Subphrenic
AbscessIntroduction: The space between the diaphragm,
which separates the chest cavities from the abdominal cavity, and the transverse
colon is called the "subphrenic space". If there is an abscess developing
in this space, this is called a subphrenic abscess. As there is a right and a
left chest cavity, there can be from an anatomical point of view a right-sided
and a left-sided subphrenic abscess. In about 50% of the cases there is
a right-sided, in 25% a left-sided and in 25% a bilateral subphrenic abscess.
Typically this develops 3 to 6 weeks following surgery in the abdomen such as
biliary surgery, appendix surgery or surgery on the stomach or duodenum. Any
anastomosis leakage or other wound contamination tends to lead to a subphrenic
abscess. The pressures from the diaphragmatic movements with respirations are
such that there is a movement of the ascitic fluid of the abdomen into the subphrenic
space and with it travel any bacteria that might be present, which facilitates
abscess formation. Symptoms: Patients
are often elderly. Symptoms can be very subtle and start perhaps with a fever
and a loss of appetite approximately 1 month after the surgery. There might be
a non-productive cough due to an atelectasis in the lung of the affected side
or a pleural effusion (fluid in the chest cavity) on that side. Abdominal pain
on the affected side in the upper abdomen is common, which is severe on deep palpation
by the physician. Blood tests show a leukocytosis, there may also be a lack of
red blood cells (anemia). Plain abdominal X-ray films may show the abscess
cavity with gas in it from gas producing bacteria. Chest X-rays often show abnormalities
in the lungs (atelectases, lower lobe pneumonia) and pleural effusions as well
as an immobile diaphragm. Other tests are useful such as an ultrasound
for a right- sided subphrenic abscess and a CT scan for a left-sided
subphrenic abscess. The link here shows a subphrenic abscess before (upper image)
and after (lower image) drainage. Because it can be rather difficult to come to
a diagnosis, radioactive isotope scanning such as an indium-111-labeled leukocyte
scan could be useful in detecting a hidden intraabdominal or subphrenic abscess.
Treatment: Like any other abscess
in the body, the abscess needs to be drained and the infection needs to be treated
with appropriate antibiotics. This can be a complex undertaking with a subphrenic
abscess. If there is an intraabdominal breakdown of an anastomosis, this
has to be attended to by the surgeon as well as the abscess has to be drained.
In another presentation it may be possible to drain the abscess through a percutaneous
(meaning by perforating the skin) drainage catheter. Parallel to the clinical
condition the physician needs to watch the patient's nutritional status as these
patients often are malnourished and may need to receive intravenous feeding. If
the nutritional status is not attended to the patients may not heal properly and
cannot fight the infection with their weakened immune system. Other complications
can be clots in the leg veins or the portal system veins, which may have to be
treated with heparin and Coumadin. The overall mortality rate is about 35% despite
the best therapy. Pain relief: There is an FDA approved non-drug
method available, IceWave patches
from Lifewave, which will control pain. This is mentioned in the book
"Breakthrough" by Suzanne Somers (Ref. 9) where newer insights of antiaging
medicine are also reviewed. Although the patches are placed over acupuncture points,
there are no needles involved. Nanotechnology, a newer technology, was used in
the manufacturing of these patches and infrared (heat) waves from body heat are
utilized to stimulate an acupuncture point, which modifies pain perception and
reduces pain to half or less. Medically this would be considered an excellent
pain reliever. For more info on the patches see the IceWave patches from Lifewave
link above (click "products"). In the US a 5 pack of the IceWave spray
is available that can be directly sprayed onto the skin in the area where the
pain is located. |
