When reactive pleurisy occurs, four-stage sounding is noted during percussion - pulmonary tone, dullness of exudate, tympanic sound of gas, dull tone of pus and liver (L.D. Bogalkov).

X-ray methods for diagnosing PDA

The basis of X-ray diagnostics in PDA is the analysis of the condition of the diaphragm; enlightenment of gas, darkening of pus. Changes in the lungs, heart, liver caused by PDA are its indirect signs.

The first study (fluoroscopy or radiography) reveals changes characteristic of PDA: either a darkening above the line of the diaphragm (like a protrusion of the shadow of the liver) with gas-free PDA, or a focus of enlightenment with a lower horizontal line separated from the lung by an arc of the diaphragm. Sometimes it is possible to note a higher standing of the dome of the diaphragm and a decrease in its mobility.

Complete immobility of the dome of the diaphragm in the vertical position of the patient and immobility or minimal passive mobility in the horizontal position are characteristic of PDA.

With PDA, a decrease in the airiness of the lower parts of the lung, raised by a high-standing diaphragm, is determined. In this case, accumulations of fluid - reactive effusion - in the pleural sinus are often observed. X-ray examination helps to identify changes in neighboring organs: displacement of the longitudinal axis of the heart, deformity of the stomach, displacement of the splenic angle of the colon downward.

However, the X-ray method does not always detect PDA. This happens either because the PDA has not "ripened" and has not taken shape, or because the picture obtained during the study is incorrectly assessed.

Due to edema and infiltration of the diaphragm in PDA, it thickens to 8-17 cm. The contours of the dome of the diaphragm become fuzzy and blurred.

The most characteristic radiological sign of PDA is changes in the area of ​​the crura of the diaphragm. V. I. Sobolev (1952) found that with PDA, the legs of the diaphragm become more clearly visible. This symptom appears very early in PDA, so it is valuable for early diagnosis.

Due to the presence of gas in the hollow organs of PD, differential diagnosis of PDA with gas from the normal picture may be required. Diagnosis of PDA on the left is difficult due to the presence of gas in the stomach and colon. In unclear cases, fluoroscopy with a barium suspension taken through the mouth helps.

The air in the free BP is determined on the radiograph in the form of a saddle-shaped strip above the liver, and there is no liquid level under it, as in the lower part of the PDA. The gas in a lung abscess and a tuberculous cavity are similar to PDA gas, the only difference is that they are located above the diaphragm.

Repeated X-ray studies are of great importance in the diagnosis of PDA. Patients who have signs of an incipient complication in the postoperative period, even if they are mild, should be subjected to x-ray examination. Serial images are especially valuable, in which not only PDA is detected, its shape and localization are determined, but the dynamics of the process, changes in the size of the abscess are also visible. Re-examinations are important after evacuation of the pleural effusion, which often masks PDA. X-ray method can be used to control the cavity of the abscess. PDA is often poorly emptied even through drains due to anatomical features. Fluoroscopy allows you to determine the reasons for the delay in the recovery of the patient, if any.

In recent years, computed tomography (CT) has been introduced into clinical practice. For the diagnosis of PDA, this method is very good. Its resolution is 95-100% (Bazhanov E.A., 1986). With CT, there is a need to differentiate fluid in the abdominal and pleural cavities, since the diaphragm is often not visualized on axial tomograms - its optical density is equal to the density of the liver and spleen. To do this, repeat the pictures on the stomach or healthy side - there is a displacement of the organs and the movement of fluid. The fluid in the pleural cavity is located posterolaterally, in the abdominal cavity - in front and medially, which corresponds to the anatomy of the BP and pleural sinuses. CT can also rule out PDA if the picture is not entirely clear. In the material of E.A. Bazhanov (“Computed tomography in the diagnosis of subdiaphragmatic abscesses // Surgery, -1991-No. 3, p. 47-49) of the observed 49 patients in 22, the diagnosis of PDA was removed after CT, in the remaining 27 it was confirmed and detected during surgery.

Other instrumental methods for diagnosing PDA

Let us briefly touch on other, except for radiological, methods of diagnosing PDA.

The most important, widely used method in recent times is ultrasonography (sonography, ultrasound). Its resolution in relation to PDA is very high and approaches 90-95% (Dubrov E.Ya., 1992; Malinovsky N.N., 1986). Smaller left-sided PDAs are visualized somewhat worse, especially those surrounded by adhesions of the abdominal cavity. The value of the method is its harmlessness, non-invasiveness, the possibility of dynamic monitoring and control of the postoperative state of the purulent cavity. Under the control of ultrasound, it is possible to perform puncture drainage of abscesses (Krivitsky D.I., 1990; Ryskulova, 1988).

The effectiveness of liquid crystal thermography is noted (Smirnov V.E., 1990), but the number of observations here is small.

Laparotomy is used as the last stage of the diagnostic search for PDA (with the aim, in addition, to drain the abscess through manipulators, if possible). However, the “closed” method of treating PDA is not recognized by everyone (Belogorodsky V.M., 1986; Tyukarkin, 1989). The possibilities of laparotomy are also limited with a pronounced adhesive process in the abdominal cavity.

B.D. Savchuk (Malinovsky N.N., Savchuk B.D., 1986) notes the effectiveness of isotopic scanning with Ga 67 and Zn 111 . These isotopes are tropic to leukocytes; this technique is based on this. Leukocytes obtained from the patient are incubated with the isotope and then returned. Leukocytes rush to the purulent focus, and there will be an increased "glow". The method is applicable in the diagnosis of not only PDA, but also other abdominal abscesses.

Laboratory diagnostics of PDA

These studies occupy a huge place in the diagnosis and control of the course of PDA. There are no specific changes in the analyzes for PDA. In blood tests, there are changes characteristic of general purulent processes (anemia, leukocytosis with a shift to the left, accelerated erythrocyte sedimentation, dysproteinemia, the appearance of C-reactive protein, etc.). Moreover, it is important that these changes persist with antibiotic therapy. Some information about the genesis of PDA can be obtained from the study of punctates (detection of tyrosine, hematoidin, bile pigments).

The main positions of differential diagnosis

In the process of diagnosing PDA, it becomes necessary to differentiate it from other diseases.

The main difference between PDA is the deep location of the focus of the disease, the domed shape of the diaphragm, its high standing, restriction of movements, as well as the appearance of tympanitis or dullness under the diaphragm.

In a patient with PDA, during percussion, the appearance of dullness in places unusual for her draws attention. It is detected above the normal borders of the liver, sometimes reaching the II-III ribs in front and the middle of the scapula behind. Such a picture can be observed with exudative pleurisy.

Much more difficult differential diagnosis in basal pleurisy. Its distinguishing features are the location of the process in the chest cavity, a sharp increase in pain with any movement of the diaphragm, shallow and frequent breathing. However, differential diagnosis of these diseases is difficult (see Table 1).

Table 1

Signs of differential diagnosis of PDA and effusion pleurisy

With gangrene of the lung, there is extensive infiltration of the lung tissue, causing dullness of percussion sound, which may resemble a picture of gasless PDA. Severe general condition, high body temperature; pronounced pulmonary phenomena and fetid sputum make it possible to correctly diagnose lung gangrene.

With pulmonary abscesses, in contrast to PDA, patients have a prolonged relapsing fever, dullness of percussion sound, weakening of breathing in the absence of wheezing, symptoms of a cavity in the lung with gases and pus. After opening the abscess, purulent sputum is secreted into the bronchus for a long time. Differential diagnosis in these cases is facilitated by echography and radiography.

Subdiaphragmatic abscess

Subdiaphragmatic abscess(lat. abscessus subdiaphragmaticus; synonyms: subphrenic abscess, infradiaphragmatic abscess) - accumulation of pus under the diaphragm (in the subphrenic space).

Most often occurs as a complication of acute inflammatory diseases of the abdominal organs, in particular: acute appendicitis, acute cholecystitis, perforation of a hollow organ, peritonitis.

Clinical picture

Subdiaphragmatic abscesses are characterized by a polymorphic clinical picture. It depends on:

• abscess localization,
• its size,
• the presence of gas in the cavity of the abscess,
• symptoms of the disease, against which a subphrenic abscess arose,
• the use of antibiotics (against which many symptoms often become erased, and the course is atypical).

The intraperitoneal location of the subdiaphragmatic abscess is observed in 90-95% of cases. According to W. Wolf (1975), in 70.1% of cases, abscesses were located in the right part of the intraperitoneal part of the subdiaphragmatic space, in 26.5% - in the left part, and in 3.4% of cases bilateral localization was observed.

The symptoms of acute or subacute purulent-septic process prevail; in particular, a high fever with chills is possible, the corresponding localization of pain. It is possible to identify a sympathetic effusion in the pleural cavity on the corresponding side.

Diagnostics

In addition to the clinical picture and changes in laboratory parameters characteristic of inflammation, imaging studies have diagnostic value. The most informative method is computed tomography of the diaphragm area, since this method allows you to clearly determine the anatomical features of the location of the abscess and choose the right access. Ultrasound examination reveals the liquid content in the abscess cavity. An X-ray examination shows a restriction of the mobility of the diaphragm on the corresponding side, an effusion in the corresponding pleural sinus.

Treatment

Conservative treatment (prescription of antibiotics, detoxification therapy, treatment of the disease that caused the abscess) is carried out either in case of doubts about the diagnosis, or as a preoperative preparation. After a confident diagnosis, the subdiaphragmatic abscess should be opened and drained. Access, which opens an abscess, is largely determined by its localization and the presence of concomitant complications.

Extraserous accesses

When available, extraserous (i.e., extrapleural and extraperitoneal access) is the best choice. According to a number of authors (published in works from 1938 to 1955), mortality with extraserous access ranged from 11 to 20.8%, and with transserous (that is, transpleural or transperitoneal) - from 25 to 35.8%.

Anterior extraserous subcostal approach

The anterior extraperitoneal subcostal approach was proposed by P. Clairmont and is used to open the anterior superior right-sided subdiaphragmatic abscesses. With this access, the incision is made just below the costal arch parallel to it, starting from the lateral border of the rectus abdominis muscle, to a width that allows the arm to be inserted. The tissues are dissected in layers to the parietal peritoneum, after which it is bluntly peeled off from the inner surface of the diaphragm in search of an abscess. An abscess is characterized by a dense wall; after its discovery, it is opened and drained.

Transpleural accesses

Transperitoneal accesses

Percutaneous puncture drainage under the control of visualization methods

Notes

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See what "Subdiaphragmatic abscess" is in other dictionaries:

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- a local abscess formed between the dome of the diaphragm and adjacent organs of the upper floor of the abdominal cavity (liver, stomach and spleen). Subdiaphragmatic abscess is manifested by hyperthermia, weakness, intense pain in the epigastrium and hypochondrium, shortness of breath, cough. The examination of the patient, the data of fluoroscopy, ultrasound, CT, and a general blood test are of diagnostic importance. For a complete cure of the subphrenic abscess, a surgical opening and drainage of the abscess is performed, antibiotic therapy is prescribed.

Subdiaphragmatic abscess is a relatively rare, but very serious complication of purulent-inflammatory processes in the abdominal cavity. The subdiaphragmatic abscess is located mainly intraperitoneally (between the diaphragmatic sheet of the peritoneum and adjacent organs), rarely - in the retroperitoneal space (between the diaphragm and the diaphragmatic peritoneum). Depending on the location of the abscess, subdiaphragmatic abscesses are divided into right-sided, left-sided and median. Most often there are right-sided subdiaphragmatic abscesses with anterior superior localization.

The shape of the subdiaphragmatic abscess can be different: more often - rounded, when compressed by organs adjacent to the diaphragm - flat. The content of the subdiaphragmatic abscess is represented by pus, sometimes with an admixture of gas, less often - gallstones, sand, feces.

A subdiaphragmatic abscess is often accompanied by the formation of a pleural effusion, with a significant size, to one degree or another, it exerts pressure and disrupts the functions of the diaphragm and neighboring organs. Subdiaphragmatic abscess usually occurs in 30-50 year old patients, while in men it is 3 times more common than in women.

Causes of a subdiaphragmatic abscess

The main role in the occurrence of subphrenic abscess belongs to aerobic (staphylococcus, streptococcus, E. coli) and anaerobic non-clostridial microflora. The cause of most cases of subdiaphragmatic abscess is postoperative peritonitis (local or diffuse), which developed after gastrectomy, gastric resection, suturing of a perforated gastric ulcer, splenectomy, resection of the pancreas. The development of a subdiaphragmatic abscess is facilitated by the occurrence of extensive surgical tissue trauma, disruption of the anatomical connections of the organs of the subdiaphragmatic space, anastomotic failure, bleeding, and immunosuppression.

Subdiaphragmatic abscesses can occur as a result of thoracoabdominal injuries: open (gunshot, stab or cut wounds) and closed (bruises, compression). Hematomas, the accumulation of leaked blood and bile formed after such injuries, suppurate, encapsulate and lead to the development of a subdiaphragmatic abscess.

Among the diseases that cause the formation of a subdiaphragmatic abscess, the leading role is played by inflammatory processes of the abdominal organs (abscesses of the liver, spleen, acute cholecystitis and cholangitis, pancreatic necrosis). Less commonly, a subphrenic abscess complicates the course of destructive appendicitis, salpingo-oophoritis, purulent paranephritis, prostatitis, festering echinococcus cyst, retroperitoneal phlegmon. The development of a subdiaphragmatic abscess is possible with purulent processes in the lungs and pleura (pleural empyema, lung abscess), osteomyelitis of the lower ribs and vertebrae.

The spread of purulent infection from the foci of the abdominal cavity into the subdiaphragmatic space is facilitated by negative pressure under the dome of the diaphragm, which creates a suction effect, intestinal motility, and also lymph flow.

Symptoms of a subdiaphragmatic abscess

In the initial stage of a subdiaphragmatic abscess, general symptoms can be observed: weakness, sweating, chills, remitting or intermittent fever, which are also characteristic of other abdominal abscesses (interintestinal, appendicular, Douglas space abscess, etc.)

A subdiaphragmatic abscess is characterized by the appearance of a feeling of heaviness and pain in the hypochondrium and lower chest on the affected side. Pain can have different intensity - from moderate to acute, intensify with active movement, deep breathing and coughing, radiate to the shoulder, shoulder blade and collarbone. There is also hiccups, shortness of breath, painful dry cough. Breathing is rapid and shallow, the chest on the side of the abscess lags behind when breathing. A patient with a subdiaphragmatic abscess is forced to take a semi-sitting position.

Diagnosis of a subdiaphragmatic abscess

Detection of a subdiaphragmatic abscess is facilitated after its full maturation. For the purpose of diagnosis, the data of the anamnesis and examination of the patient, the results of X-ray, ultrasound, laboratory studies, and CT are used.

Palpation of the upper abdomen with a subdiaphragmatic abscess shows soreness and muscle tension of the abdominal wall in the epigastric region or in the hypochondria. Smoothness and expansion of the intercostal spaces, protrusion of the subcostal region is revealed, with a right-sided abscess - an increase in the liver.

If the subdiaphragmatic abscess does not contain gas, percussion of the chest reveals dullness above the border of the liver, decreased or no mobility of the lower edge of the lung. With the accumulation of gas in the cavity of the subdiaphragmatic abscess, areas of different tones (“percussion rainbow”) are revealed. Auscultation shows a change in breathing (from weakened vesicular to bronchial) and a sudden disappearance of respiratory sounds at the border of the abscess.

A laboratory blood test shows changes characteristic of any purulent processes: anemia, neutrophilic leukocytosis with a shift of the leukocyte formula to the left, an increase in ESR, the presence of C-reactive protein, and dysproteinemia.

The main value in the diagnosis of subdiaphragmatic abscess is given to radiography and fluoroscopy of the chest. A subdiaphragmatic abscess is characterized by a change in the area of ​​the crura of the diaphragm, a higher position of the dome of the diaphragm on the affected side and limitation of its mobility (from minimal passive mobility to complete immobility). The accumulation of pus with gasless subdiaphragmatic abscesses is seen as a blackout above the line of the diaphragm, the presence of gas is seen as a band of enlightenment with a lower horizontal level between the abscess and the diaphragm. An effusion in the pleural cavity (reactive pleurisy), a decrease in the airiness of the lower parts of the lung is determined.

MSCT and ultrasound of the abdominal cavity can confirm the presence of fluid, pus and gas in the abdominal or pleural cavity, changes in the position and condition of adjacent internal organs (for example, deformity of the stomach, displacement of the longitudinal axis of the heart, etc.). Diagnostic puncture of an abscess is permissible only during the operation.

Subdiaphragmatic abscess is differentiated from gastric ulcer, peptic ulcer 12p. intestines, purulent appendicitis, diseases of the liver and biliary tract, festering echinococcus of the liver.

Treatment of subdiaphragmatic abscess

The main method of treatment of subdiaphragmatic abscess in operative gastroenterology is surgical opening and drainage of the abscess.

The operation for a subdiaphragmatic abscess is performed by transthoracic or transabdominal access, which allows to provide adequate conditions for drainage. The main incision is sometimes supplemented with counter-opening. The subdiaphragmatic abscess is slowly emptied and its cavity is examined. For quick cleansing of the subdiaphragmatic abscess, the method of forced-aspiration drainage with double-lumen silicone drains is used.

The complex treatment of subdiaphragmatic abscess includes antibacterial, detoxification, symptomatic and restorative therapy.

Forecast and prevention of subphrenic abscess

The prognosis of a subdiaphragmatic abscess is very serious: the abscess can break into the abdominal and pleural cavities, pericardium, open outward, be complicated by sepsis. Without timely surgery, complications in 90% of cases lead to the death of the patient.

The formation of a subphrenic abscess can be prevented by timely recognition and treatment of inflammatory pathology of the abdominal cavity, exclusion of intraoperative injuries, thorough sanitation of the abdominal cavity in case of destructive processes, peritonitis, hemoperitoneum, etc.

St. Petersburg Medical Academy of Postgraduate Education

Department of Transfusiology and Hematology

Subdiaphragmatic abscess

(etiology, clinic, diagnosis, treatment)

St. Petersburg

List of used abbreviations

PD - subphrenic

PDA - subdiaphragmatic abscess

PDP - subdiaphragmatic space

CT - computed tomography

Ultrasound - ultrasonography

Subdiaphragmatic abscess (SDA) is still a disease that is not clear enough in its origin, difficult to diagnose, difficult to prevent and treat. Its comparative rarity does not allow the practitioner to accumulate significant material in working with patients with PDA.

This abstract is based on the materials of articles published over the past 15 years in the Soviet and Russian medical press, and aims to summarize the data (often contradictory) on the etiology, clinic, diagnosis and treatment of PDA.

Historical information

Early information about PDA speaks of it only as a pathological finding. PDAs found during autopsies were described in their time by Thylesius (1670), Grossius (1696), Weit (1797), Gruveillier (1832).

In 1845, Barlax first described the clinical picture of PDA in a woman. She complained of pain in her side that came on suddenly. During the examination, tympanitis, amphoric breathing with a metallic tint at the angle of the left shoulder blade were found, splashing noise was also heard there, indicating the accumulation of fluid, which was a zone of dullness below the area of ​​tympanitis. The analysis of these data allowed the author to make an accurate diagnosis of PDA for the first time in his lifetime.

The section confirmed the presence of the source of the abscess - two perforated stomach ulcers.

Subsequently, a number of works on PDA appeared, in which, for the first time, diagnostic issues occupied a prominent place.

Leyden (1870) and Senator (1884) described clear signs of PDA. Jaffe (1881) proposed the term "subphrenic abscess" itself. Gerlach (1891) established the anatomical boundaries of the abscess. Novack (1891) described his pathological picture. Schehrlen (1889) was the first to propose the surgical treatment of PDA.

In the same period, domestic works on this topic appeared (Moritz E., 1882; S.A. Trivus, 1893; V.P. Obraztsov, 1888; L.P. Bogolepov, 1890). In 1895, A.A. Gromov proposed transpleural access to the PDA, and N.V. Pariysky performed an extrapleural opening of the abscess.

By the end of the 19th century, there are works that discuss the use of X-rays for the diagnosis of PDA. For this purpose, they were first used by Beclere in 1899, and in Russia by J.M. Rosenblat in 1908.

Subsequently, a number of important theoretical topographic and anatomical works were published that substantiated surgical measures for the treatment of PDA (V.N. Novikov, 1909; A.Yu. Sozon-Yaroshevich, 1919; A.V. Melnikov, 1920).

In the 1950s and 1960s, interest in this problem increased significantly in the USSR. In 1958, the issue of PDA was included in the program of the All-Russian Congress of Surgeons.

With the development of antibiotic therapy, not only surgical, but also conservative and complex treatment of PDA began to be developed. It was at this time that the principles of complex treatment of PDA were developed, which have not changed to this day (but have only been supplemented and adjusted). 2 monographs were published on this issue (Apovat B.L. and Zhielina M.M. “Subphrenic abscess”, M., 1956 and Belogorodsky V.M. “Subphrenic abscess”, L., “Medicine”, 1964) .

In the period of 70-90 years in the USSR and Russia, interest in this problem remained stable. In many articles of these years, the emphasis was not on the treatment of PDA, but on their diagnosis using modern methods (sonography, CT). These methods have greatly facilitated the diagnosis of PDA, even small and deep-seated ones. At the same time, many issues of prevention and the earliest possible detection (and, consequently, treatment) of PDA remain unresolved.

For many years, the frequency of PDA was relatively small - 0.01% (Belogorodsky V.M., 1964). However, in recent years, with the deterioration of social and hygienic conditions in Russia, with a decrease in living standards, a worsening crime situation, an increase in the incidence of PDA (injuries of the abdominal organs, operations for peptic ulcer, stomach and colon cancer, a decrease in immunoreactivity in most of the population) should be predicted. associated with a decrease in the proportion of proteins in the diet). This indicates the need for knowledge of the topic by every practical surgeon.

The concept of PDA

PDA - there is an accumulation of pus in the space between the diaphragm and the underlying organs. More often, its development is observed between the diaphragmatic sheet of the peritoneum and adjacent organs (begins as peritonitis). This is the so-called intraperitoneal PDA. Less often, the abscess is located extraperitoneally, starting in the retroperitoneal space as a phlegmon.

Abscesses can be located in different parts of the RAP (subdiaphragmatic space). Being directly under the diaphragm, this abscess, to one degree or another, disrupts the shape and function of the diaphragm and neighboring organs. The localization of the abscess in the RAP causes great difficulties for its diagnosis and emptying and distinguishes it from other abscesses of the upper floor of the abdominal cavity (hepatic, subhepatic, spleen, sac lesser omentum, abdominal wall abscesses, etc.).

Statistical data

The question about the frequency of PDA disease has not yet been given an accurate scientifically based, statistically reliable answer, despite the large number of works devoted to this pathology. The main reason for this is the rarity of the disease. According to Belogorodsky (1964) from the Kuibyshev hospital in Leningrad (1945-1960), among more than 300 thousand patients, PDA patients accounted for 0.01%. Subsequent observations studied a much smaller number of patients and therefore cannot be considered more statistically significant.

Among PDA, at present, about 90% are postoperative (Gulevsky B.A., Slepukha A.G; 1988).

Etiology and pathogenesis of PDA

In the occurrence of PDA, the leading role belongs to the microbial flora. According to most authors, streptococcus, staphylococcus, Escherichia coli are most often found in PDA pus. Often in cultures from PDA pus, growth of non-clostridial anaerobic flora is noted.

Most often, the source of infection in PDA is local purulent-inflammatory processes located in the abdominal cavity. Most often (about 90% of cases (Gulevsky B.A., Slepukha A.G., 1988) it is postoperative local or diffuse peritonitis. Any operations on the abdominal organs can lead to the occurrence of PDA. But statistics show that most often PDA develops after gastrectomy, subtotal resections of the stomach, operations for cancer of the pancreas and the left half of the colon (Gulevsky B.A., Slepukha A.G., 1988). S.N. Malkova (1988) even identifies a “risk group” for the development of PDA - these are patients who have undergone gastrectomy or subtotal resection of the stomach for cancer, especially in combination with paragastric operations (splenectomy, resection of the pancreas).The reason for this is massive surgical tissue trauma, bleeding, anastomoses failure (especially esophago-intestinal), decreased immunity against the background of cancer intoxication, disorders of leukopoiesis, splenectomy and postoperative anemia.Technical errors during the operation (rough handling of tissues, hoi hemostasis, trauma to the peritoneum, the use of dry wipes and tampons) lead to a decrease in the resistance of the peritoneum to infection. Although PDA can also occur after relatively small operations that proceeded without any special technical difficulties (appendectomy, suturing of a perforated ulcer, etc.).

The second most common group of causes of PDA is trauma to the abdominal organs (both closed and open). With all the variety of trauma, its consequences have common features - this is the formation of hematomas, accumulations of bile, which then suppurate and turn into abscesses of the RDP. With open injuries, the occurrence of PDA is observed mainly when the peridiaphragmatic region is damaged (gunshot wounds, stab and cut wounds).

Only 10% of patients with PDA (Belogorodsky V.M., 1964; Gulevsky B.A., Slepukha A.G.; 1988) did not have a history of previous operations and injuries. Among the diseases that cause PDA, the first place is occupied by diseases of the organs of the upper floor of the abdominal cavity (primarily peptic ulcer, liver abscesses). Much less often, PDA is a complication of diseases of the organs of the middle and lower floors of the abdominal cavity (non-operated appendicitis, diseases of the female genital organs, purulent paranephritis, prostatitis). Sometimes PDA complicates the course of purulent-inflammatory diseases of the lungs and pleura (conversely, reactive pleurisy is much more often associated with PDA of abdominal origin).

pathological anatomy

Most often, PDA are located intraperitoneally, less often - in the retroperitoneal space (89-93 and 7-11%, respectively - Belogorodsky V.M., 1964; Gulevsky B.A., Slepukha A.G., 1988). With intraperitoneal abscess in the initial stage, extravasation and emigration of blood cells is observed. Retroperitoneal PDA begins with cellular infiltration of cellular tissue and the development of lymphadenitis. PDA of traumatic genesis is based on suppuration of infected accumulations of blood and bile. This is stage I of PDA development. On it, the inflammation can stop. According to De Bakey, this happens about 70% of the time. Otherwise, exudate appears in the crevices of the peritoneum, and periadenitis appears retroperitoneally. The PDA is separated from the abdominal cavity by adhesions and fascia. The abscess gradually increases and can reach significant sizes. PDA have a different shape, more often rounded. The shape depends on the location of the abscess. Organs adjacent to the diaphragm exert pressure on the underside of the abscess, which can flatten it.

Subdiaphragmatic abscess

Subdiaphragmatic abscess - a local abscess formed between the dome of the diaphragm and adjacent organs of the upper floor of the abdominal cavity (liver, stomach, spleen, kidneys, intestines, greater omentum).

There are primary (very rare) and secondary, as a complication of other diseases (cholecystitis, perforated gastric ulcer, pancreatitis, etc.) or after operations on the abdominal organs.

Localization of an abscess may be different; in the abdominal cavity and in the retroperitoneal space. Most often, the abscess is located under the right dome of the diaphragm above the liver.

Symptoms

Patients complain of pain in the upper abdomen - right and left hypochondrium, epigastric region (under the spoon). The pain is constant, aggravated by movement. Worried about dry cough, weakness, shortness of breath, fatigue, hiccups. The temperature rises to 41.C, chills. The general condition is severe, the position is forced semi-sitting. Attention is drawn to the lagging of the chest during breathing on the affected side.

Breathing is rapid, shallow. On palpation of the lower parts of the chest in the upper abdomen, there is pain on the affected side. Percussion observed high standing of the diaphragm, its immobility. Weakening of breathing in the lower parts of the lungs on the affected side, pleural friction noise (when the pleura is involved in the process), increased voice trembling.

Symptoms of a subdiaphragmatic abscess do not present any features at first, and recognition of an abscess is usually possible only when an abscess has formed. Based on the anamnesis, it is sometimes possible to assume stomach or duodenal ulcers, appendicitis, diseases of the liver, biliary tract. It is often possible to establish that some time ago the patient suddenly experienced particularly severe pain. These pains are sometimes accompanied by chills. When examining a patient during this period, one can state a number of signs of acute limited peritonitis, localized in the upper abdominal cavity. However, often the disease develops gradually without acute pain and subsequent signs of local peritonitis. Appetite decreases, general weakness appears, pains in the right or left side of varying intensity, aggravated by movements or deep breathing, gradually increasing, sometimes painful, painful cough. The patient loses weight, often significantly. The color of the skin is pale, with an earthy or slight icteric hue, sweat is observed. The fever acquires a remitting or intermittent character. In general, the patient gives the impression of a severe septic patient.

In the study, one can often find pain on pressure in the area of ​​\u200b\u200bthe emerging abscess, tension in the abdominal wall in the upper abdomen - in the epigastric region and in the hypochondria.

With a right-sided subdiaphragmatic abscess, palpation establishes an increase in the liver, a displacement of its lower edge, evenly painful, rounded, protruding 2-3 cm or more from under the edge of the right costal arch.

The upper border of the liver, determined by a dull percussion tone, is raised upward, under pressure from the purulent contents located between the upper surface of the liver and the diaphragm. The upper limit of hepatic dullness is located in the form of a convex upward line, above which a pulmonary sound is determined. If a subdiaphragmatic abscess contains a significant amount of gas, then a band of tympanitis appears above the area of ​​hepatic dullness, over which a pulmonary tone is then determined. Such a three-layer distribution of percussion sounds, a kind of "percussion rainbow" (dull, tympanic and pulmonary sounds) are especially characteristic of a subdiaphragmatic abscess, but are rare in practice, with a far advanced process.

During auscultation of the lungs at the lower border of the pulmonary sound, it is sometimes possible to listen to individual wheezing and pleural friction rub.

With a left-sided subdiaphragmatic abscess, you can notice a slight protrusion of the epigastric and left hypochondrium regions, painful when palpated. Quite often at the same time the lowered down, evenly painful and rounded edge of the left lobe of the liver is palpated.

With a significant amount of subdiaphragmatic abscess, the heart is displaced to the right. On percussion of the lower part of the left half of the chest, a dull sound is determined, above which a normal pulmonary tone is noted. The Traube space is reduced or is "occupied". If gas accumulates in the abscess, the "percussion rainbow" mentioned above is revealed in the lower left half of the chest. In these cases, the recognition of an abscess is not difficult. However, when there is no band of tympanitis and a distinct location of the upper limit of dullness along a convex curve, the diagnosis of subdiaphragmatic abscess is often replaced by an erroneous diagnosis of pleural effusion, which, however, can also occur additionally with this disease.

X-ray examination is of great diagnostic value. It establishes a high standing of the diaphragm with a border convex upwards on the affected side, inactive or immobile in some places. When the abscess contains even relatively small amounts of gas, the latter is detected in the form of a narrow strip of enlightenment between the darkening from the upper edge of the liver and the abscess and the diaphragm. Sometimes a gas bubble located under the diaphragm with a horizontal liquid level, often mobile, is detected. A similar picture gives grounds for the diagnosis of subdiaphragmatic pyopneumothorax. Often, an effusion is detected in the corresponding pleural cavity - the result of "sympathetic" (reactive) exudative pleurisy.

The diagnosis of a subdiaphragmatic abscess can be confirmed by test puncture. Trial puncture, according to a number of experts, does not harm the patient's state of health. However, many surgeons, not without reason, believe that a test puncture, due to a known danger, "should not occupy a leading place", but is permissible only during an operation.

Laboratory studies only relatively help in identifying the abscess. In seriously ill patients, progressive anemia of the hypochromic type, neutrophilic leukocytosis with a left-sided shift, toxic granularity of neutrophils, aneosinophilia, and an increase in ESR are observed. In the urine, albuminuria associated with fever, urobilinuria, and in some cases indicanuria are noted in many cases.

Recognition:

Assistance in the diagnosis is provided by additional research methods: x-ray and ultrasound.

Treatment:

When forming a subdiaphragmatic abscess, one can limit oneself to conservative therapy - antibacterial, detoxification, infusion. With the help of punctures in the abscess area, inject antibiotics. Complete cure - only after surgery.

Treatment of a subdiaphragmatic abscess should usually be surgical. Recently, they have been trying to replace a wide opening of the abscess cavity by emptying it with a thick needle, followed by washing the cavity with antibiotic solutions and introducing them into the cavity (penicillin, Streptomycin-KMP, etc.). At the same time, vigorous antibiotic therapy administered intramuscularly is carried out. Nevertheless, in most cases, conservative antibiotic therapy should not replace timely surgical intervention. Treatment with antibiotics alone is carried out only until an accurate diagnosis is established.