Subphrenic Abscess

Introduction:

The space between the diaphragm, which separates the chest cavities from the abdominal cavity, and the transverse colon is called the "subphrenic space". If there is an abscess developing in this space, this is called a subphrenic abscess. As there is a right and a left chest cavity, there can be from an anatomical point of view a right-sided and a left-sided subphrenic abscess.

In about 50% of the cases there is a right-sided, in 25% a left-sided and in 25% a bilateral subphrenic abscess. Typically this develops 3 to 6 weeks following surgery in the abdomen such as biliary surgery, appendix surgery or surgery on the stomach or duodenum.

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 facilitates abscess formation.

Symptoms:

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 or a pleural effusion (fluid in the chest cavity) on that side. Upper abdominal pain on the affected side is common, which is severe on deep palpation by the physician. Blood tests show a leukocytosis, there may also be a lack of red blood cells (anemia).

Plain abdominal X-ray films may show the abscess cavity with gas in it from gas producing bacteria. Chest X-rays often show abnormalities in the lungs (atelectases, lower lobe pneumonia) and pleural effusions as well as an immobile diaphragm. Other tests are useful such as an ultrasound for a right- sided subphrenic abscess (hepar=liver; abscessus=subphrenic abscess) and a CT scan for a left-sided subphrenic abscess. The link here shows a subphrenic abscess before (upper image) and after (lower image) drainage. Because it can be rather difficult to come to a diagnosis, radioactive isotope scanning such as an indium-111-labeled leukocyte scan could be useful in detecting a hidden intraabdominal or subphrenic abscess.

Treatment:

Like any other abscess in the body, a drainage of the abscess has to be done and the infection needs to be treated with appropriate antibiotics. This can be a complex undertaking with a subphrenic abscess.

If there is an intraabdominal breakdown of an anastomosis, this has to be attended to by the surgeon as well as the abscess has to be drained. 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.

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Disclaimer:

This outline is only a teaching aid to patients and should stimulate you to ask the right questions when seeing your doctor. However, the responsibility of treatment stays in the hands of your doctor and you.

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.

9. Suzanne Somers: "Breakthrough" Eight Steps to Wellness-- Life-altering Secrets from Today's Cutting-edge Doctors", Crown Publishers, 2008

Last Modified: Jan. 13, 2012