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The authors report a case of a ruptured right subphrenic abscess causing a diffuse peritonitis complicating a chronic empyema. The authors recommend active treatment of purulent pleurisies, particularly when they are associated with a bronchopleural fistula.
Esophagectomy can be carried out without thoracotomy by referring the anastomosis to the neck. This allows for complete excision of the thoracic esophagus, while avoiding the inconveniences connected with resections via mixed abdominal and thoracic routes. The stomach is the most commonly used transplant, but only a liberal resection of the small curvature enables the surgeon to reach unmistakably the hyoid bone. This technique was used in 82 patients who were operated on between January 1982 and January 1988. The lesion was benign in 10 of them and malignant in 72 (12 Killian's operations, 9 upper thirds, 30 medium thirds, and 19 lower thirds). Gastric grafts were utilized in 69 patients and colic grafts in 13 others. There were 8 deaths: 3 pulmonary infections, 2 myocardial infarctions, 1 subphrenic abscess, 1 peritonitis, and 1 case of partial necrosis of the gastric graft. Actually, this mortality rate was mainly due to the patients' background (2.8% below 75 years of age and 43% above) and not to the technique. Eleven patients developed non lethal complications (13%) such as pulmonary infections (5), subphrenic abscesses (3), cervical fistulas (2), evisceration (1), while 63 patients (77%) had an uncomplicated course with oral realimentation starting from the 7th day and hospital stay under 3 weeks. Transhiatal esophagectomy is a safe intervention which is well tolerated as far as benign esophageal lesions are concerned, as well as those interesting the upper and lower thirds of the thoracic esophagus.(ABSTRACT TRUNCATED AT 250 WORDS)
Twenty-three patients with nonspecific pleuritis were studied to determine clinical outcome. After a mean follow-up period of 6 months (1 to 36 months), a diagnosis was reached in 17 patients, while 6 patients remained unknown. The causes of the nonspecific pleuritis diagnosed on initial pleural biopsy were tuberculosis (11 patients, 48%), neoplasm (2 patients, 8.7%), parapneumonic effusion (1 patient), subphrenic abscess (1 patient), congestive heart failure (1 patients), and nephrotic syndrome (1 patient). The diagnosis was made by therapeutic trials (tuberculosis: 11 patients, parapneumonic effusion: 1 patient, congestive heart failure: 1 patient), by repeat pleural biopsy in 1 hepatoma, by open thoractomy in 1 lung cancer, by exploratory laparotomy in 1 subphrenic abscess, and by kidney biopsy in 1 nephrotic syndrome. The WBC counts (more than 2,000/mm3) and lymphocyte percentage (more than 60%) in the pleural fluid were significantly elevated in the patients with tuberculosis compared to those with malignant pleurisy, and other laboratory data were meaningless. As a result of this investigation, we suggest that tuberculous pleurisy is the most common cause of nonspecific pleuritis in Korea and that therapeutic trial with antituberculous medication for patients with high WBC count and lymphocyte percent in pleural fluid can help to locate the nonspecific pleuritis.
Pyogenic liver abscess in Taiwan is a well-known disease entity, commonly associated with a single pathogen, Klebsiella pneumoniae. Melioidosis is an endemic disease in Taiwan that can manifest as multiple abscesses in sites including the liver. We report three cases of liver abscesses caused by Burkholderia pseudomallei. The first patient was a 54-year-old diabetic woman, who presented with liver abscess and a left subphrenic abscess resulting from a ruptured splenic abscess, co-infected with K. pneumoniae and B. pseudomallei. The second patient, a 58-year-old diabetic man, developed bacteremic pneumonia over the left lower lung due to B. pseudomallei with acute respiratory distress syndrome, and relapsed 5 months later with bacteremic abscesses of the liver, spleen, prostate and osteomyelitis, due to lack of compliance with prescribed antibiotic therapy. The third patient was a 61-year-old diabetic man with a history of travel to Thailand, who presented with jaundice and fever of unknown origin. Liver and splenic abscesses due to B. pseudomallei were diagnosed. A high clinical alertness to patients' travel history, underlying diseases, and the presence of concomitant splenic abscess is essential to early detection of the great mimicker, melioidosis. The treatment of choice is intravenous ceftazidime for at least 14 days or more. An adequate duration of maintenance oral therapy, with amoxicillin-clavulanate or trimethoprim-sulfamethoxazole for 12-20 weeks, is necessary to prevent relapse. Liver abscess in Taiwan is most commonly due to K. pneumoniae, but clinicians should keep in mind that this may be a presenting feature of melioidosis.
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28 patients were operated on for subphrenic abscess, one patient died. The author emphasises the disadvantages of excessive antibiotics. The diagnosis should be made early in order to avoid severe infective complications. The diagnosis is not difficult. It is nowadays facilitated by echotomography and scannography, which permit one to localise precisely the collection of pus and to detect multiple abscesses. The incision should carefully avoid crossing the peritoneal or pleural cavities. The quality and the permanence of the drainage are the key to success. One should therefore leave in position numerous aspiration drains. One should generally abstain from any suture or digestive anastomosis. It is sufficient to direct the digestive fistula, when present, towards the skin surface. But the best policy is to avoid this operative complication the origin of which is almost always a mistake in the design or installation of the drain at the end of various operations on the abdomen.
Between 1978 and 1983 fifty-two abdominal abscesses in 44 patients were drained percutaneously. 79% of the abscesses occurred as postoperative complications. The overall success rate was 60%, whereas only 42% of left subphrenic abscesses were cured. Complications were encountered in 4.5%. Reasons for drainage failures were: liver sequestration, loculation, fistulae and recurrences. Percutaneous abscess drainage is an alternative, and valuable addition, to surgery.
Thirty patients (17 male, 13 female; age 17 to 84 years; normal renal function in 23 cases) with severe bacterial infections were treated with ceftriaxone. The infections was septicemia in 20 cases, a septicemia-like condition in 2 and a focal infection in 8 (2 abscesses of the lung, 2 pyelonephritis, 1 abscess of the liver, 1 subphrenic abscess, 1 meningitis developed from an abscess of the brain and 1 acute intestinal infection). 25 infections were bacteriologically documented, with recovery of the following pathogens: 20 Gram negative rods (including 10 E. coli) that were all susceptible to ceftriaxone (MIC = 0.02 to 0.5 mg/l) except 2 (1 Pseudomonas and 1 E. cloacae), 5 susceptible Gram positive cocci (3 Pneumococcus, 1 Streptococcus and 1 Staphylococcus epidermidis) and 3 susceptible anaerobes (2 B. fragilis and 1 B. melaninogenicus). Ceftriaxone was given alone in 15 cases and in association with another antibiotic in 15 cases (aminoglycoside in 10 cases, nitroimidazole in 4 and fosfomycin in 1). The dose of ceftriaxone was 1 to 2 g per day in 28 cases, 3 g per day in 1 case (meningitis with abscess of the brain) and 1 g every other day in 1 case (chronic renal failure under hemodialysis). Duration of treatment ranged from 10 to 62 days (average 17 days). The usual routes of administration were IV and IM; the SC route was used on 4 occasions. Pharmacokinetic studies of serum levels were carried out in several patients including two who had ceftriaxone subcutaneously; results were consistent with those previously reported in the literature.(ABSTRACT TRUNCATED AT 250 WORDS)
Report on a 9-year-old boy with infected solitary cyst of the kidney on the left, resulting from this chronic relapsing sepsis with abscess of the spleen, perforation of the abscess into the left subphrenium, subphrenical abscess, basic empyema of the pleura on the left, purulent system of the fistulae in the left upper retroperitoneum. Causative organism: staphylococcus aureus. After 6 successless attempts to command the process from the flank side section, the transperitoneal radical operation with extirpation of the spleen, resection of the cyst and removal of the left upper retroperitoneum was carried out. After transient improvement acute relapse of the sepsis after 6 months with subcutaneous abscesses and empyema of the ankle joint on the left. Causative organism again staphylococcus aureus. Under repeated surgical, antibiotical and general treatment rapid and final disappearing of the sepsis. Since 3 1/2 years free from recidivation.
Ten of 42 patients who underwent liver transplantation were retrospectively found to have enlarging pleural effusions later than 3 days after transplantation. Seven of the 10 patients had subdiaphragmatic pathology, including 4 with hematomas, 1 with a biloma, and 2 with abscesses. One patient with a subphrenic abscess also had an empyema. Patients with a enlarging pleural effusion later than 3 days after transplantation should be evaluated for subdiaphragmatic pathology.
UNLABELLED: Abscess formation is a rare cause of febrile illness in childhood but always has to be considered in such clinical presentations. Belonging to the resident flora of the oropharyngeal region, Fusobacteria are known to cause local infections; from here they may extend to other sites via the bloodstream or are aspirated into the lung (Lemierre disease). We report on two boys with Lemierre disease due to infection by Fusobacteria in monoculture causing two different clinical phenotypes. Case 1 presented with a large subphrenic abscess and pneumonic infiltration of the right middle lobe. Primary focus of infection was periodontal disease. Case 2 presented with a life-threatening septicaemia due to a retropharyngeal abscess and perforated otitis media followed by osteomyelitis of the atlas and thrombosis of the left sigmoid sinus and internal jugular vein. CONCLUSION: Fusobacteria should be considered in any abscess formation in children. A thorough examination of the oropharyngeal region as a possible site of primary manifestation is mandatory.
Septic complications following total gastrectomy usually require relaparotomy, which is associated with a high operative mortality. Due to the improvement of percutaneous drainage of abdominal abscesses we prefer this therapy for septic complications after total gastrectomy. Among 141 total gastrectomies, 14 patients developed subphrenic abscesses. While 2 patients required relaparotomy, 12 had interventional therapy by sonographically guided drainage and insertion of a pigtail catheter. The catheters were irrigated daily, and the patients received systemic antibiotics. Complete resolution of the abscess cavity was achieved, even in 1 case with simultaneous duodenal stump insufficiency without increasing morbidity. The hospital stay was prolonged for an average of 20 days by this "conservative" treatment. The management of septic complications following total gastrectomy with interventional techniques may reduce the number of operative reinterventions. The indication for such a therapy, however, needs to be evaluated on an individual basis.
Despite the very high accuracy rate of imaging studies (ultrasound, computed tomography, liver-lung-spleen scans and gallium-67 scans) in detecting intraabdominal abscesses, our experience with 80 recent cases indicate that these techniques have not significantly altered traditional methods of decision-making about when and where to drain such abscesses. In only 12.5 percent of cases were such decisions based on special imaging techniques alone, and most of these cases subphrenic abscesses were diagnosed late after surgery. In the remainder, physical examination and routine radiologic studies sufficed, with special imaging techniques primarily corroborating clinical evidence based on these methods. We conclude that the use of special imaging techniques alone in a search for the cause of fever early after abdominal surgery does not provide evidence upon which clinical decisions can be based unless there are already physical signs of an abscess.
The bacteriology of the gastrointestinal tract is rapidly changing in laboratory techniques and clinical correlations. The flora is found to be very complex, predominantly anaerobic, and importantly dependent on diet. An etiologic role for colon bacteria in colon cancer is suggested by correlations between epidemiologic data and prevalent dietary patterns and stool culture findings. Cultures from aspiration pneumonia, subphrenic abscess, and other intra-abdominal sepsis all yield anaerobes, and for best results antibiotic therapy should combat them as well as aerobes.
Over the past 9 years, ten patients have presented to the Thoracic Unit, Glasgow Royal Infirmary, with 12 empyemas secondary to intra-abdominal sepsis. In eight patients, the presenting signs and symptoms were wrongly attributed to primary intra-thoracic pathology. All were subsequently found to have intra-abdominal sepsis. The presence of empyema after recent abdominal surgery or abdominal pain strongly suggests a diagnosis of ipsilateral subphrenic abscess. Adequate surgical drainage is essential. In our experience, limited thoracotomy with subdiaphragmatic extension offers the best access to both pleural and subphrenic spaces and provides the greatest chance of eradicating infection on both sides of the diaphragm.
UNLABELLED: Introduction of percutaneous drainage (pcd) of subphrenic space in early subphrenic abscesses or fluid collections (e.g. bile) seems to be an alternative to common surgical treatment, if the indication is restricted to single contaminated abscesses. Septicemia, continued contamination, hematomas and multiple abscesses are contraindications. METHOD: A modified angiocatheter is placed directly or by a Seldinger technique. Adjunct antibiotic treatment is important. The advantages of subphrenic pcd are: simple low risk procedure in local anesthesia, rapid improvement of associated respiratory symptoms, no further contamination of the abdomen. 4 of 6 patients were treated successfully by this procedure.
Computerised tomography produces an excellent image of the liver. The author discusses the relevant technical factors such as the use of window levels and window widths, tissue attenuation values and filtering. The importance of the applied anatomy and the use of contrast agents are discussed and then the findings on computed tomography in clinical practice are presented. The lesions that can be visualised include cysts, abscesses, primary tumours, metastases, fatty liver, subphrenic abscess, dilated bile ducts and cholelithiasis as well as surrounding ascites. These appearances are described and illustrated.