What signs does the symptomatology of a subdiaphragmatic abscess include? Subphrenic abscess - causes, symptoms, diagnosis and treatment Diaphragm abscess symptoms

Subphrenic abscess is considered rare and very dangerous disease. It represents suppuration and inflammation abdominal cavity. This disease in most cases is observed in people 35-55 years old and in males it occurs almost 4 times more often.

When an abscess appears externally, there are no difficulties in diagnosing the disease. If the abscess is located on internal organs, diagnosis becomes significantly more difficult. It is necessary to study the symptoms and take an x-ray.

This disease is divided according to the location of the abscess:

• Right-sided (most often a right-sided abscess is observed);
• Left-handed;
• Median.

The abscess has different shapes: most often round, and sometimes flat. The abscess contains pus and sometimes contains gas, stool and gallstones. Often, a subdiaphragmatic abscess is accompanied by pleural effusion, which puts pressure on the diaphragm and neighboring organs, thereby impairing their functionality.

Symptoms of the disease

This disease often occurs against the background of another more life-threatening disease.

On initial stage There are symptoms that occur with other types of abdominal abscess:

• Severe weakness;
• Increased sweating;
• High body temperature;
• Chills.

When the disease gradually comes into full force, the following symptoms are actively observed:

• Chest pain;
• Nausea;
• Pain in the ribs;
• Heart rate increases;
• Shortness of breath appears.

If such symptoms appear, urgent hospitalization is necessary. If you treat this disease at home, there is an 85% chance of death.

Main causes of the disease

There are many reasons for the appearance of this disease. The rapid spread of the inflammatory-purulent process occurs due to the entry of pus into the life support systems and internal organs body through blood and lymph circulation.

This disease is often directly associated with various complications:

• Surgeries for ulcers or duodenum;
• Inflammation of appendicitis with pus;
• Inflammatory kidney diseases;
• Operations on the abdominal organs;
• Inflammation of the gallbladder and liver.

Treatment at the initial and advanced stages

In the initial stages, this disease is quite easy to cure. An antibiotic is selected for the patient, which is administered intravenously as an injection, and it is also used for external abscesses (they prick it from all sides). In addition, various procedures and application of bandages with ointment are prescribed. At each stage of treatment it is recommended to use medications group of enteroprotectors, which will protect the structure and integrity of the mucous membrane of the stomach and intestines at the initial stage of the disease, and will also help restore the proper functioning of the gastrointestinal tract in rehabilitation therapy after the elimination of the abscess.

If the abscess is fully formed, a surgical opening is performed. If the abscess is located on internal organs, then it is necessary to remove the pus and introduce special antibacterial drugs. There are severe cases where the doctor is required to remove an abscess from an organ that was damaged during the course of the disease.

A successful outcome of treatment of subdiaphragmatic abscess is guaranteed if the patient seeks help from a doctor on time. Modern drugs will help the patient avoid complications of the disease and recover as quickly as possible.

Subphrenic abscess is a limited purulent peritonitis that develops directly under the dome of the diaphragm. There are right, or diaphragmatic-hepatic, left, or diaphragmatic-splenic, median, or diaphragmatic-gastric, abscesses (the latter is extremely rare).

Causes

The causes of subphrenic abscess are varied. The first place is occupied by perforated ulcers of the stomach and duodenum.

According to consolidated data from Moscow hospitals, out of 182 reliable cases of subphrenic abscess, in 24.7% its source was diseases of the stomach, in 20% - diseases of the appendix, in 14.3% - the gallbladder.

Less commonly, the cause of a subphrenic abscess can be purulent inflammatory processes in the circumference of the esophagus, pelvic suppuration, and occasionally lesions of the prostate gland. In these cases, the infection spreads mainly through the lymphatic tract. Suppurative processes in the chest are also important: purulent pleurisy, lung abscess, etc. The infection penetrates through the transdiaphragmatic lymphatic pathways (lymphatic reflux), communicating lymphatic system chest and abdominal cavities.

Occasionally, an encysted abscess under the diaphragm occurs in diseases of the spleen (festering echinococcus, etc.), pancreas, kidney (abscess), perforation of the transverse colon, purulent diseases lower ribs or vertebral bodies (osteomyelitis), closed liver injuries (the latter are observed in almost 6% of cases).

The occurrence of a right subdiaphragmatic abscess (diaphragmatic-hepatic) is usually associated with a perforated duodenal ulcer, purulent appendicitis, diseases of the liver, gall bladder and right kidney. The left subdiaphragmatic abscess (diaphragmatic-splenic) is most often caused by perforation of a stomach ulcer, ulcers of the left kidney, spleen, and left lobe of the liver.

Subphrenic abscesses most often develop under the right dome of the diaphragm: pus accumulates between the diaphragm and the upper surface of the right lobe of the liver to the right of the suspensory ligament; the dome of the diaphragm is pushed high upward, and the liver downward. When the abscess is left-sided, it is located to the left of the suspensory ligament of the liver between the surface of its left lobe and the diaphragm. And in this case, the abscess lifts the left dome of the diaphragm upward, and the liver is pushed down and sometimes extends onto the anterior surface of the stomach. Cases of bilateral subphrenic abscess have been described, which is particularly severe. In more than 25% of cases, the subdiaphragmatic abscess contains gas along with pus, since during perforations the contents of hollow organs and air enter the abdominal cavity. In other cases, gas is formed due to the activity of microbial flora. Subphrenic abscesses, both right- and left-sided, are often accompanied by the formation of pleural effusion on the corresponding side.

Symptoms

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, biliary tract. It is often possible to establish that some time ago the patient suddenly experienced a particularly severe pain. These pains are sometimes accompanied by chills. When examining the patient during this period, a number of signs of acute limited peritonitis, localized in upper section abdominal cavity. However, the disease often develops gradually without acute pain and subsequent signs of local peritonitis. Appetite decreases, general weakness, pain in the right or left side appear varying intensity, aggravated by movements or deep breathing, gradually increasing, sometimes an excruciating painful cough. The patient loses weight, often significantly. Coloring skin pale, with a sallow or slightly jaundiced tint, and sweating. 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 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.

Big diagnostic value has an x-ray examination. 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.

Course of the disease

If diagnosis and active treatment are delayed, significant exhaustion of the patient develops, the abscess can break into the abdominal or chest cavity. In some cases, a breakthrough of the abscess outward followed by spontaneous recovery has been described.

Diagnosis and differential diagnosis subdiaphragmatic abscess encounters significant difficulties until the abscess “maturation”, when the percussion and radiological symptoms described above appear. It can be very difficult to differentiate a subphrenic abscess from a suppurating echinococcus of the liver. For diagnosis you should use positive reactions Cazzoni and Weinberg, anamnestic data, examination results, the “percussion rainbow” symptom, X-ray and laboratory test(leukocytosis, accelerated ROE).

Treatment

Treatment of subdiaphragmatic abscess, as a rule, should be surgical. IN Lately They strive to replace a 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, 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.

Forecast

The prognosis for subphrenic abscess remains serious. If it occurs independently, the mortality rate reaches 90%, and with an operation to open the abscess it drops to 15%.

X-ray diagnostics. X-ray examination with subdiaphragmatic abscess it is of great, sometimes decisive importance for the diagnosis; it makes it possible to establish the presence and localization of a subphrenic abscess, as well as associated complications in the pleura and lung tissue. The main types of examination are fluoroscopy and radiography in a vertical (straight and lateral) position and lying on the side (lateral position). Study of the patient in horizontal position on the trochoscope does not reach the target, since the horizontal level of the liquid is not visible.

The X-ray picture of a right-sided gas subdiaphragmatic abscess is very typical; it is characterized by the presence of gas and a horizontal liquid level with a highly located or slightly or completely motionless dome of the diaphragm. The shadow of the dome is expanded due to the involvement of the diaphragm and the covering layers of the peritoneum and pleura in the inflammatory process (Fig. 2, 1 and 2). Non-gas subdiaphragmatic abscess does not have a typical x-ray picture. Indirect diagnostic signs for identifying a subphrenic abscess are high standing and a steep arched protrusion of the dome of the diaphragm and almost complete immobility, and sometimes paradoxical movements (Fig. 2, 3 and 4). These symptoms may also occur with other pathological processes.

X-ray diagnosis of a left-sided subdiaphragmatic abscess is more difficult, since the gas bubble of the stomach and gas in the colon can simulate gas in a subdiaphragmatic abscess. Lateroscopic examination makes it possible to clarify the intra- or extra-intestinal location of gas. For the diagnosis of left-sided subdiaphragmatic abscess, the symptom of compression and downward displacement of the vault of the stomach and the splenic angle of the colon is important (Fig. 2, 6). Along with these signs, contrasting the stomach and colon with a barium suspension is very valuable (Fig. 3).

A middiaphragmatic abscess, as a rule, is gas-containing, and therefore its X-ray diagnosis is not difficult. A subdiaphragmatic abscess is projected along midline at the level of the xiphoid process in the form of a gas bubble with a horizontal level of liquid; on lateral examination it is adjacent to the anterior abdominal wall (Fig. 2, 7 and 8).

In all cases of subphrenic abscess, concomitant reactive pleurisy is determined.

Retroperitoneal subphrenic abscesses are much less common than intraperitoneal abscesses. With a highly located retroperitoneal subdiaphragmatic abscess, a high location of the dome of the diaphragm and reactive pleurisy are determined. If there is gas in the subdiaphragmatic abscess, under the dome of the diaphragm, a gas bubble with a horizontal level of liquid is visible, which, in a lateral position, is located posteriorly, projected onto the shadow of the spine (Fig. 2, 9 and 10).

When differentiating a subdiaphragmatic abscess from radiologically similar diseases, it is necessary to keep in mind following states: perforated pneumoperitoneum, gas in the colon during its interposition between the liver and the diaphragm (Fig. 2, 5), encysted basal empyema (Fig. 2, 11 and 12), large abscesses lower lobes lungs (Fig. 2, 13 and 14), cortical liver abscess (Fig. 2, 15 and 16), diaphragmatic hernia and relaxation of the diaphragm.

Rice. 2. X-ray picture of subdiaphragmatic abscesses: 1 and 2 - right-sided gas subdiaphragmatic abscess, high standing of the right dome of the diaphragm and expansion of its shadow, under the dome of the diaphragm - gas and horizontal liquid level, small reactive pleurisy in the right pleural cavity; 3 and 4 - right-sided non-gas subphrenic abscess, high position of the diaphragm with a steep arcuate protrusion of the dome, small reactive pleurisy in the sinus; 5 - interposition of the transverse colon, the intestine swollen with gas is located between the diaphragm and the liver; c - left-sided non-gas subphrenic abscess, the gastric bladder is pressed inward, the splenic angle of the colon is displaced downward; 7 and 8 - median gas subphrenic abscess, the stump of the stomach is displaced posteriorly, the abscess is adjacent to the anterior abdominal wall, in the abdominal cavity under the diaphragm there are crescent-shaped shadows of gas remaining in it after the operation.
Rice. 2. X-ray picture of subphrenic abscesses (continued): 9 and 10 - retroperitoneal gas subphrenic abscess caused by a purulent process in the kidney, under the right dome of the diaphragm - a horizontal level of liquid with a gas bubble above it, located posterior to the liver and projected onto the shadow of the spine; 11 and 12 - basal empyema, a sharpening of the contour of the upper border of the shadow (interlobar mooring) is visible; 13 and 14 - large abscess of the lower lobe of the lung, uneven, as if torn contour of the cavity roof; 15 and 16 - gas bubble located in the upper part of the liver; in the position on the side (lateral position), it is determined that the abscess cavity is located in the thickness of the liver tissue and has a spherical shape.
Rice. 3. Left-sided gas subphrenic abscess. The gastric bladder is deformed and pushed inward and downward. The splenic bend of the colon is displaced downward.

Pus with a subdiaphragmatic abscess is localized in natural pockets of the peritoneum, called the subdiaphragmatic space, which is located in the upper floor of the abdominal cavity and is limited from above, from behind by the diaphragm, from the front and sides - by the diaphragm and the anterior abdominal wall, from below - by the upper and posterior surfaces of the liver and its supporting surfaces. ligaments.

In the subdiaphragmatic space, intraperitoneal and retroperitoneal parts are distinguished. The intraperitoneal part is divided into right and left sections by the falciform ligament of the liver and the spine. In the right section, anterosuperior and posterosuperior regions are distinguished. The anterior-superior region is limited medially by the falciform ligament of the liver, behind by the upper layer of the coronary ligament, above by the diaphragm, below by the diaphragmatic surface of the right lobe of the liver, in front by the costal part of the diaphragm and the anterior abdominal wall. The posterosuperior region is limited in front by the posterior surface of the liver, in the back by the parietal peritoneum covering the posterior abdominal wall, and above by the lower layer of the coronary and right triangular ligaments of the liver (Figure 1). Both of the above areas communicate with the subhepatic space and the abdominal cavity. The left-sided subphrenic space has a slit-like shape and is located between the left dome of the diaphragm above and the left lobe of the liver to the left of the falciform ligament of the liver, the spleen and its ligaments and the anterior outer surface of the stomach.

The retroperitoneal part of the subphrenic space has a diamond shape and is limited above and below by the leaves of the coronary and triangular ligaments of the liver, in front - by the posterior surface of the extraperitoneal part of the left and right lobe liver, behind - the posterior surface of the diaphragm, the posterior abdominal wall and passes into the retroperitoneal tissue.

Most often, a subphrenic abscess occurs in the intraperitoneal part of the subphrenic space.

The etiology is quite diverse and is caused by infection entering the subphrenic space from local and distant foci.

The most common causes of subphrenic abscess: 1) direct (contact) spread of infection from neighboring areas: a) with perforated ulcer stomach and duodenum, destructive appendicitis, purulent cholecystitis and liver abscess, b) with limited and diffuse peritonitis of various origins, c) with postoperative complications after various operations on the abdominal organs, d) with a suppurating hematoma due to closed and open damage parenchymal organs, e) with purulent diseases of the lungs and pleura, f) with inflammation of the retroperitoneal tissue as a result of purulent paranephritis, kidney carbuncle, paracolitis, destructive pancreatitis and others; 2) lymphogenous spread of infection from the abdominal organs and retroperitoneal tissue; 3) hematogenous dissemination of infection from various purulent foci through blood vessels during furunculosis, osteomyelitis, tonsillitis and others; 4) often Subphrenic abscess occurs with thoracoabdominal wounds, especially gunshot wounds.

The microbial flora of the subphrenic abscess is diverse.

The penetration of infection into the subdiaphragmatic space is facilitated by negative pressure in it, resulting from the respiratory excursion of the diaphragm.

The clinical picture is characterized by significant polymorphism. This is due to the different localization of abscesses, their sizes, the presence or absence of gas in them, and is often due to the symptoms of the disease or complication against which the Subdiaphragmatic abscess developed. The use of antibiotics, especially wide range actions due to which many symptoms become erased, and the course often becomes atypical. In 90-95% of cases, the subphrenic abscess is located intraperitoneally, and right-sided localization is observed, according to Wolf (W. Wolf, 1975), in 70.1%, left-sided - 26.5%, and bilaterally - in 3.4% of cases.

Despite the variety of forms and variants of the course of subdiaphragmatic abscess, the clinical picture is dominated by symptoms of an acute or subacute purulent-septic condition. With intraperitoneal right-sided subdiaphragmatic ulcers after a previous, usually recent, acute illness organs of the abdominal cavity or in the immediate postoperative period after abdominal operations, general weakness, an increase in temperature to 37-39° occur, often with chills and sweating, tachycardia, an increase in leukocytosis with shift leukocyte formula to the left, as well as hypoproteinemia and anemia of the patient. Many patients complain of pain of varying intensity and nature in the lower parts of the chest on the right, in the back, in the right half of the abdomen or in the right hypochondrium. The pain usually intensifies with deep breathing, coughing, sneezing, and also with body movement. Sometimes there is irradiation of pain to the right shoulder, scapula, shoulder girdle, and the right half of the neck. A common symptom is shortness of breath and pain with deep inspiration on the side. Subdiaphragmatic abscess. Some patients experience a dry cough and pain with deep breathing (Troyanov's symptom). When examining patients, a forced semi-sitting position, pallor of the skin, and sometimes subicteric sclera are noted. You can observe, especially with large abscesses, smoothing of the intercostal spaces in the lower half of the chest, thickening of the skin fold, pastiness, and rarely hyperemia on the affected side.

Retroperitoneal Subdiaphragmatic abscess in the initial stage is distinguished by an erased clinical picture and manifests itself as dull or throbbing pain in the lumbar region, often on the right, elevated temperature(37-38°), leukocytosis and local pain in the abscess area. Subsequently, pastiness or swelling appears in the lumbar region and the region of the lower ribs, thickening of the skin fold, and, less often, hyperemia. At the same time, the picture of purulent intoxication increases.

Diagnosis. With anterior superior abscesses, there is often a lag in breathing of the anterior abdominal wall, tension and pain in the right hypochondrium and epigastric regions, which is associated with inflammation of the areas of the peritoneum adjacent to the subphrenic abscess. Palpation of the IX - XI ribs on the right, especially in the area of ​​their confluence at the costal arch, is accompanied by pain (Kryukov's symptom).

The results of physical examinations for subdiaphragmatic abscess largely depend on the size and location of the abscess, as well as on changes in the topography of the organs of the thoracic and abdominal cavities adjacent to it. In the initial stage and with small accumulations of pus, percussion provides little information. As the abscess increases, the diaphragm shifts upward and the liver is pushed downward, resulting in upper limit The diaphragm can rise on the right to the level of the III - IV ribs in front and compress the lung. In many cases, the boundaries of hepatic dullness increase. In case of right-sided subdiaphragmatic abscess, percussion of the chest in a sitting position of the patient often reveals dullness of the pulmonary sound in its lower parts, the boundaries of which run along an arcuate line with the apex located along the midclavicular and parasternal lines. Compression lung tissue with this localization, the subdiaphragmatic abscess is observed mainly from front to back and laterally due to the high position of the dome of the diaphragm, and therefore, with percussion, it is sometimes possible to detect an area of ​​pulmonary sound in the interval between the subdiaphragmatic abscess laterally and cardiac dullness medially (Trivus symptom).

G. G. Yaure (1921) described a symptom for subphrenic abscess, which consists in the fact that when tapping with one hand on the back surface of the chest, the second hand on the abdominal wall experiences jerking movements in the liver area. Right-sided gas-containing subdiaphragmatic abscess in some cases may be accompanied by so-called percussion three-layeredness. A clear sound over the lung turns into a tympanic sound in the area where the gas is localized and into a dull sound over the abscess and liver (Barlow phenomenon).

Tympanitis in the area of ​​Traube's semilunar space (see full body of knowledge: Traube's space) complicates percussion recognition of left-sided subphrenic abscess, detected in most cases only with large accumulations of pus.

Auscultation for subphrenic abscess small sizes does not give results. With a large abscess, high standing of the diaphragm, the presence of concomitant pleurisy, significant compression of the lung, weakened vesicular breathing, sometimes with a bronchial tint, which is usually not detected above the site of the abscess, can be heard, especially on the right above the chest. When the patient shakes in this area, it is occasionally possible to hear the sound of splashing.

X-ray examination for suspected subdiaphragmatic abscess includes transillumination and radiography when vertical position the patient’s body, and, if necessary, in a position on his side, as well as on his back (see full body of knowledge: Polypositional study).

The X-ray picture of a subdiaphragmatic abscess consists of an image of the abscess itself, displacement of adjacent organs and signs of acute diaphragmatitis (see full body of knowledge: Diaphragm). With a subdiaphragmatic abscess of traumatic origin, this may be accompanied by x-ray signs of damage to the chest and organs of the thoracic and abdominal cavities, as well as the shadow of foreign bodies.

X-ray diagnostics is most effective in the case of gas-containing Subdiaphragmatic abscess With fluoroscopy and radiography performed in the patient’s upright position (with in serious condition patients - in the later position), a cavity with a horizontal fluid level is determined under the dome of the diaphragm (Figure 2). When the position of the patient’s body changes, the liquid moves into the cavity, and its level remains horizontal and changes little in size, which distinguishes a subdiaphragmatic abscess from the accumulation of gas and liquid in the stomach or intestinal loop. Images in different projections make it possible to clarify the size of the cavity and topography. Subdiaphragmatic abscess Most often it is located in the right part of the intraperitoneal part of the subphrenic space, occupying all of this space or only its anterior, posterior or lateral sections. With left-sided localization, it is possible to distinguish between a perisplenic subdiaphragmatic abscess and ulcers formed above or below the left lobe of the liver. In some cases, not one, but two or three cavities are observed (Figure 3).

The right-sided subdiaphragmatic abscess, which does not contain gas, does not provide an independent image on ordinary photographs; the left-sided one causes intense darkening, visible against the background of gas in the stomach and intestines. Differential diagnosis of subdiaphragmatic abscess and intrathoracic pathological process in such cases is helped by the symptom of deformation and downward pushing of the vault of the stomach and the left (splenic) flexure of the colon. For greater confidence, the patient is given two or three sips of an aqueous suspension of barium sulfate. If at the same time a depression is detected on the vault of the stomach, this means that the infiltrate is located under the diaphragm. In the case of a subdiaphragmatic abscess, which developed due to insufficiency of the anastomotic sutures after gastrectomy, the contrast mass sometimes passes from the stomach into the cavity of the subdiaphragmatic abscess

New opportunities in recognizing subdiaphragmatic abscess have been opened CT scan(see full body of knowledge: computed tomography), ultrasound diagnostics (see full body of knowledge) and angiography (see full body of knowledge). Computed tomograms provide a direct image of a subdiaphragmatic abscess. In this case, the exact localization of the abscess is established, including the distinction between intraperitoneal and extraperitoneal subdiaphragmatic abscess located between the layers of the coronary ligament or above the upper pole of the kidney. Aortography (see full body of knowledge) in combination with celiacography (see full body of knowledge) makes it possible to determine the position and condition of the phrenic and hepatic arteries. Along with ultrasound scanning data, this sometimes makes it easier difficult task differentiation between subdiaphragmatic abscess and liver abscess.

Subdiaphragmatic abscess, according to M. M. Vikker (1946), V. I. Sobolev (1952), is of great importance in X-ray diagnostics, and has a syndrome of acute diaphragmatitis. It is expressed in deformation and high position of the affected half of the diaphragm or part of it, in a sharp weakening, absence or paradoxical nature of its movements during breathing, in thickening and blurring of the contours of the diaphragm due to its edema and inflammatory infiltration. The costophrenic sinuses are reduced due to infiltration of fiber and reactive effusion. As a rule, this is accompanied by small atelectasis and foci of lobular pneumonia at the base of the lung and effusion in the pleural cavity. However, acute diaphragmatitis syndrome with damage to the right half of the diaphragm can be caused by liver abscess (see full body of knowledge). Therefore, for the final conclusion, it is very important to compare clinical symptoms, symptoms and results of x-ray, radionuclide and ultrasound examinations.

With a subdiaphragmatic abscess of medial localization, thickening of the legs of the diaphragm and the disappearance of their outlines are observed. In the case of a retroperitoneal adrenal subdiaphragmatic abscess, the images show blurred or absent outlines of the upper pole of the kidney, and with a large abscess, a downward displacement of the kidney is noted.

In the case of diagnostic puncture of an abscess, some surgeons and radiologists consider it advisable to replace part of the removed pus with gas or high-atomic tri-iodinated contrast agent. This provides a complete picture of position and dimensions purulent cavity and usually facilitates the differential diagnosis of subphrenic abscess with liver abscess.

With subdiaphragmatic abscess as a result gunshot wound possible development of external purulent fistula(B.V. Petrovsky). In this case, they resort to fistulography (see full body of knowledge) to study the direction and extent of the fistula tract, identify purulent leaks, establish the connection of the fistula with the abscess cavity, foci of destruction in damaged bones, with foreign bodies.

Treatment. Conservative treatment Subphrenic abscess is usually performed when there is doubt about the diagnosis or for the purpose of preoperative preparation. It consists of prescribing antibacterial and detoxification therapy and treating the underlying disease that served as the source of the Subdiaphragmatic abscess. A diagnosed Subdiaphragmatic abscess is subject to mandatory opening and drainage.

The surgical approach and the nature of the surgical intervention largely depend on the location of the subdiaphragmatic abscess and associated complications.

Transpleural access was first described by Roser in 1864. It consists of thoracotomy (see full body of knowledge) in the area of ​​projection of the abscess, dissection of the diaphragm, opening and drainage. Subphrenic abscess The method is quite simple, but as a result of infection of the pleural cavity, empyema often occurs, flowing heavily.

To prevent this complication, F. Trendelenburg (1885) developed next way. An incision is made along the X rib on the side between the posterior and anterior axillary lines on the right or posteriorly between the paravertebral and middle axillary lines, depending on the location of the subphrenic abscess, and then its subperiosteal resection (Figure 4). After careful dissection of the periosteum, without opening the pleura, it is sutured to the diaphragm with continuous sutures in the form of an oval to isolate the pleural cavity. The subphrenic abscess is opened with a longitudinal incision between the sutures through the pleura and the diaphragm.

Many surgeons prefer to use the extrapleural access developed by A.V. Melnikov in 1921. With this access, the diaphragm is exposed and the subdiaphragmatic abscess is opened through the so-called parapleural space after the costophrenic sinus is displaced upward, as a result of which the pleural cavity remains intact. The skin incision is planned depending on the location of the subphrenic abscess in the anterior or posterior part of the subdiaphragmatic space and extends 2-3 transverse fingers above the edge of the costal arch. After subperiosteal resection of one or two ribs (most often IX - X) for several centimeters, the periosteum is dissected and peeled away from the pleural sinus, which is separated from the chest wall and move up. Along the wound, the diaphragm is dissected to the parietal peritoneum and carefully peeled off. The cranial edge of the transected diaphragm is sutured to the muscles of the chest wall along the upper perimeter of the wound (Figure 5).

The extrapleural and extraperitoneal method of opening a subphrenic abscess includes retroperitoneal access, which is more often used for right-sided posterosuperior abscesses. This operation is based on the fact that pleural sinus on the right it almost never descends below the spinous process of the first lumbar vertebra. The operation is performed with the patient positioned on the left side. The incision is made along the XII rib with subperiosteal resection. A transverse incision at the level of the spinous process of the first lumbar vertebra is used to dissect the posterior layer of the periosteum, the adjacent intercostal and serratus posterior muscles and expose the diaphragm near its attachment. The latter is opened and the peritoneum covering the lower surface of the diaphragm is peeled off, the Subphrenic abscess is found (Figure 6) and it is opened.

To open the right anterior superior subdiaphragmatic abscess, most surgeons use a very convenient extraperitoneal subcostal approach (Figure 7), proposed by P. Clairmont in 1946. The incision is parallel and immediately below the costal arch. The muscular aponeurotic layers of the anterior abdominal wall are dissected layer by layer to the parietal peritoneum, which is bluntly peeled off from the inner surface of the diaphragm to the subphrenic abscess. The latter is opened and drained.

Mortality with subdiaphragmatic abscess depends on the nature of the underlying disease, the location of the abscess, the age of the patient, concomitant diseases, duration of the disease, timeliness of recognition and timing of surgical intervention. According to Wang and Wilson (S. Wang, S. Wilson, 1977), mortality with subdiaphragmatic abscess that occurred after emergency operations, was 35%, after planned - 26%, and overall mortality - 31%.

Clinic, diagnosis and treatment of subdiaphragmatic abscess in children do not differ from those of subdiaphragmatic abscess in adults.

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Exacerbations of diseases of the abdominal organs may occur due to various reasons: inflammatory processes, pathogenic microflora, surgical interventions, injuries. A fairly rare, but extremely dangerous complication is a subdiaphragmatic abscess. Its symptoms are often hidden under the manifestations of diseases that provoke suppuration, which makes timely diagnosis difficult.

What is an abscess in the subphrenic space?

Subdiaphragmatic abscess - a concentration of pus under the diaphragm and next to the abdominal organs - stomach, liver, spleen, transverse colon. This section, located in the upper abdomen, is called the subphrenic space. Inside it there are intraperitoneal and retroperitoneal parts. In most cases, the abscess develops in the intraperitoneal area. The spinal column and falciform ligament of the liver divide it into right and left halves. Subdiaphragmatic abscess is assigned ICD 10 code K65.

Participate in the formation of the inflammatory infiltrate superficial areas organs, diaphragm and greater omentum. A fully formed abscess is enclosed in a capsule of connective tissue with an uneven contour. There is pus inside. In addition, gases may be present in the capsule; sometimes there are gallstones and sand. The liquid contents of the capsule contain different kinds microorganisms. Most often this is anaerobic flora, coli, streptococci, white or golden staphylococcus. If the abscess is large enough, pressure is exerted on nearby organs, disrupting their normal functioning. The increase most often occurs due to the accumulation of gases. Often the abscess is accompanied by the formation of pleural effusion.

This secondary disease Both men and women are susceptible. Most of them are elderly and senile people. Malaise is more common in men.

Why does an abscess form?

More than 80% of cases of local abscess formation occur due to acute inflammatory diseases of the abdominal organs. Pathological processes in nearby and neighboring organs become foci of infections. There are different ways for infection to get under the diaphragm: creating negative pressure in the dome of the diaphragm during breathing, intestinal peristalsis, lymph flow, blood vessels. The most common reasons are contacts with diseased organs.

Subphrenic abscess is considered a serious complication postoperative period. The accumulation of pus can be caused by a number of factors that often accompany operations on organs located in the abdominal cavity:

• errors in hemostasis technique;
• local or diffuse peritonitis;
• extensive organ trauma with destruction of anatomical connections;
• failure of anastomotic sutures;
• depressed systemic and immunological reactivity;
• infection;
• ineffective drainage.

The risk group includes people with malignant lesions of the abdominal organs. This is due to the low level of the body's immune defense against infections. Removal of the spleen removes the main barrier to infections in the subdiaphragmatic region and significantly slows down the process of formation of leukocytes.

The cause of the formation of a purulent capsule can be thoracoabdominal injuries, both open (gunshot, knife wounds) and closed (impacts, compression). Enclosed hematomas that occur as a result of injury are often susceptible to suppuration.

Where might the abscess be located?

Depending on the location, the subdiaphragmatic abscess can be right-sided, left-sided or middle. Right-sided abscess is much more common. Localization with right side is explained by anatomical and topographical conditions conducive to the creation of a restrictive membrane of the abscess. On the right are the internal organs that are susceptible to the formation of inflammatory processes.

Bilateral abscesses form very rarely. They make up only 4-5% of the total.

A median abscess can form after gastric resection, which disrupts anatomical structure subdiaphragmatic region.

It is extremely rare that an abscess forms in the retroperitoneal part of the department. Fluid accumulation occurs in upper areas, between the diaphragm and the extra-abdominal part of the liver.

Symptoms of intra-abdominal abscess

Diagnosis of subphrenic abscess is quite difficult. This is due to the fact that the manifestations of the pathological process are hidden under the symptoms of diseases that are the main cause of the accumulation of pus under the diaphragm. In addition, the location of the purulent capsule, its size, and the presence or absence of gas-forming microflora in the pus are important.

At surgical intervention signs of abscess development are hidden under phenomena characteristic of the postoperative period. Antibiotics taken by the patient help erase the symptoms. That's why clinical picture can be unclear. The presence of a complication may be indicated by the following symptoms:

• weakness;
• chills and fever;
• sweating;
• temperature increase;
• tachycardia;
• dyspnea;
• vomit.

The clinical picture largely depends on the degree of intoxication. A pulse reaching 120 beats/min indicates severe poisoning body.

Heaviness and pain are felt under the ribs. The pain is localized on the side affected by the pathology and can be either acute or moderate. Gain occurs when sudden movements, coughing, sneezing, deep breaths. Sometimes the pain radiates to the shoulder, shoulder blade, neck. Breathing is usually rapid. Wherein rib cage at the site of formation of the abscess it lags slightly. Relief may come if you take a semi-sitting position.

How is diagnostic testing performed?

A blood test reveals a shift in the leukocyte formula to the left. X-rays and ultrasound examination, CT scan.

To identify an exacerbation, a standard examination plays an essential role. The presence of an abscess is indicated by the following external signs:

• smoothing of intercostal spaces;
• protrusion with large abscess sizes;
• bloating;
• change in breathing tones;
• pain on palpation.

Treatment of subphrenic abscess

If an abscess is detected under the diaphragm surgery- the main method of treatment. Minimally invasive technologies are usually used. During the operation, the abscess is opened and drained. Then antibiotics are prescribed, the choice of which depends on the data of bacteriological studies.

The prognosis of the disease is ambiguous, since there are many possible complications. The mortality rate is about 20%.

Subphrenic abscess refers to severe complications, the clinic, diagnosis and treatment of which are quite difficult. Compliance preventive measures, including timely diagnosis and adequate treatment of inflammatory processes in the abdominal cavity, as well as the exclusion of postoperative infectious complications, significantly reduce the risk of pathology.