Subphrenic Abscess

Subphrenic Abscess: Overview

Alternative names: Subdiaphragmatic Abscess

A subphrenic abscess is a localized accumulation of pus in the abdominal cavity just beneath the diaphragm in the "subphrenic space".  This is the space between the diaphragm (which separates the chest cavities from the abdominal cavity) and the transverse colon.

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There may be more than one area of pus accumulation – a "multiple-space abscess".  About 50% of subphrenic abscesses are right-sided; about 25% are left-sided; about 25% are bilateral (on both sides).

Incidence; Causes and Development; Contributing Risk Factors

This condition usually affects the elderly.

A "primary" abscess is one for which no cause can be found.  The vast majority of subphrenic abscesses are "secondary" (due to a known cause), typically developing 3 to 6 weeks after abdominal surgery such as biliary surgery, appendix surgery or surgery on the stomach or duodenum.  About half of all cases are due to complications of abdominal surgery.

Risk factors for secondary subphrenic abscess include:

Signs and Symptoms

Symptoms can be very mild in the beginning, for example a fever, dry cough and loss of appetite.  A comprehensive list of symptoms includes the following:

  • Pain in the chest and/or upper abdomen on the affected side, and/or shoulder
  • Abdominal tenderness
  • Abdominal swelling
  • Nausea
  • Vomiting
  • Fever
  • Chills
  • Sweating
  • Edema, especially of the abdomen and/or lower legs
  • Loss of appetite
  • Non-productive cough
  • Rapid heart rate
  • Rapid breathing
  • Difficult breathing
  • Absence of breathing sounds
  • Absence of bowel sounds
  • Foul-smelling sputum
  • Tenderness across the eighth through twelfth ribs ("Krukow's sign")
  • Mental confusion/apprehension
  • Chronic hiccoughing
  • Jaundice
  • Leukocytosis
  • Anemia

Diagnosis and Tests

The upper abdominal pain is severe on deep palpation by the physician.  Blood tests (including CBC with white blood cell differential, erythrocyte sedimentation rate) show a leukocytosis and the patient may be anemic.  Blood and/or urine cultures may show presence of specific bacteria.

A chest X-ray may show the abscess cavity containing gas from gas-producing bacteria, lung abnormalities, pleural effusions, and/or an immobile diaphragm.

Other useful diagnostic tests include ultrasound for a right-sided subphrenic abscess and a CT scan for a left-sided subphrenic abscess.  Hidden intra-abdominal or subphrenic abscesses can be detected by using radioactive isotope scanning such as an indium-111-labeled leukocyte.  An MRI may also be helpful.

Treatment and Prevention

Conservative treatment consists of nutritional support and broad-spectrum antibiotic therapy.

As with any other abscess, a drainage needs to be performed and the infection needs to be treated with appropriate antibiotics.  Because of the location of a subphrenic abscess, this can be a complex procedure.

Patients who are malnourished or have a weakened immune system need proper nutrition (via intravenous feeding if necessary) in order to heal properly and fight the infection.

Prognosis; Complications

Conservative (nonsurgical) treatment consisting of nutritional support and antibiotic therapy results in poor survival rates.  Operative treatment with no antibiotics improves survival, while using antibiotics in combination with surgery reduces mortality substantially.  The overall mortality rate is about 35% even with the best therapy.

Complications include:

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Subphrenic Abscess:

Signs, symptoms & indicators of Subphrenic Abscess:

Symptoms - Abdomen

Moderate/severe/significant right hypochondriac pain or mild right hypochondriac discomfort

The pain occurs on the affected side, in the chest, upper abdomen, and/or shoulder.

Moderate/severe/significant left hypochondriac pain or mild left hypochondriac discomfort

The pain occurs on the affected side, in the chest, upper abdomen, and/or shoulder.

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