time ago the patient suddenly experienced particularly severe pain. These pains are sometimes accompanied by chills. When examining the patient during this period, one can note a number of signs of acute limited peritonitis, localized in the upper abdominal cavity. However, the disease often develops gradually without acute pain and subsequent signs of local peritonitis. Appetite decreases, general weakness appears, pain in the right or left side of varying intensity, aggravated by movements or deep breathing, gradually increasing, sometimes an excruciating painful cough. The patient loses weight, often significantly. The color of the skin is pale, with an earthy or slightly jaundiced tint, and sweat is observed. The fever becomes remitting or intermittent. In general, the patient gives the impression of being seriously septic.

During examination, one can often detect pain when pressing in the area of ​​the forming abscess, tension in the abdominal wall in the upper abdomen - in the epigastric region and in the hypochondrium.

With a right-sided subphrenic abscess, palpation reveals an enlarged liver, displacement of its lower edge, uniformly painful, rounded, protruding 2-3 cm or more from under the edge of the right costal arch.

The upper border of the liver, determined by a dull percussion tone, turns out to be raised upward, under the pressure of the purulent contents located between the upper surface of the liver and the diaphragm. The upper limit of hepatic dullness is located in the form of a line convex upward, above which a pulmonary sound is detected. If the subphrenic abscess contains a significant amount of gas, then a strip of tympanitis appears above the area of ​​hepatic dullness, above which a pulmonary tone is then determined. Such a three-layer distribution of percussion sounds, a kind of “percussion rainbow” (dull, tympanic and pulmonary sounds) are especially characteristic of subdiaphragmatic abscess, but in practice they are rare, with an advanced process.

When auscultating the lungs at the lower border of the pulmonary sound, it is sometimes possible to listen to individual wheezing and pleural friction noise.

With a left-sided subdiaphragmatic abscess, you can notice a slight protrusion of the epigastric and left hypochondrium areas, painful when palpated. Often, a lowered, uniformly painful and rounded edge of the left lobe of the liver is palpated.

With a significant size of the subdiaphragmatic abscess, the heart shifts to the right. When percussing the lower part of the left half of the chest, a dull sound is detected, above which the usual pulmonary tone is noted. Traube space is reduced or becomes “occupied”. If gas accumulates in the abscess, the above-mentioned “percussion rainbow” is detected in the lower part of the left half of the chest. In these cases, recognizing an abscess is not difficult. However, when a strip of tympanitis and a clear location of the upper limit of dullness along a convex curve are absent, the diagnosis of subdiaphragmatic abscess is often replaced by an erroneous diagnosis of pleural effusion, which, however, can also occur additionally with this disease.

X-ray examination is of great diagnostic importance. It establishes a high position of the diaphragm with a convex upward border on the affected side, inactive or motionless in some places. When the abscess contains even relatively small amounts of gas, the latter is detected in the form of a narrow strip of clearing between the darkening from the upper edge of the liver and abscess and the diaphragm. Sometimes a gas bubble located under the diaphragm with a horizontal level of liquid, often moving, is detected. A similar picture provides grounds for the diagnosis of subdiaphragmatic pyopneumothorax. Often, effusion is detected in the corresponding pleural cavity - the result of “sympathetic” (reactive) exudative pleurisy.

The diagnosis of a subdiaphragmatic abscess can be confirmed by a test puncture. A test puncture, according to a number of experts, does not harm the patient’s health. However, many surgeons, not without reason, believe that a test puncture, due to a known danger, “should not occupy a leading place,” but is permissible only during surgery.

Laboratory tests are only relatively helpful in identifying an abscess. In seriously ill patients, progressive anemia of the hypochromic type, neutrophilic leukocytosis with a left-side shift, toxic granularity of neutrophils, aneosinophilia and an increase in ROE are observed. The urine often shows albuminuria associated with fever, urobilinuria and in some cases indicanuria.

Recognition:

Additional research methods help in diagnosis: x-ray and ultrasound.

Treatment:

When a subphrenic abscess forms, you can limit yourself to conservative therapy - antibacterial, detoxification, infusion. Using punctures, administer antibiotics to the abscess area. Complete cure is only after surgery.

Treatment of subdiaphragmatic abscess, as a rule, should be surgical. Recently, attempts have been made to replace the wide opening of the abscess cavity by emptying it with a thick needle, followed by washing the cavity with antibiotic solutions and introducing them into the cavity (penicillin, Streptomycin-KMP, etc.). At the same time, vigorous therapy with antibiotics administered intramuscularly is carried out. However, in most cases, conservative antibiotic therapy should not replace timely surgical intervention. Treatment with antibiotics alone is carried out only until an accurate diagnosis is established.