What are the symptoms of a subdiaphragmatic abscess? Subdiaphragmatic abscess - errors in the diagnosis and treatment of acute diseases and injuries of the abdomen
20201 0
Subdiaphragmatic abscesses are serious complications that occur after abdominal surgery.
The subdiaphragmatic region is the most common location for postoperative ABP. 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 a part of common surgical infections that pass 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 resection of the stomach, gastrectomy, resection of the OK due to malignant neoplasms [D.P. Chukhrienko, 1977; DI. Krivitsky et al., 1990]. The development of a subdiaphragmatic abscess is associated mainly with infection of the abdominal cavity or with insufficient drainage efficiency.
Subdiaphragmatic abscess is especially common in patients with malignant diseases of the stomach, pancreas and the left half of the OK [S.K. Malkova, 1989]. Such a frequent development of them in cancer patients (“risk group”) is due to the nature of the disease, accompanied by suppression of immunity. An important role is played by the removal of the spleen, which leads not only to the elimination of an important barrier to the penetration of infection, but also to a violation of leukopoiesis. It would seem that drainage of the subphrenic space and massive antibiotic therapy should prevent the formation of a subphrenic abscess. However, as experience shows, despite adequate drainage with a silicone tube, this formidable complication cannot be avoided. In the development of a subdiaphragmatic 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 the technique of hemostasis, an inferior 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 characterized by the paucity of symptoms indicating the presence of inflammation.
A subdiaphragmatic abscess is often localized (in relation to the liver and diaphragm) in the right posterior superior, right anteroposterior, left superior, right inferior, left posterior inferior, left anteroinferior spaces [V.Sh. Sapozhnikov, 1976] (Figure 14). Most often (up to 70% of cases) they are localized in the right anterior and posterior superior spaces [D.P. Chukhrienko and Ya.S. Bereznitsky, 1977].
Figure 14. Division of the subphrenic space by the coronary ligament (a) and typical localization of subphrenic abscesses (b):
1 - diaphragm; 2 - liver; 3 - upper back space; 4 - upper anterior space; 5 - kidney; 6 - full-time abscesses are baked; 7 - suprahepatic abscesses
Right-sided localization of the complication occurs after interventions on the liver, gallbladder, CBD, duodenum, the right half of the OK; left-sided - on the pancreas, spleen, stomach, left half of the OK. With intra-abdominal localization of an abscess (occurs 5 times more often), pus accumulates between the diaphragm and the right or left lobes of the liver, the fundus of the stomach, the spleen, and the splenic angle of the OK (Figure 15). A subdiaphragmatic abscess can also be localized in the space limited by the lower surface of the liver and the root of the mesentery of the transverse OK.
Figure 15. Right-sided subdiaphragmatic abscess under the dome of the diaphragm
Retroperitoneal subphrenic abscesses are formed in loose tissue between the diaphragm, liver, kidneys, sheets of the coronary ligament of the liver (central subphrenic abscess) and can spread through adipose tissue into the retroperitoneal space.
Very rarely bilateral (right and left) subdiaphragmatic abscesses are observed. According to O. B. Milonov et al. (1990), their frequency is 0.8%. It should be constantly remembered about the possibility of a multi-chamber structure of a subdiaphragmatic abscess [B.V. Petrovsky et al., 1966]. Sometimes under the influence adhesive process, surgery, or in cases where pus, pushing the tissues apart, finds new containers, an indefinite, atypical location of the subdiaphragmatic abscess is observed.
A "median subdiaphragmatic abscess" is distinguished, which develops after resection of the stomach and borders on the right and behind the left lobe of the liver, with the stump of the stomach, below with the transverse mesentery OK and in front of the anterior abdominal wall. There is also a retroperitoneal subdiaphragmatic abscess, in which pus accumulates very high, between the extra-abdominal part of the liver and the diaphragm, and also between the sheets of the coronary ligament of the liver, forming the so-called extraperitoneal central subdiaphragmatic abscess; they make up from 2 to 18% of the number of all subdiaphragmatic abscesses, differing in a peculiar clinical picture [D.P. Chukhrienko and Ya.S. Bereznitsky, 1976].
The frequent right-sided localization of the subdiaphragmatic 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 by the presence of organs on the right, in which pathological processes most often lead to the development of this postoperative complication. The direction of peristalsis of the OK 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, JL. 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 and others]. 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. considered differentially, it turns out that after oncological operations on the stomach, a subdiaphragmatic abscess occurs in 2.2% of patients, after resection of the stomach for PU - in 0.9%, after surgery on the biliary tract - in 0.2%, after allendectomy - in 0.1% of patients.
Mortality in subdiaphragmatic abscess varies within a fairly wide range -10.5-54.5% [V.M. Sapozhnikov, 1976; V. Halliday, 1976]. It depends on the timely diagnosis, type of surgery, intensity of anti-inflammatory and antibiotic therapy. Of course, the experience of the surgeon in the treatment of this very severe postoperative complication cannot be ignored [M.I. Kuzin et al., 1976; I'M WITH. Bereznitsky, 1986].
In reducing mortality is of great importance:
1) timely, before the development of secondary complications, clinical and radiological diagnosis of abscesses, which allows you to operate in early dates;
2) the use of predominantly extraserous methods of drainage of purulent cavities;
3) the transition from open management of opened abscesses under tampons to a closed one, enabling 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 surgery for diseases of the esophagus, stomach, duodenum, pancreas, gallbladder and extrahepatic diseases. bile ducts(Y.S. Bereznitsky, 1986; O.B. Milonov et al., 1990]. Less commonly, a subdiaphragmatic abscess develops after surgery on the intestines (6.1%), as well as those performed for abdominal injuries (6.6%) and others. diseases (5.6%).
Subdiaphragmatic abscess often occurs after surgery for destructive forms of appendicitis, cholecystitis, perforated gastroduodenal ulcers, acute purulent and hemorrhagic pancreatitis [KD. Toskin and V.V. Zhebrovsky, 1986]
Complications are equally common in both sexes. Patients are predominantly elderly and old age. The predisposing factors for the formation of an abscess are the neglect of acute surgical diseases of the abdominal organs and the 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 a subdiaphragmatic abscess should be considered the inhibition of systemic and immunological reactivity [Ya.S. Bereznitsky, 1986].
Very rarely, a subdiaphragmatic abscess occurs due to hematogenous or lymphogenous spread of infection from any single focus. Even more rarely, the suppurative process spreads into the subdiaphragmatic space from the pleural cavity.
Bacteriological examination of the microflora of pus reveals different kinds microorganisms and their associations, more often E. coli, Staphylococcus aureus and white, anaerobic flora [O.B. Milonov et al., 1990].
In our opinion, in a significant proportion of cases, a subphrenic abscess develops, passing through the stage of subphrenic peritonitis. During operations on the stomach, gallbladder, with perforations of these organs, infection of the peritoneum of varying intensity occurs within the subdiaphragmatic space. As a result, a limited widespread subdiaphragmatic peritonitis often develops, which in the future may have a different course and a different outcome [A.K. Shilov, 1969].
Subphrenic peritonitis can be serous, end in recovery, or go to the next stage - become fibrinous-purulent, which, in turn, can turn into a septic focus and form into a subphrenic abscess.
In the formation of an inflammatory infiltrate with a subdiaphragmatic abscess, the walls of neighboring organs, parts of the diaphragm adjacent to the abscess, and the greater omentum take part. The formed abscess usually has a connective tissue capsule. About 15-35% of subdiaphragmatic abscesses contain gas [D.P. Chukhrienko, Ya.S. Bereznitsky, 1976, 1986]. Subdiaphragmatic abscess can give a number of intra-abdominal complications. These include: perforation into the abdominal cavity, diffuse peritonitis, perforation through the abdominal wall to the outside, and so on.
The high frequency of intrathoracic complications (pleurisy, pleural empyema, bronchopulmonary fistula (Figure 16), pericarditis, mediastinal abscess, pneumonia, pneumothorax, lung abscess) allows us to consider subdiaphragmatic abscess as a thoracoabdominal pathology [Ya.S. Bereenitsky, 1986; ABOUT. Milonov et al., 1990].
Figure 16 Fistula between abscess cavity and bronchial tree
Clinic and diagnostics subdiaphragmatic abscess is extremely difficult. They are characterized by a severe course and are masked by the symptoms of those diseases that serve as their source, as well as significant absorption of pus. This is facilitated by the abundance of lymphatic tracts of the subdiaphragmatic space. The complexity of diagnosis is due to the small number of reliable clinical signs and their frequent masking by the picture of the underlying disease. Therefore, in relation to the diagnosis of a subdiaphragmatic abscess, the old saying of Deniss is true: "When there is pus somewhere, but pus is not found anywhere - pus under the diaphragm." The condition of patients is usually severe. There is a lack of positive dynamics in the postoperative period, loss of body weight.
The symptomatology of a subdiaphragmatic abscess is very diverse. It is characterized by two groups of symptoms - general and local. This complication develops acutely (usually for 3-10 days) and is accompanied by pronounced general phenomena or, as they are also called, early signs: general weakness, loss of strength, rapid fatigue, deterioration, tachycardia, shortness of breath, persistent fever, increased respiration, changes in the blood picture (leukocytosis, shift leukocyte formula to the left). Later, hysteria of the sclera, effusion in the pleural cavity, and icteric coloration of the skin appear. The latter has more prognostic than diagnostic value. Usually, the symptoms depend mainly on the intoxication of the body. A very constant symptom is an increase in heart rate up to 120 beats / min. This speaks of high degree intoxication, representing a formidable phenomenon.
The initial stage is often manifested by the clinical picture of pleurisy or lower lobe pneumonia.
local symptoms 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. Constantly high temperature (38-40 ° C) indicates the most severe abscess, which is large and insufficiently limited by the capsule. Often this temperature is periodically accompanied by chills. At hectic temperature, which is observed most often, daily temperature ranges reach 2 °C [M.I. Kuzin et al., 1976].
Some patients have intermittent fever, in which the subfebrile temperature alternates with a higher one. This is usually observed in cases where, against the background of massive antibacterial and polydrug therapy, the complication develops very slowly and secretly. The temperature reaction is absent mainly in sharply 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. Pain in the abdomen (usually moderate) radiates to the shoulder girdle, shoulder blade 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), do not participate in respiratory movements.
Rise and fluctuations in temperature are intermittent symptoms. However, there is usually no very high temperature with a subdiaphragmatic abscess. Its fluctuation within 37.5-38.5 "C is more often noted. A rather early and pathognomonic sign is a change in the direction of breathing. With a subdiaphragmatic abscess, the excursion of the diaphragm is painful; breathing is superficial, the patient, as if for fear of causing an excursion of the diaphragm, tries to hold his breath , therefore, there is a lagging of the affected half of the chest during respiratory movements.It is also characteristic to identify the frenicus symptom of pain with pressure between the legs of the sternocleidomastoid muscle.
There is pain along the IX-XI intercostal spaces. One of the early symptoms of a subdiaphragmatic abscess is hiccups due to irritation of the branches of the phrenic nerve. With the immobility of the diaphragm and the limited process, vomiting and belching are possible. The fate of patients for this reason develops a moderate respiratory failure. The temperature later becomes hectic. Sometimes patients complain about pulling pain in the right half of the chest and epigastric region, radiating to the neck. The pain increases with a change in position. Gradually, all the signs of a catastrophe appear in the upper floor of the abdominal cavity.
Signs of severe intoxication are revealed: pallor skin, pointed features and a feverish gleam in the eyes. Consciousness is usually preserved, as in any purulent infection, excitation, delusional state, hallucinations can be observed. This complication develops gradually. On the 3-10th day after the operation, instead of the expected improvement in the general condition, deterioration occurs. The patient complains of general weakness, malaise, constant pain in the upper abdomen, feeling of pressure or heaviness, fever. The pain is aggravated by movement or coughing (cough symptom) and radiates to the shoulder and shoulder blade. Pain in the area shoulder joint in some patients it is so intense that it deprives sleep. Often, the onset of development of a subdiaphragmatic abscess is masked by symptoms of the underlying disease.
Postoperative subdiaphragmatic abscess develops slowly and therefore is diagnosed late. The expected improvement in the condition of patients does not occur. The temperature does not decrease, sometimes, on the contrary, it even rises. The pulse quickens, the pain in the lower parts of the chest increases. Deterioration is often mistaken for a pulmonary complication (especially since reactive pleurisy is often noted in RI).
When the abscess is localized in the anteroinferior space, symptoms characteristic of lesions of the abdominal organs prevail, and in the region of the dome of the diaphragm, the chest. The general condition of patients is different. With prolonged formation of a subdiaphragmatic abscess, the patient usually develops weakness, sleep and appetite are disturbed. The temperature, as a rule, rises, acquiring a hectic character.
On examination, the patient is usually inactive, tries to lie on his back or on the side where the abscess is located, with adducted hips. The patient takes such a forced position due to increased pain during 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 localization 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 subdiaphragmatic space [B.V. Petrovsky et al., 1965). Sometimes, when examining the chest in lean subjects, one can see the indrawing of the intercostal spaces with deep inspiration (Litgen's symptom).
Note that the lower chest and upper abdomen on the side of the lesion lag behind when breathing. During examination of the abdomen (especially with subhepatic abscesses), there are characteristic symptoms: 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 - Duchenne's symptom). On palpation of the abdominal wall and the lower half of the chest, there is pain and, accordingly, localization of the abscess, muscle tension. Palpation from the back reveals pain in the costal arch (IX-XI ribs) and intercostal spaces.
Note that a valuable symptom is punctate pain in the intercostal space at the edge of the costal arch, and this symptom can be considered the leading one, especially in relation to the localization of the inflammatory focus.
Valuable indications are given by hiccups - the result of a reflex of the inflamed peritoneum. It usually starts from the first or second, sometimes from the third day after the operation. This symptom is one of the earliest in cases of slowly developing postoperative subdiaphragmatic 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 region (Kryukov's symptom) on palpation and pressure. The area of pain in the neck, scapula, shoulder joint, the 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's symptom), dry excruciating 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 smoothed intercostal spaces on the affected side), displacement of the border of the heart.
It is necessary to be able to determine the balloting of the liver (Yaure's symptom). The surgeon puts one hand on the region of the right hypochondrium, the other makes jerky movements in the subscapular region. In some patients, a clear asymmetry of the chest (Langenbuch's symptom) and an inclination of the body forward and towards the lesion (Senator's symptom) are determined. Shortening of the percussion sound under the lower edge of the lung at the upper limit of dullness on inspiration is also characteristic (Leyden's symptom).
Abdominal symptoms are more often observed at low localizations of the subdiaphragmatic abscess: soreness and limited tension of the muscles of the anterior abdominal wall, palpable or visible protrusion in the hypochondrium and upper abdomen. On the side of the lesion, there is a presence in the wall of the right half of the abdomen of the transverse shaft of the thickened edge of the lowered abscess, bloating, and dyspeptic disorders. If the abscess is located under the diaphragm, the abdomen is usually soft on palpation, but the liver is mixed downwards. A noticeable tension in the muscles of the abdominal wall and severe pain are constant signs of subhepatic abscesses.
If the phenomena of local peritonitis are not expressed, then palpation often reveals a dense painful infiltrate. On percussion, the classic symptom of a subphrenic abscess containing gas, complicated by exudative pleurisy, is Barlow's phenomenon, in which a clear lung sound heard upward along the midaxillary line is successively replaced downward by zones of dull tympanic sound (Figure 17). This phenomenon is of diagnostic value only in gas-containing abscesses. large sizes[ABOUT. Milonov et al., 1990].
Figure 17. Alternation of percussion sound in a patient with a subdiaphragmatic abscess (scheme according to B.L. Ospovat)
Of the liver symptoms, pain in the lower chest should be noted; with its percussion - dullness, the border of which reaches the middle of the scapula; limited pain in the lower chest; tension of the soft tissues of this department and below the XII rib, sometimes pastosity of the soft tissues of the lower intercostal spaces (edema of the subcutaneous tissue, Moril's symptom), as well as smoothness and protrusion of the upper lumbar fossae in the absence of changes in the kidney area in front.
Auscultatory in the initial stages of pleurisy, you can listen to the pleural friction noise, which, when fluid appears in the costophrenic sinus, is replaced by the absence of respiratory noise in the lower lung. In other departments there is hard breathing with increased voice trembling and various rales.
It must be remembered that all of the above symptoms are not pathognomonic for a subdiaphragmatic abscess. Each of them individually can be observed at various diseases chest and abdominal organs. Only with their combination, as well as on the basis of the results of additional studies, the correct diagnosis should be made.
We distinguish between early and late signs subphrenic abscess. The early ones 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; late - swelling of the subcutaneous tissue of the lumbar region, positive symptom Kryukov and Barlow.
Late diagnosis of a 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, smoothed. Pain can be non-localized, in this regard, the leading symptom is persistent postoperative intestinal paresis, interpreted as early adhesive NK. Late diagnosis is also facilitated, as already noted, by a 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 hypochondria, tension of the abdominal wall in these areas, while it is absent 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, weakening of breathing, increased heart rate, leukocytosis, increased ESR, hiccups, etc., in most cases, a diagnosis can be made.
Diagnostics is also aided 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 have hylochromic anemia due to a decrease in the number of red blood cells and a decrease in hemoglobin. There are also pronounced disturbances of biochemical processes, manifested in a change 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 (catepsin 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. Direct radiological signs of a subdiaphragmatic abscess, which are of decisive importance, include the presence of gas above the horizontal fluctuating level of the liquid. However, it should be remembered that not always abscesses contain gas; in addition, the presence of gas under the diaphragm after laparotomy can serve as a source of diagnostic error.
With the localization of an abscess 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 OC is interposed between the liver and the abdominal wall, gas under the diaphragm is also observed, which may cause an erroneous conclusion. For a subphrenic abscess that does not contain gas, an increase in the shadow of the liver and the fuzziness of its contours are characteristic. By given reasons these signs make it possible to determine a subdiaphragmatic abscess in some patients (25-30%) [G.N. Zakharova et al., 1985].
With an erased clinical picture of a subdiaphragmatic abscess, a complex of x-ray studies is performed in the horizontal and vertical positions of the patient, if necessary, x-rays in a later position with contrasting of the stomach and duodenum.
Despite the serious condition of the patient, RI should be carried out in a vertical position, since the images taken in horizontal position are usually less informative. However, if the patient's condition still does not allow performing the study in a vertical position, it is necessary to conduct it in a horizontal position both in frontal projection and in later positions. It should be noted 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 repeatedly.
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 OK, an area of solid darkening under the diaphragm, a change in the position of neighboring organs, flatulence [I.L. Rabkin et al., 1973].
To detect a subdiaphragmatic abscess, especially at an 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], citrate 67 Ca [N. Cattee et al., 1977], and leukocytes labeled with 111 J [B. Solleman 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 gives reason to assume 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 detecting subdiaphragmatic abscess, especially in early diagnosis[EL. Berseneva, 1984; E.L. Bazhenov, 1986; R. Kochler, 1980; M.L. Meyers, 1981]. It gives especially useful information in those cases when it is impossible to exclude with certainty a purulent complication according to the available indirect x-ray signs and data from other research methods (ultrasound); if necessary, a detailed description of the abscess detected using traditional RI, its exact localization, relationships with neighboring organs, as well as determining the optimal operational 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 RI, as well as to establish the exact localization, size, relationship of the abscess with vital organs, which is of great importance in determining tactics surgical treatment.
On CT scan, a subdiaphragmatic abscess is defined as soft tissue, in most cases, inhomogeneous masses in the upper sections, in which irregularly shaped gas bubbles are visible.
With the localization of an infiltrate or abscess in the right posterior superior and anterior superior and left upper sections of the subdiaphragmatic space, characteristic changes in the adjacent zone between the abdominal and chest cavities, in fiber, muscles, as well as in the liver and kidney of the corresponding side [D.I. Krivitsky et al., 1990].
With ultrasound, the detection of an acute subdiaphragmatic abscess is associated with certain difficulties. The thin wall of the abscess is indistinctly differentiated from the surrounding tissues. The thickened and compacted wall of a chronic abscess is more echogenic. A clear identification of gas in the abscess cavity is difficult due to the same echogenicity of the gas of the intestine, superimposed on this area.
Infrared thermography reveals a focus of sharply increased infrared radiation with clear boundaries and a homogeneous structure, respectively, of the projection of the inflammatory focus.
The use of liquid crystal thermography in dynamics reveals the "hot" zones of the blue glow of the inflammatory-infiltrative process; green-violet glow on a red-brown background characterizes abscess formation; The "cold" zone in the projection of the encysted abscess indicates the formation of a limited cavity.
To clarify the diagnosis of subdiaphragmatic 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, J.A. 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 the effusion or its absence are assessed.
The final diagnostic method for 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 the danger of damage to the lung, liver, spleen or other organs is not excluded.
The presence of an abscess is evidenced by pus. If it is absent, the patient should be given an inclined position, while measuring the ratio of pus and gas bubble. After receiving pus, without removing the needle, open the abscess. If there is no pus, then the needle is removed with a constant vacuum in the syringe (danger of infection of the pleural cavity).
During the puncture, two main conditions are observed:
1) be ready for immediate operation;
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 a subdiaphragmatic abscess consists in gentle surgery, good hemostasis, in the time of the operation, the correct implementation of surgical techniques during surgical interventions on the abdominal organs. Rough handling of tissues, leading to disruption of the peritoneal endothelium, leaving blood clots, hematomas as a good nutrient medium for microorganisms, should be avoided, thorough treatment of the abdominal cavity, intensive antibiotic therapy should be carried out.
Treatment of postoperative subdiaphragmatic abscess is sometimes carried out by multiple punctures under the control of ultrasound and CT. Multiple punctures of abscesses allow, in addition to medical measures(evacuation of pus, washing the cavity of the abscess with solutions of antiseptics and antibiotics, drainage of the cavity of the abscess with silicone tubes) to conduct a bacteriological examination of the pus [F.I. Todua, M.Yu. Vilyavin, 1986 and others].
For small abscesses up to 3-4 cm in diameter, microdrainage is used according to the Seldinger method. For large subdiaphragmatic abscesses, transthoracic drainage according to Monaldi 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 antibiotic therapy can also cure patients. However, it should be noted that during puncture there is great danger infection of the pleural cavity. In addition, there is no confidence in the complete evacuation of pus.
Sometimes the abscess cavity has a rather complex structure, part of it can lace off with adhesions, and then some decrease in intoxication under the influence of punctures and antibiotic therapy can be positive effect treatment. Some prospects for conservative therapy appeared after the Kanshin method was used in the treatment of closed abscesses (Figure 18), the principle of which is to combine constant irrigation of the abscess cavity antibacterial agents with continuous active suction. For a wide range of practical surgeons, only the surgical method is recommended.
Figure 18. Drainage of abscesses according to H.H. Kanshin
primary goal surgical treatment- wide opening, emptying of the abscess cavity, its adequate drainage. Note that the opening of the subdiaphragmatic abscess is dangerous for the patient due to the complex topographic and anatomical relationships of the organs located here. When opening an abscess, it is necessary to approach it in the shortest way, avoiding wide contact with the pleural and abdominal cavities.
The prognosis of this complication, in addition to the timeliness of the diagnosis, also depends on rational surgical access, the correct choice of the drainage method, a full-fledged antibacterial, desensitizing, detoxifying and restorative therapy [Ya.S. Bereznitsky, 1986]. The operation is performed under endotracheal anesthesia (the patient must lie on the healthy side with a roller under the lumbar region in order to form "scoliosis" of the lower part of the thoracic and lumbar spine).
Surgical approaches to the subdiaphragmatic abscess are determined by their localization. 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 median location of the abscess is noted (Figure 19).
Figure 19. Drainage of subdiaphragmatic abscesses according to Lauenstein-Clermont:
1 - cut line; 2 - cavity of the abscess; 3 - liver; 4 - fascia; 5 - parietal peritoneum
In these cases, it is important to carefully delimit the free sections of the abdominal cavity before opening the abscess, which is drained through additional contra-openings.
Operations are often performed by extra-pleural or extra-abdominal posterior or postero-lateral Melnikov's approach (Figure 20).
Figure 20. Lumbar extraserous approach to the subdiaphragmatic abscess according to Melnikov:
a - dissection of the periosteum over the XII rib: b, c - mobilization of the rib; d - subperiosteal resection of the rib
With pustules located closer to the anterior abdominal wall, an incision of the soft tissues of the anterior abdominal wall is made along the costal arch (on the right or left side) of the IX or X ribs from the outer edge of the rectus abdominis muscle to the anterior axillary line, and the peritoneum is separated from the costal arch and diaphragm in a blunt way to the abscess. The peritoneum is mobilized until the abscess cavity is reached, into which the drainage tube is inserted, preferably through a separate incision in the minimum low place in relation to the abscess cavity (Figure 21).
Figure 21. Transpleurodiaphragmatic approach:
a - subdiaphragmatic 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 sheets and drainage
With regard to abscesses located in the posterior part of the subdiaphragmatic space, access A.B. is usually used. Melnikov. In this case, the incision is made along the X or XII ribs, for 5-6 cm between the anterior and posterior axillary lines with subperiosteal resection of the ribs for 10-12 cm. When accessing through the bed of the X rib, if there is no fusion of the pleural sheets, the costal pleura is sutured to the diaphragm with interrupted sutures to reduce the possibility of infection of the pleural cavity.
Through the bed of the XI rib, access to these abscesses is rather difficult and may be less effective for postoperative drainage. After resection of the rib, the subdiaphragmatic space is punctured with a thick needle, and after receiving pus, without removing the needle, the abscess is opened along the needle. If the costophrenic sinus of the pleura interferes with the dissection of the diaphragm, the surgeon stupidly mobilizes it upwards.
After the evacuation of pus with an electric suction, the abscess cavity is examined with a finger, washed with a solution of furacilin and drained with a double-lumen tube.
If this fails or the sinus is damaged, then the sheets 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 upwards or it is completely obliterated, the diaphragm is incised without prior suturing. The diaphragm is dissected carefully to the peritoneum.
Before opening the abscess, the upper edge of the transected diaphragm is sutured to the muscles top edge chest wounds, which allows you to further isolate the pleural cavity and restore the attachment of the damaged diaphragm. Next, open the abscess along the entire length of the wound. When opening an abscess from the upper median laparotomic access, lavage of the abdominal cavity is performed.
If necessary, counter-opening is done 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 counter-opening significantly improves the outflow of contents. Extrapleural accesses are well tolerated by patients, as they are not accompanied by respiratory disorders.
Abscesses located in the right anteroposterior, right inferior, left anteroinferior and left upper sections under the diaphragm can also be drained through the anterior abdominal wall, the incision is made 3 cm above the costal margin 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 online access to abscesses of the upper half of the abdomen, they are used mainly with unclear localization, with their multiple and accidental detection during RL for other complications.
Purification of the abscess cavity from pus and necrotic masses is performed with care so as not to cause severe capillary bleeding. Since several abscesses may form in the subdiaphragmatic space, an intraoperative examination is necessary. Sometimes these abscesses communicate with each other, therefore, on the operating table after the removal of pus, it is appropriate to carry out "abscessography".
Quite often, the presence of other communicating cavities can be detected on the radiograph, which dictates the need for additional drainage through the counter-opening, followed by washing with antibacterial solutions. After opening the abscess, pus or exudate should be taken to bacteriological research. To wash the cavity of abscesses, first use a 3% solution of hydrogen peroxide, then other antiseptic liquids. In the fight against both aerobic and anaerobic non-clostridial infections, solutions of furacilin, 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 drainages through counter-openings of small sizes. The main laparotomic incision is tightly sutured for prevention, to avoid suppuration of the postoperative wound and the possibility of eventration. Drainages are changed 6-7 days after the operation; covered with mucus, they easily come out. Drainage of the cavity should be carried out until complete obliteration, achieving its implementation with granulations from the depth (open method). With a closed method of treatment, the purulent cavity is drained with two- or single-channel tubes that can provide all 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-opening 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, nitrafuran preparations.
With the development of abscesses with bilateral localization at the same time, first of all, an abscess of a 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, a shift of the leukocyte formula to the left, this makes one look for another source of intoxication and leads to the recognition of an abscess of another localization. In the postoperative period, multicomponent treatment is carried out: antibacterial therapy, restorative treatment, the introduction of low molecular weight dextrons, vitamins, cardiac drugs, protein preparations, detoxification (hemodez, polydez) of glucose with insulin and correction of immunity.
- a local abscess formed between the dome of the diaphragm and adjacent organs of the upper floor of the abdominal cavity (liver, stomach and spleen). Subdiaphragmatic abscess is manifested by hyperthermia, weakness, intense pain in the epigastrium and hypochondrium, shortness of breath, cough. Examination of the patient, X-ray data, ultrasound, CT, general analysis blood. For a complete cure of the subphrenic abscess, a surgical opening and drainage of the abscess is performed, antibiotic therapy is prescribed.
General information
Subdiaphragmatic abscess is a relatively rare, but very serious complication of purulent-inflammatory processes in the abdominal cavity. The subdiaphragmatic abscess is located mainly intraperitoneally (between the diaphragmatic sheet 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, subdiaphragmatic abscesses are divided into right-sided, left-sided and median. Most often there are right-sided subdiaphragmatic abscesses with anterior superior localization.
The shape of the subdiaphragmatic abscess can be different: more often - rounded, when compressed by organs adjacent to the diaphragm - flat. The content of the subdiaphragmatic abscess is represented by pus, sometimes with an admixture of gas, less often - gallstones, sand, feces.
A subdiaphragmatic abscess is often accompanied by the formation of a pleural effusion, with a significant size, to one degree or another, it exerts pressure and disrupts the functions of the diaphragm and neighboring organs. Subdiaphragmatic abscess usually occurs in 30-50-year-old patients, while in men it is 3 times more common than in women.
The reasons
The main role in the occurrence of subdiaphragmatic abscess belongs to aerobic (staphylococcus, streptococcus, E. 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, resection of the pancreas. 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.
Subdiaphragmatic abscesses can occur as a result of thoracoabdominal injuries: open (gunshot, stab or cut wounds) and closed (bruises, compression). Hematomas, the 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 subdiaphragmatic abscess, the leading role is played by inflammatory processes abdominal organs (abscesses of the liver, spleen, acute cholecystitis and cholangitis, pancreatic necrosis). Less commonly, a subdiaphragmatic abscess complicates the course of destructive appendicitis, salpingo-oophoritis, purulent paranephritis, prostatitis, festering echinococcus cyst, retroperitoneal phlegmon. The development of a subdiaphragmatic abscess is possible with purulent processes in the lungs and pleura (pleural empyema, lung abscess), osteomyelitis of the lower ribs and vertebrae.
The spread of purulent infection from the 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 also lymph flow.
Symptoms of a subdiaphragmatic abscess
AT initial stage subdiaphragmatic abscess, general symptoms can be observed: weakness, sweating, chills, remitting or intermittent fever, characteristic of other abdominal abscesses (interintestinal, appendicular, Douglas space abscess, etc.).
A subdiaphragmatic abscess is characterized by the appearance of a feeling of heaviness and pain in the hypochondrium and lower chest on the affected side. Pain can vary in intensity from moderate to acute, and worsen with active movement, deep breathing and coughing, radiate to the shoulder, shoulder blade and collarbone. There is also hiccups, shortness of breath, painful dry cough. Breathing is rapid and shallow, the chest on the side of the abscess lags behind when breathing. A patient with a subdiaphragmatic abscess is forced to take a semi-sitting position.
Diagnostics
Detection of a subdiaphragmatic abscess is facilitated after its full maturation. For the purpose of diagnosis, the data of the anamnesis and examination of the patient, the results of X-ray, ultrasound, laboratory studies, and CT are used.
Palpation of the upper abdomen with a subdiaphragmatic abscess shows soreness and muscle tension of the abdominal wall in the epigastric region or in the hypochondria. Smoothness and expansion of the intercostal spaces, protrusion of the hypochondrium is revealed, with a right-sided abscess - an increase in the liver.
If the subdiaphragmatic abscess does not contain gas, percussion of the chest reveals dullness above the border of the liver, decreased or no mobility of the lower edge of the lung. With the accumulation of gas in the cavity of the subdiaphragmatic abscess, areas of different tones (“percussion rainbow”) are revealed. Auscultation shows a change in breathing (from weakened vesicular to bronchial) and a sudden disappearance of respiratory sounds at the border of the abscess.
A laboratory blood test shows changes characteristic of any purulent processes: anemia, neutrophilic leukocytosis with a shift of the leukocyte formula to the left, an increase in ESR, the presence of C-reactive protein, and dysproteinemia.
The main value in the diagnosis of subdiaphragmatic abscess is assigned to x-ray and chest x-ray. A subdiaphragmatic abscess is characterized by a change in the area of the crura of the diaphragm, a higher standing 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 with gasless subdiaphragmatic abscesses is seen as a blackout above the line of the diaphragm, the presence of gas is seen as a band of enlightenment with a lower horizontal level between the abscess and the diaphragm. An effusion in the pleural cavity is determined (gastroenterology is a surgical opening and drainage of the abscess.
The operation for a subdiaphragmatic abscess is performed by transthoracic or transabdominal access, which allows to provide adequate conditions for drainage. The main incision is sometimes supplemented with counter-opening. The subdiaphragmatic abscess is slowly emptied and its cavity is examined. For quick cleansing of the subdiaphragmatic abscess, the method of forced-aspiration drainage with double-lumen silicone drains is used.
The complex treatment of subdiaphragmatic abscess includes antibacterial, detoxification, symptomatic and restorative therapy.
Forecast and prevention
The prognosis of a subdiaphragmatic abscess is very serious: an abscess can break into the abdominal and pleural cavities, pericardium, open up, be complicated by sepsis. Without timely surgery, complications in 90% of cases lead to the death of the patient.
To prevent the formation of a subdiaphragmatic abscess allows timely recognition and treatment inflammatory pathology abdominal cavity, exclusion of intraoperative injuries, thorough sanitation of the abdominal cavity in case of destructive processes, peritonitis,
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, behind the diaphragm, in front and from the sides - by the diaphragm and the anterior abdominal wall, from below - by the upper and posterior surface of the liver and supporting it bundles.
In the subdiaphragmatic space, intraperitoneal and retroperitoneal parts are distinguished. The intraperitoneal part of the falciform ligament of the liver and the spine is divided into the right and left sections. In the right section, the anterior superior and posterior superior regions are distinguished. The anterior-upper region is limited medially by the falciform ligament of the liver, posteriorly by the upper sheet 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 posterior-upper region is bounded in front by the posterior surface of the liver, behind - by the parietal peritoneum covering the posterior abdominal wall, from above - by the lower sheet of the coronary and right triangular ligaments of the liver (Figure 1). Both of the above areas communicate with the subhepatic space and with the abdominal cavity. The left-sided subdiaphragmatic space has a slit-like shape and is located between the left dome of the diaphragm from 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 surface of the stomach.
The retroperitoneal part of the subdiaphragmatic space has a rhomboid shape and is bounded above and below by the sheets of the coronary and triangular ligaments of the liver, in front - by the posterior surface of the extraperitoneal part of the left and right lobes of the liver, posteriorly - by the posterior surface of the diaphragm, 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 in the subdiaphragmatic space from local and distant foci.
Most common causes Subdiaphragmatic abscess: 1) direct (contact) spread of infection from neighboring areas: a) with a perforated stomach ulcer and duodenum, destructive appendicitis, purulent cholecystitis and liver abscess, b) with delimited and diffuse peritonitis of various origins, c) with postoperative complications after various operations on the abdominal organs, d) with festering hematoma due to closed and open injuries of parenchymal organs, e) with purulent diseases lungs and pleura; 2) lymphogenous spread of infection from the abdominal organs and retroperitoneal tissue; 3) hematogenous dissemination of infection from various purulent foci along blood vessels with furunculosis, osteomyelitis, tonsillitis and others; 4) often Subdiaphragmatic abscess occurs with thoracoabdominal wounds, especially gunshot wounds.
The microbial flora of the subdiaphragmatic abscess is diverse.
The penetration of infection into the subdiaphragmatic space contributes to the 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 size, the presence or absence of gas in them, and is often due to symptoms of a disease or complication, against which a Subdiaphragmatic abscess has developed. symptoms become blurred, and the course is often atypical. In 90-95% of cases, the Subdiaphragmatic abscess is located intraperitoneally, and right-sided localization is observed, according to Wolf (W. Wolf, 1975), in 70.1%, left-sided - 26.5%, and bilateral - 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 subphrenic abscesses after an acute, usually recent, acute disease of the abdominal organs or in the immediate postoperative period after abdominal operations, there are general weakness, temperature rise to 37-39 °, often with chills and sweating, tachycardia, an increase in leukocytosis with a shift of the 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 chest on the right, in the back, the right side of the abdomen or the right hypochondrium. Pain is usually aggravated by deep breathing, coughing, sneezing, and also by moving the torso. Sometimes there is irradiation of pain in the right shoulder, shoulder blade, shoulder girdle, right half of the neck. Common symptom is shortness of breath and pain with deep inspiration on the side Subdiaphragmatic abscess Some patients experience 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. It can be observed, especially with large abscesses, smoothness of the intercostal spaces in the lower half of the chest, thickening skin fold, pastosity, rarely hyperemia on the side of the lesion.
Retroperitoneal Subdiaphragmatic abscess in the initial stage are distinguished by an erased clinical picture and are manifested by dull or throbbing pains in the lumbar region, more often on the right, fever (37-38 °), leukocytosis and local pain in the abscess area. In the future, pastosity or swelling appears in the lumbar region and the region of the lower ribs, thickening of the skin fold, less often hyperemia. At the same time, the picture of purulent intoxication is growing.
Diagnosis. With anterior-upper abscesses, a lag in breathing of the anterior abdominal wall is often detected, tension and soreness in the right hypochondrium and epigastric regions, which is associated with inflammation of the peritoneal areas adjacent to the subdiaphragmatic 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 in subdiaphragmatic abscess largely depend on the size and location of the abscess, as well as changes in the topography of the organs of the chest and abdominal cavities adjacent to it. In the initial stage and with small accumulations of pus, percussion gives little information. As the abscess grows, the diaphragm moves upward and the liver is pushed downward, as a result of which the upper border of the diaphragm can rise to 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. With right-sided subdiaphragmatic abscess, percussion of the chest in a sitting position of the patient often reveals dullness of pulmonary sound in its lower sections, the boundaries of which run along an arcuate line with a 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 standing of the dome of the diaphragm, and therefore, during percussion, it is sometimes possible to detect a section of pulmonary sound in the interval between the subdiaphragmatic abscess laterally and cardiac dullness medially (Trivus symptom).
GG Yaure (1921) described a symptom in subdiaphragmatic abscess, which consists in the fact that when tapping with one hand on the posterior surface of the chest, the second hand, located on the abdominal wall, experiences jerky movements in the liver area. Right-sided gas-containing subdiaphragmatic abscess in some cases may be accompanied by the so-called percussion three-layered. A clear sound over the lung turns into a tympanic one in the area of gas localization and into a dull one over an abscess and liver (Barlow's phenomenon).
Tympanitis in the area of Traube's semilunar space (see the full body of knowledge: Traube's space) makes it difficult for percussion to recognize left-sided subdiaphragmatic abscess, which is detected in most cases only with large accumulations of pus.
Auscultation with a subdiaphragmatic abscess of small size 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, can be heard, especially on the right above the chest, sometimes with a bronchial tinge, which is usually not determined above the site of the abscess. When the patient is shaken in this area, it is occasionally possible to listen to the splashing noise.
X-ray examination for suspected subphrenic abscess includes transillumination and radiography with the patient in the vertical position of the patient's body, and, if necessary, in his position on his side, as well as on his back (see the full body of knowledge: Polypositional examination).
X-ray picture A subdiaphragmatic abscess consists of the image of the abscess itself, the displacement of neighboring organs and signs of acute diaphragmatitis (see the complete code of knowledge: Diaphragm). With a subdiaphragmatic abscess of traumatic origin, this may be added radiological signs damage to the chest and organs of the chest and abdominal cavities, as well as the shadow of foreign bodies.
X-ray diagnostics is most effective in the case of a gas-containing subdiaphragmatic abscess. During fluoroscopy and radiography, performed in the vertical position of the patient (in a serious condition of 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 fluid moves into the cavity, and its level remains horizontal and changes little in size, which distinguishes the subdiaphragmatic abscess from the accumulation of gas and fluid in the stomach or intestinal loop. Pictures 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 this space or only its anterior, posterior or lateral sections. With left-sided localization, it is possible to distinguish between a near-splenic subdiaphragmatic abscess and abscesses that have formed above or below the left lobe of the liver. In some cases, not one, but two or three cavities are observed (Figure 3).
A right-sided Subdiaphragmatic abscess that does not contain gas does not give an independent image on ordinary photographs, a left-sided one causes intense darkening, distinguishable against the background of gas in the stomach and intestines. Differential diagnosis of a subphrenic abscess and an intrathoracic pathological process in such cases is helped by a symptom of deformation and pushing down the fornix of the stomach and the left (splenic) flexure colon. For greater confidence, the patient is given inside two or three sips of an aqueous suspension of barium sulfate. If at the same time an impression is detected on the roof of the stomach, then this means that the infiltrate is located under the diaphragm. In the case of a subdiaphragmatic abscess that developed due to insufficient anastomotic sutures after gastric resection, the contrast mass sometimes passes from the stomach into the cavity of the subdiaphragmatic abscess
New opportunities in the recognition of subdiaphragmatic abscess were opened by computed tomography (see the full body of knowledge: Computer tomography), ultrasound diagnostics (see the full body of knowledge) and angiography (see the full body of knowledge). On computed tomograms, a direct image is obtained. Subphrenic abscess. This establishes the exact localization of the abscess, including the distinction between intraperitoneal and extraperitoneal abscess, located between the sheets of the coronary ligament or above the upper pole of the kidney. Aortography (see the complete body of knowledge) in combination with celiacography (see the full body of knowledge) makes it possible to determine the position and condition of the diaphragmatic and hepatic arteries. Along with data ultrasound scanning it makes it easier sometimes difficult task differentiation Subphrenic abscess with liver abscess.
Of great importance in radiodiagnosis Subdiaphragmatic abscess, according to M. M. Vikker (1946), V. I. Sobolev (1952), has a syndrome of acute diaphragmatitis. It is expressed in the 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 fuzzy contours of the diaphragm due to its edema and inflammatory infiltration. Costophrenic sinuses decrease due to fiber infiltration and reactive effusion. As a rule, small atelectasis and foci of lobular pneumonia at the base of the lung and effusion in the pleural cavity join this. However, the syndrome of acute diaphragmatitis with damage to the right half of the diaphragm can be with a liver abscess (see full body of knowledge). Therefore, for the final conclusion, it is very important to compare the clinical, symptoms and results of X-ray, radionuclide and ultrasound studies.
With a subphrenic abscess of medial localization, there is a thickening of the legs of the diaphragm and the disappearance of their outlines. With a retroperitoneal adrenal subdiaphragmatic abscess, blurring or lack of outlines of the upper pole of the kidney is noted on the pictures, and with a large abscess, the kidney is shifted downward.
In the case of a diagnostic puncture of an abscess, some surgeons and radiologists consider it appropriate to replace some of the pus removed with gas or high-atomic tri-iodinated contrast agent. This provides a complete picture of the position and size of the purulent cavity and usually facilitates differential diagnosis Subphrenic abscess with liver abscess.
With a subdiaphragmatic abscess as a result of a gunshot wound, the development of an external purulent fistula is possible (BV Petrovsky). At the same time, they resort to fistulography (see the full body of knowledge) to study the direction and extent of the fistulous tract, identify purulent streaks, establish a connection between the fistula and the abscess cavity, foci of destruction in damaged bones, and foreign bodies.
Treatment. Conservative treatment A subdiaphragmatic abscess is usually done when the diagnosis is in doubt or for the purpose of preoperative preparation. It consists in the appointment of antibacterial and detoxification therapy and the treatment of the underlying disease that served as the source. Subdiaphragmatic abscess Diagnosed Subdiaphragmatic abscess is subject to mandatory opening and drainage.
Surgical access and the nature of surgical intervention largely depend on the location of the subphrenic abscess and associated complications.
Transpleural access was first described by Roser in 1864. It consists of a thoracotomy (see the complete body of knowledge) in the area of the projection of the abscess, dissection of the diaphragm, opening and drainage. flowing heavily.
To prevent this complication, F. Trendelenburg (1885) developed the following method. An incision is made along the X rib from the side between the posterior and anterior axillary lines on the right or behind 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 subdiaphragmatic abscess is opened with a longitudinal incision between the sutures through the pleura and diaphragm.
Many surgeons prefer to use the extrapleural approach developed by A.V. Melnikov in 1921. With this approach, the diaphragm is exposed and opened. The subdiaphragmatic abscess is performed 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 localization. Subphrenic abscess in the anterior or posterior part of the subphrenic 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), the periosteum is dissected over several centimeters and peeled off from the pleural sinus, which is sharply and bluntly separated from the chest wall and pushed upward. 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 subdiaphragmatic abscess includes retroperitoneal access, which is more often used for right-sided postero-superior abscesses. This operation is based on the fact that the pleural sinus on the right almost never descends below the spinous process of the 1st lumbar vertebra. The operation is performed with the patient on the left side. The incision is made along the XII rib with its subperiosteal resection. A transverse incision at the level of the spinous process of the 1st lumbar vertebra dissects the posterior periosteum sheet, adjacent intercostal and serratus posterior muscles, and exposes the diaphragm near its attachment. The latter is opened and the peritoneum covering the lower surface of the diaphragm is peeled off, the Subdiaphragmatic abscess is found (Figure 6) and opened.
Most surgeons use the very convenient extraperitoneal subcostal approach (Figure 7) proposed by P. Clairmont in 1946 to open right-sided anterior-superior abscesses. The incision runs parallel to and immediately below the costal arch. The muscular-aponeurotic layers of the anterior abdominal wall are dissected in layers to the parietal peritoneum, which is bluntly peeled off from inner surface diaphragm to Subdiaphragmatic abscess The latter is opened and drained.
Mortality in subdiaphragmatic abscess depends on the nature of the underlying disease, the localization of the abscess, the age of the patient, concomitant diseases, the duration of the disease, the timeliness of recognition and the timing of surgical intervention. According to Wang and Wilson (S. Wang, S. Wilson, 1977), lethality in subdiaphragmatic abscess that occurred after emergency operations, was 35%, after planned - 26%, and the overall mortality - 31%.
Clinic, diagnosis and treatment Subdiaphragmatic abscess in children do not differ from those in Subdiaphragmatic abscess in adults.
Are you categorically not satisfied with the prospect of irretrievably disappearing from this world? You don't want to end your life path in the form of a disgusting rotting organic mass devoured by grave worms swarming in it? Do you want to return to your youth to live another life? Start all over again? Fix the mistakes you've made? Fulfill unfulfilled dreams? Follow this link:
Page 40 of 67
A significant number of errors occur when recognizing complications such as subdiaphragmatic or subhepatic abscess. A subdiaphragmatic abscess is a disease of unknown origin, difficult to diagnose, complex in course and severe in outcome (V. M. Belogorodsky, 1964).
With an unfavorable course of the postoperative period of a perforated ulcer of the stomach and duodenum, acute cholecystitis, acute appendicitis and pancreatitis, it is necessary to think about the possibility of subdiaphragmatic abscesses. According to 15 authors, in 3379 patients after suturing the perforated hole of the gastric and duodenal ulcer, subdiaphragmatic abscesses were observed in 1.9% of cases (I. I. Neimark, 1958).
T. A. Nadzharova (1942) cites materials from the staff of the Institute. N. V. Sklifosovsky: out of 1226 patients with perforated ulcers of the stomach and duodenum, 21 (1.7%) had a complication - subdiaphragmatic abscess.
According to V. M. Belogorodsky (1964), gastric ulcers as the cause of subdiaphragmatic abscess occurred in 24.7% of cases, appendicitis - in 20%, gallbladder disease - in 14.3% of cases.
About 85% of subdiaphragmatic abscesses were of intra-abdominal origin. Approximately 2/3 of patients underwent surgical intervention in the abdominal cavity. In 10% of patients, no reason for the occurrence of an abscess was found (Wendt, Hiibner, Kunz, 1968).
At the beginning of the development of this complication, the clinical picture is poorly expressed and diagnosis is difficult. The disease develops either acutely or slowly, the symptoms of a subdiaphragmatic abscess are vague and they may be characteristic of a liver abscess or exudative pleurisy, which is actually "sympathetic pleurisy." The symptomatology of a subphrenic abscess varies depending on its location: in front, behind, or in the upper part of the subphrenic space. Sometimes there is also a subhepatic abscess, which is located between the liver and stomach. Subhepatic abscesses can be independent or combined with subdiaphragmatic or other ulcers of the abdominal cavity. The clinical picture of subhepatic abscesses is more blurred than that of subphrenic abscesses. This is explained by the fact that a large organ is located at the top - the liver, which, covering the abscess, does not give physical changes in the lungs, therefore the position and function of the diaphragm do not change and there is no "sympathetic pleurisy". It is very difficult to determine radiographically the presence of a fluid level and a gas bubble under the liver.
The main complaints of patients: pain in the upper abdomen, high intermittent temperature with chills, a large amount of sweat, leukocytosis with a shift of the leukocyte blood count to the left. Often you can find icteric sclera, and sometimes jaundice of the skin. In connection with such a clinical picture, a diagnosis of "liver abscess or subphrenic, but not subhepatic" is made.
Subphrenic abscesses occur in patients of all ages. Intraperitoneal abscesses are more common and more rarely extraperitoneal abscesses. As a rule, subdiaphragmatic abscesses occur secondarily, are more often observed on the right (58%), less often on the left (37%) and are rarely bilateral (5%). The size of the abscess can vary from size hazelnut up to the size of the cavity, with a volume of 4-5 liters, which may contain pus with a variety of microflora (streptococci, staphylococci and other microbes). E. coli gives pus a fecal smell. Pus can perforate the diaphragm and enter the lungs, bronchi, pleural and abdominal cavities, pericardium, or intestinal lumen.
To avoid errors, late diagnosis or misrecognition of a subdiaphragmatic abscess, the following symptoms should be considered: bad feeling or deterioration of the general condition of the patient in the postoperative period, fever up to 39-40 ° with chills and profuse sweats. The temperature drops in the morning and rises in the evening. Usually found in blood increased amount leukocytes with a shift of the leukocyte formula to the left, ROE is accelerated. A feeling of pressure, heaviness, fullness and pain is noted in the hypochondrium or upper outer quadrant of the abdomen or epigastric region. These pains can radiate to the back or lower back, as well as upward to the supraclavicular and scapular regions, and can intensify when the patient moves. The patient develops nausea, vomiting, hiccups and flatulence.
Pain is localized in the intercostal spaces, especially when inhaling. When pressing on the IX, X, XI ribs on the side of the lesion, severe pain is noted (M. M. Kryukov, 1901). In a patient, when breathing, the affected side of the chest lags behind, on the same side at the bottom of the lungs there may be weakened breathing; in some patients, a pleural friction rub is heard and an increase in voice trembling is determined. There is shortness of breath and dry cough, with involvement in the process of the pleura, tachycardia and severe symptoms of intoxication. With percussion, the upper border of the liver rises and tympanitis is determined above it (due to the lung tissue).
During inspiration, sometimes there is a retraction of the epigastric region, and during expiration - a protrusion (Duchenne's symptom). With significantly pronounced symptoms, the patient's intercostal spaces are smoothed or protruded, or a protrusion may appear in the lumbar region or epigastric region. Fluoroscopy reveals high standing, limited movement or immobility of the diaphragm, and low liver position. An effusion may be found in the pleural cavity on the side of the lesion. Under the diaphragm, in 25-30% of patients, a horizontal level of fluid is found, and above it, a gas bubble, which is considered characteristic of abscessus subphrenicus. A reliable sign of a subdiaphragmatic abscess is the receipt of pus when the abscess is punctured.
Patient A., aged 28, was admitted with a typical clinical picture of a subdiaphragmatic abscess on the right. In the operating room, the abscess was punctured and pus was obtained. They gave me anesthesia. Suddenly there was a stoppage of breathing, it was not possible to restore breathing. Death on the operating table.
At autopsy: festering echinococcus of the liver; no subdiaphragmatic abscess was found.
Diagnostic puncture of the subdiaphragmatic space is not an easy manipulation and must be performed under local anesthesia in the place of the greatest protrusion, dullness and pain after the analysis of fluoroscopic data. Usually, II, III and IX intercostal spaces along the axillary lines are chosen for puncture. If the needle penetrates only into the gas bubble of the abscess, then a fecal odor appears, due to the presence of coli. Sometimes you have to do a lot of punctures (up to 20, according to VF Voyno-Yasenetsky, 1946) before you can find pus, sometimes they don’t get it, but an abscess is found at the autopsy. In one of the patients we observed, an abscess was found only after 12 punctures, and in another patient it was not found even after 13 punctures. The patient continued to have a fever, lost weight, the symptoms did not increase, X-ray a horizontal level and a gas bubble under the diaphragm were not noted. When pressing on the ribs, there was no pain, there were no protrusions of the intercostal spaces. During diagnostic punctures, pus was never obtained.
The patient died, and the autopsy revealed a small subdiaphragmatic abscess that had burst into the abdominal cavity.
The puncture should be performed on the operating table in order to immediately operate on the patient after receiving pus, without removing the needle, in order to avoid infection of healthy tissues, infection of the pleura, peritoneum and for a simpler approach to the abscess. With a "controversial" diagnosis, B. A. Petrov recommends performing an extrapleural or extraperitoneal opening of the site of the alleged abscess.
Lethality, according to old statistics (Maydl, Lang and Peritz), without surgical intervention reaches 85-100%. Surgery significantly reduces mortality. Before antibiotics deaths in patients with subphrenic abscesses were observed in 20% of cases.
Frequency this disease small. There are separate reports of the successful treatment of subdiaphragmatic abscesses by aspiration of pus, followed by the introduction of antibiotics into the cavity (Ya. D. Vitebsky, 1953; A. A. Gerasimenko, 1957; V. Ya. Shlapobersky, 1957, etc.). According to A. A. Gerasimenko, one patient was cured after 10 punctures, 2 - after 7, one - after 6, 2 - after 4, one - after 2 punctures; with a bilateral subdiaphragmatic abscess, 22 punctures were required within 90 days. After aspiration of pus, 200,000-600,000 units of penicillin, rarely 800,000 units of penicillin and 250,000 units of streptomycin were injected into the abscess cavity. V. M. Belgorodsky used sulfa drugs and penicillin in 27 patients, 13 of them recovered. The author speaks about the possibility of antibiotic treatment of infiltration and initial forms of subdiaphragmatic abscesses.
Rice. 14. Posterior extraperitoneal access to the abscess (according to W. A. Oshner and Graves):
a - liver, b - abscess, c - pleura, d - diaphragm, e - peritoneum.
At present, it is impossible to underestimate the appearance of penicillin-resistant forms of microorganisms. Antibiotic treatment should be used after laboratory determination of the sensitivity of pathogens to antibiotics. Where a pyogenic abscess capsule has formed, the puncture method of abscess treatment will not be effective and surgical treatment is necessary. 
Rice. 13. Diaphragm incision and exposure of the abscess capsule according to A. V. Melnikov:
a - sinus of the pleura, b - dissected diaphragm, c - ends of the excised rib, d - abscess capsule (according to V. M. Belogorodsky).
The patient is given a semi-sitting position on a healthy side and resection of the IX-X ribs is performed from the side (between the posterior and middle axillary lines) or from behind (inwards from the posterior axillary line). The abscess is opened after the parietal pleura is sutured to the diaphragm with an "overlap" suture. As a suture material, catgut or silk is used. Its thickness should be such that
when the thread was folded in half, it was not thicker than the needle, otherwise the thread will damage the pleura during stitching. After suturing the pleura in the sheathed area, the diaphragm is dissected and the abscess is drained.
This approach is dangerous in relation to infection of the pleural cavity. Infection of the pleural cavity during puncture or during surgery in these debilitated patients is often "fatal" for them. Therefore, depending on the location of the abscess - in front or behind - it is better to use an extrapleural-extraperitoneal incision. If the abscess is located in front, then the incision is made along the IX or X ribs in front from the cartilage to the middle axillary line (Fig. 13), if behind, then along the XI-XII ribs from the long muscles of the back to the middle axillary line (Fig. 14) with rib resection. Bluntly peel off the pleura upwards, expose the diaphragm, which is dissected, peel off the peritoneum to the abscess and drain it. When the abscess is located in front, you cannot approach it from behind and vice versa. In the postoperative period, the patient under the control of the X-ray screen can adjust the position of the rubber drainage in the cavity in accordance with the presence of fluid under the diaphragm.
In some patients, intraperitoneal access to a subdiaphragmatic abscess is allowed; located in the abdominal cavity. In the presence of postoperative suppuration in the wound, the latter opens. Having found an abscess, it is opened, having previously introduced tampons that isolate the abscess from the free abdominal cavity and cause the formation of adhesions afterward, isolating the site of the operation of the former abscess.
After surgery, the principles of treatment of subdiaphragmatic abscesses consist in a set of measures, which we briefly discussed in the section on peritonitis.