What is Subphrenic Abscess?
Subphrenic abscesses are pockets of infection located above the diaphragm (the muscle that helps you breathe) and below parts of the colon (part of your digestive system) and the omentum (a fatty sheet in your abdomen). This condition was first described by a doctor named Barlow in 1845, and the first surgical treatment was recorded in 1879 by Von Volkman who used a combination of abdominal and thoracoscopic (a minimal surgery that uses small incisions) exploration.
Typically, these abscesses occur due to abdominal surgery, injuries, or local inflammation in the area between the liver, intestines, and lungs. This location makes draining these abscesses quite tricky. Diagnosing a subphrenic abscess can be hard, leading to a well-known saying among doctors: ‘pus somewhere, pus nowhere else, pus under the diaphragm.’ This quote emphasizes that if there’s pus somewhere in the body, and nowhere else it can be found, it’s probably located under the diaphragm.
What Causes Subphrenic Abscess?
A subphrenic abscess is a pocket of pus that forms underneath the diaphragm, usually following contamination from bowel content and gut bacteria. A study looking at 52 patients between 1974 and 1988 found that most abscesses had multiple types of infection, mainly from bacteria like Escherichia coli, Enterococcus spp, Enterobacter, and Staphylococcus aureus. The most common anaerobes, or bacteria that can live without oxygen, include Peptostreptococcus, Bacteroides fragilis, Clostridium spp, and Prevotella.
The type of bacteria found in these abscesses can vary depending on the type of surgery the patient has had. For instance, Staphylococcus aureus is most often found after stomach surgery, while Bacteroides fragilis and Clostridium spp are usually found after colon surgery or appendicitis. Enterococcus group D is common after surgery involving the gallbladder and bile duct, and Fusobacterium and Prevotella species are usually present after stomach or duodenal (part of the small intestine) surgery.
Certain risk factors may increase your chances of developing a subphrenic abscess. These include having had a previous abdominal surgery that caused a significant amount of contamination from the gastrointestinal tract. This could be due to conditions such as a burst appendix, gastric ulcer or diverticulitis (inflammation of small pouches in the intestine), stomach and intestinal perforation (holes), reduced blood supply to the network of blood vessels in the abdomen (mesenteric ischemia), appendicitis, injuries, empyema (a pocket of pus in the lining of the lungs), and sepsis (a severe infection that spreads throughout the body).
Risk Factors and Frequency for Subphrenic Abscess
Thanks to recent advancements, early diagnosis and non-surgical treatment of subphrenic abscesses have led to lower occurrence rates and better patient outcomes. A primary subphrenic abscess is an abscess that forms in the stomach area without being caused by outside bacteria. This type of abscess is thought to be very rare, and its exact frequency is still unknown. In one study, they made up 13% of the cases.
Most subphrenic abscesses happen due to bacteria being introduced into the subphrenic space. When looking at secondary subphrenic abscesses, those resulting from surgeries on the stomach and bile ducts make up 52% of cases. Appendicitis is responsible for another 8%, and surgeries on the colon and injuries make up 19% and 8% respectively.
- 40% of subphrenic abscesses occur on the left side.
- And in 20% of patients, abscesses occur in multiple places.
Signs and Symptoms of Subphrenic Abscess
Subphrenic abscesses, or pockets of pus located beneath the diaphragm, can cause a range of symptoms based on their specific location in the body. Common symptoms include a fever, pain in the upper part of the abdomen, tenderness along the edge of the ribs, shoulder pain, discomfort throughout the abdomen, and difficulty breathing. Some people may also experience hiccups, coughing, or certain lung-related problems, such as pneumonia, fluid in the lungs, or a lung condition known as basal atelectasis. It’s also not uncommon for someone to have a fever without an apparent cause. If left untreated, the patient’s condition may worsen, leading to a rapid heartbeat, low blood pressure, and decreased urine production. This can escalate into a severe response to infection throughout the body, multiple organ failure, and, in the worst-case scenario, death.
- Fever
- Pain in the upper part of the abdomen
- Tenderness along the edge of the ribs
- Shoulder pain
- Abdominal discomfort
- Difficulty breathing
- Hiccups or coughs
- Lung-related issues such as pneumonia or fluid in the lungs
- Fever without a known cause
- Rapid heartbeat
- Low blood pressure
- Decreased urine production
- Response to infection throughout the body
- Multiple organ failure
- Potentially death if untreated
Testing for Subphrenic Abscess
If a doctor suspects you have a subphrenic abscess, which is a pocket of pus located just beneath the diaphragm, you might see increased white blood cell count and elevated sedimentation rate in your blood. Sedimentation rate here means how fast your red blood cells settle at the bottom of a tube, which can be a sign of inflammation in the body. Also, a specific bacteria might show up in your blood cultures indicating the presence of the abscess.
You could also undergo an X-ray test, which might show that one side of the diaphragm is lifted, signs of fluid in the chest cavity (pleural effusion), and abnormal findings in your lungs, all of which could suggest a subphrenic abscess.
If the abscess is on your right side, your doctor most likely will use an ultrasound scan to take a closer look. An ultrasound is excellent at detecting fluid collection within the body, so it is considered the best method for this type of abscess.
If the abscess is on your left side, a CT (computed tomography) scan may be more helpful. CT scans generate detailed images of your body using X-rays and a computer. This method is generally the first choice for any suspected abdominal abscess, due to its effectiveness in showing detailed images of the body.
If your doctor needs to see under your diaphragm, a CT scan done in a sagittal plane (from front to back) can come in handy. In some cases, an MRI (magnetic resonance imaging) or a scan using a substance called indium-111, labeled onto white blood cells, can help find hidden abscesses within your abdomen or under your diaphragm. If you have inflammatory bowel disease, an MR enterography can be performed. It takes detailed pictures of your intestines using MRI technology.
Finally, a blood gas test may show faster than normal breathing (respiratory alkalosis) initially, which might progress into an imbalance of body’s acids and bases (metabolic acidosis). This could happen if the condition is left untreated, and the body’s way of compensating goes out of balance.
Treatment Options for Subphrenic Abscess
Subphrenic abscess management involves using antibiotics, draining the abscess, and taking general care of the patient. At the time of diagnosis, broad-spectrum antibiotics are started to fight a wide range of bacteria. These antibiotics can then be tailored based on the results of a lab test that identifies the specific bacteria causing the infection. Early treatment with antibiotics can greatly improve a patient’s outcome. Sometimes, a combination of treatments or a potent antibiotic can be initiated. Cephalosporins are often the initial choice, supplemented with metronidazole. If the patient has a weakened immune system, antifungal medication may also be needed to combat certain types of yeast (candida).
Draining the abscess is a crucial step in treating a subphrenic abscess and helps prevent the infection from spreading further in the body. This can be done using either a non-surgical approach (percutaneous drainage) or a surgical procedure. The non-surgical approach, which involves inserting a small drain into the abscess guided by imaging technology, is less invasive and is generally as effective as surgery. It’s also the current standard of care due to its proven effectiveness in controlling the infection and reducing hospital stay and complications.
In patients who are critically ill, this non-surgical technique can also help control the infection and stabilize the patients until they are well enough for a definitive surgical treatment. Possible complications of the procedure can include bleeding, injury to nearby organs, fluid in the lungs, a collapsed lung, or inflammation of the lining of the heart (mediastinitis). To avoid these risks, additional techniques using an endoscope (a long, flexible tube with a light and camera at the end) and ultrasound guidance have been developed with high success rates.
If the non-surgical approach fails, a minimally invasive surgical technique can be attempted to allow for visualization and drainage of the abscess without a large incision. If this laparoscopic technique does not work and the patient’s condition doesn’t improve, a more comprehensive open surgical procedure might be needed. However, this method can be complicated due to the presence of scar tissue, risk of injury to fragile organs, and changes in anatomy caused by prior surgery or inflammation.
Nonetheless, with prompt treatment and supportive care such as intravenous hydration to keep the patient stable, most patients recover well. However, those who worsen and develop septic shock, a serious infection that affects the whole body, may require intensive care. These patients may need help supporting multiple organs such as assistance with breathing through a ventilator, medications to help maintain blood pressure, and dialysis to help the kidneys filter the blood.
What else can Subphrenic Abscess be?
When doctors are trying to diagnose a subphrenic abscess, which is a pocket of pus that forms beneath the diaphragm, they also consider other conditions that could cause similar symptoms. These conditions include:
- Inflammatory bowel disease, an ongoing problem that causes inflammation in the digestive tract
- Prolonged ileus, a condition where the intestines stop working and cause a blockage
- Unexplained postoperative fever, which is a high body temperature after surgery that does not have a clear cause
Surgical Treatment of Subphrenic Abscess
For individuals with stomach cancer who have undergone gastrectomies (a medical term for the surgical removal of all or part of the stomach), there’s a 4% chance that they may develop a subphrenic abscess. This is a buildup of pus that forms under the diaphragm, the muscle which separates the chest from the abdomen. This often happens after total removal of the stomach and is believed to be due to leaks at the surgical connections.
The treatment for a subphrenic abscess is the same as for other abscesses—draining the pus through an intraabdominal catheter (a thin tube inserted into the abdomen) and administering antibiotics through an intravenous (IV) line to fight the infection.
What to expect with Subphrenic Abscess
The use of computed tomography (CT), a type of imaging that shows detailed pictures of areas inside the body, in diagnosing and draining has greatly decreased illness and death rates. Multiple organ failure is the primary cause of death in these cases.
Early restoration of body fluids and adequate control of the infection source have reduced the death rate due to severe sepsis (a life-threatening infection that can lead to organ failure) from 40%-60% to 18%-30%.
Possible Complications When Diagnosed with Subphrenic Abscess
A subdiaphragmatic abscess, which is an accumulation of pus beneath the diaphragm, can cause several health issues. It can cause complications in your chest such as pleurisy (when the lining of your lungs gets irritated), a build-up of fluid around the lungs (pleural effusion), pus in the chest cavity (empyema), an abscess in the lung, or a connection between your bronchial tubes and the outside environment (bronchial fistula).
This abscess can also lead to problems inside your abdomen, like generalized peritonitis (a serious infection in the abdomen), a pus-filled pocket in the pelvic area (pelvic abscess), and an abscess in the right paracolic gutter (a region near your colon).
Lastly, it can lead to severe body-wide complications like sepsis (when an infection triggers a body-wide inflammation), septic shock (a life-threatening condition that happens when your blood pressure drops so low that your cells don’t get enough oxygen), and multiorgan failure (when several of your body’s vital organs start failing).
Possible Issues:
- Chest complications such as pleurisy, pleural effusion, empyema, lung abscess, and bronchial fistula
- Intraabdominal problems like generalized peritonitis, pelvic abscess, and abscess in the right paracolic gutter
- Systemic complications like sepsis, septic shock, and multiorgan failure
Recovery from Subphrenic Abscess
Most patients usually get better without facing any significant complications. Performing breathing exercises and moving around as soon as possible are important for a quick recovery. Managing pain effectively using multiple methods is crucial.
Preventing Subphrenic Abscess
When conditions like cholecystitis (inflammation of the gallbladder), diverticulitis (inflammation of the pouches that form in the walls of the colon), or appendicitis (inflammation of the appendix) occur, they can sometimes lead to the formation of abscesses, or pockets of pus, beneath the diaphragm in the stomach region. Having recent surgery, diabetes, or inflammatory bowel disease can make a person more susceptible to these abscesses.
If you have any of these risk factors, it’s important to be aware of the symptoms of these abscesses, which can include fever, stomach pain, chest or shoulder pain, and lack of appetite. The outcome for patients who have these abscesses can vary depending on what caused the infection and how soon they seek treatment.
If you notice any of these symptoms, especially after having undergone surgery in your abdominal region recently, it’s vital to seek medical help straight away to get the necessary treatment and improve your recovery chances.