SUBPHRENIC ABSCESS (abscessus subdiaphragmaticus; synonym: subphrenic abscess, infradiafragmalny abscess) — the intra belly abscess which is located in subphrenic space.
Pus at P. and. it is localized in the natural pockets of a peritoneum which received the name of subphrenic space, a cut it is located in the upper floor of an abdominal cavity and limited from above, behind to a diaphragm, in front of and from sides — a diaphragm and a front abdominal wall, from below — an upper and back surface of a liver and ligaments supporting her.
In subphrenic space distinguish intraperitoneal and retroperitoneal speak rapidly. An intraperitoneal part is divided a crescent ligament of a liver and a backbone into the right and left departments. The right department distinguishes anterosuperior and posterosuperior areas. The anterosuperior area is limited to medially crescent ligament of a liver, behind — an upper leaf of a coronal sheaf, from above — a diaphragm, from below — a phrenic surface of the right hepatic lobe, in front — a costal part of a diaphragm and a front abdominal wall. The posterosuperior area is limited in front to a back surface of a liver, behind — the pristenochny peritoneum covering a back abdominal wall, from above — the lower leaf coronal and right triangular ligaments of a liver (fig. 1). Both areas stated above are reported with subhepatic space with an abdominal cavity. The left-side subphrenic space has the slit-like form and is located between the left dome of a diaphragm from above and the left hepatic lobe to the left of a crescent ligament of a liver, a spleen and its ligaments and the anteroexternal surface of a stomach.
A retroperitoneal part of subphrenic space has the rhomboid form and is limited from above and from below to leaves of coronal and triangular ligaments of liver, in front — a back surface of an extra peritoneal part the left and right hepatic lobe, behind — and passes with a back surface of a diaphragm, a back abdominal wall into retroperitoneal cellulose.
Most often subphrenic abscess arises in an intraperitoneal part of subphrenic space.
Etiology it is quite various and caused by hit of an infection in subphrenic space from the local and remote centers.
The most frequent reasons of P. and.: 1) direct (contact) spread of an infection from the neighboring areas: a) at perforated stomach ulcer and a duodenum, destructive appendicitis, purulent cholecystitis and abscess of a liver, b) at the delimited and diffuse peritonitis of various origin, c) at postoperative complications after various abdominal organs operations, d) at the suppurated hematoma owing to the closed and open damages of parenchymatous bodies, e) at purulent diseases of lungs and pleurae, e) at an inflammation of retroperitoneal cellulose as a result of a purulent paranephritis, an anthrax of a kidney, a paracolitis, destructive pancreatitis, etc.; 2) lymphogenous spread of an infection from abdominal organs and retroperitoneal cellulose; 3) hematogenous dissimination of an infection from various suppurative focuses on blood vessels at a furunculosis, osteomyelitis, quinsy, etc.; 4) P. is frequent and. arises at thoracoabdominal wounds, especially fire.
Microbic flora of P. and. it is various.
Penetration of an infection into subphrenic space is promoted by the negative pressure in it resulting from a respiratory excursion of a diaphragm.
Clinical picture it is characterized by considerable polymorphism. It is connected with various localization of abscesses, their sizes, existence or lack in them of gas and quite often caused by symptoms of a disease or a complication, against the background of to-rogo P. developed and. Significant effect on a wedge, P.'s manifestations and. renders use of antibiotics, especially a broad spectrum of activity, thanking the Crimea many symptoms become erased, and a current — quite often atypical. In 90 — 95% of cases of P. and. is located intraperitoneally, and right-hand localization is observed, according to Wolf (W. Wolf, 1975), in 70,1%, left-side — 26,5%, and bilateral — in 3,4% of cases.
Despite variety of forms and options of a current of P. and., in a wedge, a picture symptoms of acute prevail or subacute it is purulent - a septic state. At intraperitoneal right-hand subphrenic abscesses after postponed, as a rule recently, an acute disease of abdominal organs or in the next postoperative period after abdominal operations there are the general weakness, temperature increase to 37 — 39 °, is frequent with oznoba and perspiration, tachycardia, increase of a leukocytosis with a deviation to the left, and also a hypoproteinemia and an anemi-zation of the patient. Many patients complain of pains of various intensity and character in lower parts of a thorax on the right, in spin, the right half of a stomach or the right hypochondrium. Pains usually amplify at deep breath, cough, sneezing, and also at the movement of a trunk. Irradiation of pains in the right shoulder, a shovel, a shoulder girdle, the right half of a neck is sometimes noted. A frequent symptom is short wind and pains at a deep breath on P.'s party and. At nek-ry patients dry cough and pains at deep breath (Troyanov's symptom) are observed. At survey of patients are noted forced semi-sitting-chee situation, pallor of integuments, sometimes a subikterichnost of scleras. It is possible to observe, especially at big abscesses, a smoothness of mezhreberiya in the lower half of a thorax, a thickening of a skin fold, pastosity, seldom a hyperemia on the party of defeat.
Retroperitoneal P. and. in an initial stage differ erased a wedge, a picture and are shown by dull or throbbing pains in lumbar area, a thicket on the right, elevated temperature (37 — 38 °), a leukocytosis and local morbidity in a zone of an abscess. Further there is pastosity or a swelling in lumbar area and area of the lower edges, a thickening of a skin fold, the hyperemia is more rare. At the same time the picture of purulent intoxication accrues.
At anterosuperior abscesses quite often comes to light lag at breath of a front abdominal wall, tension and morbidity in the right subcostal and epigastric areas that is connected with an inflammation adjacent to P. and. sites of a peritoneum. The palpation of the IX—XI edges on the right, especially in the field of their merge at a costal arch, is followed by morbidity (Kryukov's symptom).
Results of physical researches at P. and. in many respects depend on the sizes and localization of an abscess, and also on change of topography of bodies of chest and belly cavities, adjacent to it. In an initial stage and at small accumulations of pus percussion gives not enough information. In process of increase in abscess there is a shift of a diaphragm up and a pushing off of a liver from top to bottom therefore the upper bound of a diaphragm can rise to the III—IV level of edges in front on the right and squeeze a lung. In many cases limits of hepatic dullness increase. At right-hand P. and. percussion of a thorax in a sitting position of the patient quite often reveals obtusion of a pulmonary sound in its lower parts, borders to-rogo pass across the arc-shaped line with the top located on sredneklyuchichny and okologrudinny Lines. Prelum of pulmonary fabric at this localization of P. and. it is observed preferential in front back and lateralno due to high standing of a dome of a diaphragm in this connection at percussion sometimes it is possible to find the site of a pulmonary sound in an interval between P. and. lateralno and cordial dullness medially (Trivus's symptom).
G. G. Yaure (1921) described at P. and. a symptom which is that at effleurage by one hand on a back surface of a thorax the second hand which is on an abdominal wall experiences the tolchkoobrazny movements in a liver. Right-hand gassy P. and. in some cases can be followed by a so-called percussion trekhsloynost. The clear sound over a lung passes in tympanic in the field of localization of gas and in stupid — over abscess and a liver (Barlow's phenomenon).
A tympanites in the field of semi-lunar space of Traube (see. Traube space ) complicates percussion recognition of left-side P. and., revealed in most cases only at big accumulations of pus.
Auscultation at P. and. the small sizes does not yield results. At a big abscess, high standing of a diaphragm, existence of consensual pleurisy, a considerable prelum of a lung it can be listened, especially on the right over a thorax, the weakened vesicular breath, sometimes with a bronchial shade, a cut usually is not defined over the place of an abscess. At concussion of the patient in this area occasionally it is possible to listen to capotement.
Rentgenol, a research at suspicion on P. and. includes raying and a X-ray analysis at vertical position of a body of the patient, and if necessary and in situation it on one side, and also on spin (see. Polyposition research ).
Rentgenol, picture P. and. it consists of the image of the abscess, shift of the next bodies and signs of an acute diaphragmatitis (see. Diaphragm ). At P. and. a traumatic origin to it can increase rentgenol, signs of injury of a thorax and bodies of chest and belly cavities, and also shadows of foreign bodys.
Radiodiagnosis is most effective in case of gassy P. and. At the roentgenoscopy and a X-ray analysis made in vertical position of the patient (at serious condition of patients — in lateroposition), under a dome of a diaphragm the cavity decides on a horizontal fluid level (fig. 2). At a postural change of a body of the patient liquid moves to cavities, and its level remains horizontal and changes in sizes a little that distinguishes P. and. from accumulation of gas and liquid in a stomach or an intestinal loop. Pictures in different projections allow to specify the size of a cavity and P.'s topography and. Most often it is located in the right department of an intraperitoneal part of subphrenic space, occupying all this space or only its lobbies, back or lateral departments. At left-side localization it is possible to differentiate perisplenic P. and. and the abscesses created above or below the left hepatic lobe. Not one, but two-three cavities (fig. 3) are in some cases observed.
Right-hand P. and., free of gas, does not give the independent image in usual pictures, left-side — causes intensive blackout, distinguishable against the background of gas in a stomach and intestines. To differential diagnosis of P. and. and intrathoracic patol, process the symptom of deformation and a pushing off from top to bottom of the arch of a stomach and the left (splenic) bend of a colon helps with such cases. For bigger confidence the patient is given inside two-three drinks of a water suspension of fixed white. If at the same time impression on the arch of a stomach comes to light, then it means that infiltrate is under a diaphragm. In case of P. and., the anastomosis which developed because of insufficiency of seams after a resection of a stomach, contrast weight sometimes passes from a stomach into P.'s cavity and.
New opportunities in P.'s recognition and. opened a computer tomography (see. Tomography computer ), ultrasonic diagnosis (see) and angiography (see). On computer tomograms the direct image of P. turns out and. At the same time exact localization of an abscess, including intraperitoneal and extra peritoneal P.' differentiation is established and., located between leaves of a coronal sheaf or over an upper pole of a kidney. Aortografiya (see) in combination with tseliakografiya (see) gives the chance to define situation and a state phrenic and hepatic arteries. Along with data of ultrasonic scanning it facilitates sometimes a complex challenge of differentiation of P. of ampere-second abscess of a liver.
Great value in P.'s radiodiagnosis and., according to M. M. Vikker (1946), V. I. Soboleva (1952), has a syndrome of an acute diaphragmatitis. It is expressed in deformation and a high position of the struck half of a diaphragm or its part, in sharp weakening, absence or the paradoxical nature of its movements at breath, in a thickening and an illegibility of contours of a diaphragm owing to its hypostasis and inflammatory infiltration. Costal and phrenic sine decrease due to infiltration of cellulose and a reactive exudate. As a rule, small atelectases and the centers of lobular pneumonia in the basis of a lung and an exudate in a pleural cavity join it. However the syndrome of an acute diaphragmatitis with defeat of the right half of a diaphragm can be at abscess liver (see). Therefore comparison a wedge, symptoms and results of radiological, radionuclide and ultrasonic researches is very important for the final conclusion.
At P. and. medial localization the thickening of legs of a diaphragm and disappearance of their outlines is observed. At retroperitoneal epinephral P. and. in pictures the smazannost or lack of outlines of an upper pole of a kidney is noted, and at a big abscess — and a displacement of the kidney from top to bottom.
In case of a diagnostic puncture of abscess some surgeons and radiologists consider it expedient to replace a part of the deleted pus with gas or high-atomic triiodi-rovanny contrast medium. It provides complete idea of situation and the sizes of a purulent cavity and usually facilitates differential diagnosis of P. of ampere-second abscess of a liver.
At P. and. as a result of a gunshot wound development of outside purulent fistula is possible (B. V. Petrovsky). At the same time resort to fistulografiya (see) for studying of the direction and extent of the fistular course, identification of purulent zatek, establishment of communication of fistula with an abscess cavity, the centers of destruction in the injured bones, with foreign bodys.
Conservative treatment of P. and. carry usually out at doubt in the diagnosis or for the purpose of preoperative preparation. It consists in purpose of antibacterial and disintoxication therapy and treatment of the basic disease which was a source to P. and. The diagnosed P. and. is subject to obligatory opening and drainage.
Operational access and the nature of surgery in many respects depend on P.'s localization and. and the accompanying complications.
Transpleural access was for the first time described by Roser in 1864. It consists in thoracotomies (see) in a zone of a projection of an abscess, a section of a diaphragm, opening and P.'s drainage and. The way is quite simple, but infection of a pleural cavity is quite often resulted by its empyema proceeding hard.
Developed the next way for prevention of this complication of F. Trendelenburg (1885). Make a section on the course of the X edge sideways between back and front axillary lines on the right or behind between paravertebral and average podlgyshechny lines depending on P.'s localization and., and then subperiostal resection of its (fig. 4). After a careful section of a periosteum, without opening a pleura, sew it with a diaphragm continuous sutures in the form of an oval for isolation of a pleural cavity. Item and. open with a slit between seams through a pleura and a diaphragm.
Many surgeons prefer to use the extra pleural access developed by A. V. Melnikov in 1921. At this access an exposure of a diaphragm and P.'s opening and. it is made through so-called parapleural space after supraplacement of a costal and phrenic sine therefore the pleural cavity remains intact. The section of skin is planned depending on P.'s localization and. also takes place in front or back department of subphrenic space on 2 — 3 cross fingers above edge of a costal arch. After a subperiostal resection of one-two edges (most often the IX—X) throughout several centimeters the periosteum is cut and otslaivat from a pleural sine which is separated in the acute and stupid way from a chest wall and removed up. On the course of a wound cut a diaphragm to a parietal peritoneum and carefully otslaivat it. The cranial edge of the crossed diaphragm is hemmed to muscles of a chest wall along an upper perilgetr of a wound (fig. 5).
To an extra pleural and extra peritoneal way of opening of P. and. retroperitoneal access which is more often used at right-hand posterosuperior abscesses belongs. This operation is based that the pleural sine on the right practically never falls below an acantha of the I lumbar vertebra. Operation is made in position of the patient on the left side. The section is carried out on the course of the XII edge with its subperiostal resection. Cross section at the level of an acantha of the I lumbar vertebra cut a back leaf of a periosteum, adjacent to it intercostal and back gear muscles also bare a diaphragm near its attachment. The last is opened and otslaivat the peritoneum covering a lower surface of a diaphragm, find P. and. (fig. 6) also open it.
For right-hand anterosuperior P.' opening and. most of surgeons apply very convenient Extra peritoneal subkostalny access (fig. 7) offered by Clermont (R. of Clairmont) in 1946. The section goes in parallel and immediately below a costal arch. Layer-by-layer cut musculoaponeurotic layers of a front abdominal wall to a parietal peritoneum, to-ruyu stupidly otslaivat from an inner surface of a diaphragm to P. and. The last is opened and drained.
A lethality at P. and. depends by nature basic disease, localization of an abscess, age of the patient, associated diseases, duration of a disease, timeliness of recognition and terms of an operative measure. According to Uonga and Wilson (S. Wang, S. Wilson, 1977), a lethality at P. and., the immediate surgeries which arose later, made 35%, after planned — 26%, and an over-all mortality — 31%.
Clinic, diagnosis and P.'s treatment and. at children do not differ from those at P. and. at adults.
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O. K. Skobelkin; L. D. Lindenbraten (rents.).