X-ray signs of subdiaphragmatic abscess is not. Subdiaphragmatic abscess (subdiaphragmatic abscess, infradiaphragmatic abscess)
St. Petersburg Medical Academy of Postgraduate Education
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, and a worsening crime situation, an increase in the incidence of PDA should be predicted (injuries to the abdominal organs, operations for peptic ulcer, cancer of the stomach and colon, a decrease in immunoreactivity in most of the population 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, sacs of the 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, poor 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.
There are intra- and extraperitoneal PDA, which are divided into left-, right-sided and median. These abscesses, in turn, differ in location in relation to the arch of the diaphragm. Right-sided: anterior superior, superior posterior, central, inferior posterior. Left-sided: superior, inferior anterior, posteroinferior, parasplenic. In addition, there are lower extraperitoneal right- and left-sided abscesses.
The data of different authors on the frequency of PDA of different localization sometimes differ quite significantly. So, for example, V.M. Belogorodsky (1964) observed 163 right-sided, 72 left-sided and 5 bilateral abscesses. S.M.Malkova (1986) writes that in her work there were 52% left-sided, 19% right-sided and 29% median PDA.
Considering the data of recent works (Aliev S.A., 1991; Gulevsky B.A., Slepukha A.G., 1988; Nepokoinitsky E.O., Rodina L.I., 1988), one should, apparently, talk about an approximately equal occurrence left- and right-sided PDA; in any case, the difference in their frequency does not exceed 10-12%
By the nature of the contents of the PDA are gas-free (contain only pus) and gas.
Diagnosis of PDA
Symptoms of PDA
The first and main symptom of PDA is pain. Pain in PDA is usually localized. Most patients note acute pain, "sharp", "burning". At the beginning of the disease, pain is moderate, less often severe. There are frequent complaints of pulling pains in the right half of the chest, radiating to the neck. Pain accompanies PDA for almost the entire duration of the disease. Pain may decrease and / or increase with movement, coughing, breathing, exertion. Characteristic irradiation - in the shoulder girdle, shoulder blade, collarbone from the side of the PDA of the same name. This is a consequence of irritation of the n.phreniсi endings, the fibers of which spread in the tendon center, therefore, irradiation is more often observed when PDA is localized under the center of the diaphragm.
Body temperature in patients with PDA is usually elevated. Hectic fever is sometimes the only symptom of developing PDA. According to E.I. Bakuradze, fever is the leading symptom of PDA (Belogorodsky V.M, 1964). It is accompanied by chills, sweating, pallor of the face, dryness of the tongue, a feeling of heaviness in the lower chest. Pulse at these patients, as a rule, is speeded up.
Inspection and palpation allow you to establish changes that can talk about PDA. In the first place - the forced position of the patient. In bed, patients occupy a high elevated position on the back, often with bent legs. Sometimes patients lie on their affected side. When moving, patients avoid unnecessary body movements, keeping straight or, for example, with right-sided PDA, bending forward and to the right.
A lot of symptoms, and the most characteristic ones, are determined by examining the chest.
Already during its examination, an expansion of the chest can be detected. Langenbuch (1897) compared its shape to a bell (however, no one describes such drastic changes now). Smaller changes are quite common. There are smoothness of the intercostal spaces, their expansion; their protrusion, respectively, PDA; protrusion of false ribs on the diseased side (it is more pronounced with the accumulation of pus in the peripheral parts of the RAP).
At the onset of the disease, examination of the abdomen fails to detect any symptoms of PDA. Later, characteristic symptoms appear - swelling of the hypochondrium with right-sided PDA and paradoxical breathing, in which the epigastric region is drawn in during inhalation and protrudes during exhalation. In some cases, changes in the skin and subcutaneous fat are determined. In advanced stages, the skin becomes slightly yellowish and dry to the touch. Sometimes there is a band of swelling and swelling on the lateral surface of the lower half of the chest; this symptom is due to a violation of blood circulation in this area.
Feeling the chest and abdomen near the diaphragm reveals muscle tension corresponding to the localization of the PDA (more clear from the side of the abdominal wall). Sometimes you can feel the edge of the PDA when it descends from under the diaphragm along the posterior surface of the anterior abdominal wall. Palpation from the back with posterior PDA reveals smoothness and tension of the upper part of the lumbar fossae. Unlike paranephritis, palpation of the lumbar region from the front will be painless (more precisely, the kidney area).
The most important symptom of PDA, obtained by palpation, is sensitivity and especially pain in the area of its location. In this case, a diffuse zone of soreness is sometimes noted, corresponding to the location of the abscess. Chest compression (Fakson) is recommended to detect tenderness.
For topical diagnosis, it is necessary to identify the area of pain corresponding to PDA. Pain in the region of the costal arch (opposite the IX-XI ribs), first noted by M.M. Kryukov (1901), is characteristic. This symptom is now called Kryukov's symptom.
Sometimes there are areas of severe pain on the neck at the place of attachment of the legs of the sternocleidomastoid muscle, in the shoulder girdle.
Physical research methods
They can detect changes in the position and state of neighboring organs. With PDA, detect the accumulation of fluid and gas in places where they should not be, effusion in the pleural cavity, compression of the lung tissue, hepatoptosis. These symptoms are outlined in the early stage, are clearly manifested in the II and III stages.
Non-gas PDA
Percussion of the chest may reveal dullness above the normal border of the liver; this dullness is less intense than hepatic. The mobility of the lower edge of the lung is often reduced or absent.
The reaction of the pleura with PDA is noted already in the first days (dry pleurisy). A.A.Troyanov noted a dry, painful cough in patients with PDA (without sputum), explaining this by irritation of the sensitive nerve endings of the diaphragmatic pleura.
Pleural effusion is also common in early PDA. Effusive pleurisy of a different origin can complicate diagnosis. It is important to note that such pleurisy, even of a large size, does not displace the edge of the liver down, but can displace (unlike PDA) the shadow of the heart.
The lower edge of the lung is compressed by the PDA, its airiness decreases up to atelectasis. Depending on the degree of compression of the lung, there will be percussion results - from a pulmonary sound to absolute dullness (especially clearly in front). With auscultation, you can listen to various changes - from weakened vesicular to bronchial breathing. At the border of the abscess, breath sounds suddenly disappear.
Dullness of percussion sound above the PDA does not change with respiratory movements, but when the position of the body changes, the band of dullness shifts. When the patient is positioned with a right-sided abscess on the left side, the dullness zone shifts to the left. The abscess will move away from the right side wall of the chest, which is manifested by the appearance of a clear pulmonary tone here.
The displacement of the liver, along with an abscess above it, gives grounds for obtaining a ballot of the liver. If the chest is beaten from behind at the angle of the patient's right shoulder blade, the hand placed in the right hypochondrium in front will feel the tremors of the liver. This is a symptom of G. G. Yaure (1921).
With right-sided PDA, as a rule, the lower edge of the liver descends and is well palpable.
When examining the left half of the chest, the same relationships are determined as on the right, the left dome of the diaphragm does not rise as high as the right one (not higher than the III rib, while the right one - up to the II rib).
The appearance of dullness in the back in the lower part of the chest is also observed with retroperitoneal PDA. The blunting zone does not reach a great height. The accumulation of pus in the retroperitoneal space smoothes the upper part of the lumbar fossa, and sometimes even protrudes it. In these cases, pain, soft tissue pastosity on palpation and the absence of pain in the front (unlike paranephritis) are determined.
Sometimes percussion of the chest from the front reveals below the lung tone not dullness, but tympanitis. This is a sign of gas in the abscess cavity (gas PDA). Percussion reveals 3 areas of different tones - a clear tone of the lung, gas tympanitis and dullness of pus. The PDA gas shifts as the position of the torso changes. It is always in the upper part of the PDA (symptom of Deve). The ratio of gas and liquid is well revealed on roentgenoscopy. During auscultation in the abscess area, you can hear the sound of a falling drop, and with a quick change in the position of the patient, there is a “splash noise” of Hippocrates.
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). Small 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
| PDA | Purulent pleurisy |
| History of abdominal disease | History of thoracic disease |
| With anterior PDA, dome-shaped dullness reaches II-III ribs along l. medioclavicularis | The highest point of dullness is in the axilla, and from there the level of dull sound decreases towards the spine and anteriorly (Garland's Triangle) |
| Above dullness, a distinct mobility of the edge of the lung with a deep breath | The pulmonary edge above the dullness is motionless |
| In the lower lobes of the lung - vesicular breathing, suddenly stops at the border of dullness | Breathing slows down gradually |
| Voice tremor increased | Voice trembling is weakened |
| Rubbing noise of the pleura over dullness | There is no pleural friction noise (appears with a decrease in effusion) |
| Between the dullness of the PDA and the heart - an area of \u200b\u200bnormal pulmonary sound (Grievous symptom) | With purulent pleurisy on the right, its dullness merges with the heart |
| Slight displacement of the heart (with a raised edge of the liver) | Often displacement of the heart according to the volume of the effusion |
| Pain and tenderness in the area of the lower ribs (s-m Kryukov) | May be higher, above the effusion, there are no ribs in the zone IX-XI |
| There are abdominal symptoms | No abdominal symptoms |
| Downward displacement of the liver (to the navel) | Liver displacement is rare and small |
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.
Acute pyopneumothorax often occurs after physical exertion, gives a picture of shock or collapse with sharp pains in the chest, shortness of breath, pallor, which resembles a picture of a PDA breakthrough into the pleural cavity. Acute pyopneumothorax is preceded by a long-term lung disease (tuberculosis, lung abscess).
The hallmarks of a liver abscess are a subacute course of the disease, relapsing fever, pain in the right hypochondrium, aggravated by coughing and inhalation, weakening of the respiratory excursions of the diaphragm, hepatomegaly with a normal location of the anterior edge of the liver, changes in the borders of the liver with a change in body position, pain in the suprahepatic region, absence reactive pleurisy. The most accurate differential diagnosis is possible by echography and CT.
Diseases of the retroperitoneal space can give symptoms similar to those of extraperitoneal PDA. These are paranephritis, retroperitoneal abscesses and phlegmon. Common signs for these diseases and PDA are the localization of pain in the back and posterolateral part of the body, fever, swelling of the skin. Pain in paranephritis is localized between the XII rib and the iliac crest, radiates to the thigh and intensifies with a change in body position. There are no personal phenomena with paranephritis. The focus with it lies closer to the surface of the body, so the phenomena from the soft tissues of the back appear earlier and occur more often than with PDA. The outlines of the back are smoothed out, the diseased half of it swells, which is especially clear when examining a sitting patient. With paranephritis, the pain is more pronounced in the angle between the XII rib and the long back muscles. And again, the results of ultrasound and CT are decisive in the diagnosis.
table 2
Differential diagnosis of PDA and gallbladder diseases
| Cholecystitis | PDA |
| Fever | Fever |
| Pain in the right hypochondrium | Pain in the right hypochondrium |
| Associated with poor diet | Not related to diet |
| Removed by drugs | Not removed by drugs |
| Obesity as a predisposing condition | Previous purulent disease, trauma (surgery) |
| Symptoms of Ker, Ortner, Murphy (+) | Symptoms of Ker, Ortner, Murphy (-) |
| There is no zone of hyperesthesia on the skin of the right shoulder girdle | There is a zone of hyperesthesia on the skin of the right forearm |
| Normal standing and diaphragmatic mobility | High standing of the diaphragm and limitation of its movements |
| The course of the disease is intermittent, with remissions | The course is more or less long, without remissions |
| Pain in the right hypochondrium | (+) Kryukov's symptom |
Table 3
Differential diagnosis of PDA and diaphragmatic hernia
| PDA | Diaphragmatic hernia |
| History of PD disease (more precisely, its organs) | History of trauma prior to onset of illness |
| The disease develops according to the type of inflammation in a longer or shorter period | The disease flows for years and is manifested by pain and symptoms of intestinal passage disorders. |
| Sometimes severe inflammation in the PD | No inflammatory events |
| Diaphragm high, dullness on percussion (non-gas abscess), tympanitis with gas abscess | Dullness over the diaphragm when dense organs are in a hernia. Tympanitis on the diaphragm, sometimes dullness from the contents of hollow organs (stomach) under it |
| X-ray: under a high-standing diaphragm, a hemispherical shape of gas and under it a horizontal level of pus | X-ray: blackout under the diaphragm - if there is a hernia of the liver, peristalsis of the strangulated organ, sometimes the level of fluid. Contrast study with basis helps |
| The stability of the x-ray picture | Typical (!) inconsistency of the x-ray picture |
PDA treatment
The basis of PDA treatment is surgical treatment (opening and drainage). Usually it is supplemented with conservative therapy (detoxification, antibacterial, symptomatic). But conservative methods cannot replace surgery. Therefore, in this section, surgical methods will be considered, more precisely, various approaches for opening the PDA.
The operation of opening the PDA is far from a safe intervention associated with the anatomical features of the location of the abscesses and for a long time gave a high mortality rate. The question of the best operation for PDA comes down, in fact, to the question of safe access to it.
The largest number of methods for the surgical treatment of PDA was proposed at the end of the 19th and beginning of the 20th century. At this time, a number of the simplest, shortest and safest accesses to the PDA are resumed.
In each individual case, the approach to PDA is determined by the localization of PDA and topographic and anatomical relationships in the abscess area.
But there are a number of general provisions during the operation, regardless of the method of intervention. This includes the position of the patient on the operating table. The patient should lie either on a healthy side or on his back, slightly inclined to the healthy side and with a roller placed under the body. When positioned on its side, the leg lying on the table is bent and attached to it.
Anesthesia during operations is usually general.
The incision is often made in the area of the abscess, but not necessarily in the center of it. More often, the abscess is opened sharply through a small incision and then the hole is enlarged with a forceps to the desired size. The emptying of the PDA must be done slowly, otherwise the patient may collapse. After emptying the abscess, it is necessary to revise the abscess cavity, tear the existing strands with your finger, open the pockets and bays widely, eliminating the jumpers between them. Further, it is necessary to ensure good drainage of the abscess cavity. Previously, tampons with Vishnevsky's ointment were most often used, introduced into the cavity, sometimes tampons and drainage were introduced. In recent years, the most popular (as more effective) method is the intake-aspiration drainage of the PDA cavity, in particular, with double-lumen silicone drainages (according to Kashinin N.N., Bystritsky A.L.; 1980). With this method of treatment, the abscess cavity is cleared faster, the length of the patient's stay in the hospital is reduced.
The most common accesses to the RAP of the most common localization
Transpleural access for upper anterior and posterior abscesses
A skin incision 10-12 cm long is made above the location of the PDA, preferably at its lower edge. The tissue is dissected in layers up to the rib. 1-2 ribs are resected subperiosteally. After that, sutures are applied along the edges of the wound, bringing together and suturing the periosteum and costal pleura with the diaphragmatic one. Sewn with a needle, or interrupted sutures, or intermittent. After suturing, an incision is made in the area limited by the sutures, while the stitched pleura sheets are cut, the diaphragm is cut deeper and the abscess is emptied. Swabs (drainages) are inserted into the abscess cavity.
The difficulty and danger of this method is that the operation is performed on a moving diaphragm and requires fine technique. It is not always possible to avoid the release of pus through punctures in the diaphragm, sometimes the pleura breaks, the holes in it are difficult to sew up, and therefore there is a great danger of purulent pleurisy.
Right-sided pleural access for anterior-superior abscesses is universal. Lateral approach.
A skin incision 10-12 cm long is made in lines along the X rib, parallel to the supposed edge of the sinus of the pleura. The skin, subcutaneous tissue is dissected, m.serratus post is incised; The IX and X ribs are resected for 8-10 cm. Thin fibrous fibers are cut, fixing the edge of the sinus to the edges of the ribs. After that, the edge of the sinus easily exfoliates from the chest wall, diaphragm and moves upward. Pleural tears are immediately sutured. An incision along the fibers exposes the intraperitoneal fascia and diaphragmatic peritoneum above the abscess. The diaphragm is dissected along the wound, its upper edge is sutured with catgut to the muscles of the chest. They puncture the abscess, and, having received pus, open it. If pus is not obtained, the peritoneum is peeled off to the sides and punctures are made in different directions until an abscess is found and then it is emptied with a cut. Revision halfway, smoothing the walls, tamponade (drainage).
Rear approach
Skin incision along the 11th rib, starting from the long muscles of the back. The XI rib (if necessary, the end of the XII) is exposed and resected, and the intercostal muscles are bluntly divided. Having mobilized the sinus (see the mobilization technique above), the pleura is separated from the ribs (with a tupfer), then from the diaphragm and pushed up. The diaphragm muscle is cut along the fibers, the RAP is opened. Opening, drainage. If there is no abscess in the incision area, peel off the peritoneum from the lower surface of the diaphragm until an abscess is found.
Extraperitoneal subcostal access. Front and side approach
Skin incision 10 cm long parallel to the costal arch, starting from the lateral edge of the rectus abdominis muscle and up to l.axillaris ant. (anterior approach) or according to l.medioclav. to l.axillaris media. Dissect the tissue to the aponeurosis and fibers of the transverse muscle. An incision is made in the presenting part of it, the costal arch is pulled up and forward. The surgeon slides his finger upward along the transverse fascia, exfoliating it from the inner surface of the transverse muscle and the lower surface of the diaphragm. Having determined the fluctuation, the surgeon opens the abscess by moving his finger up. If the abscess is not palpable, a puncture is made. The lack of access is the retention of pus if the edge of the costal arch is pressed against the liver. This may require the imposition of counter-opening. A second incision of the skin, tissue and superficial fascia is made 5-6 cm outside the wound, after which the abdominal wall tissue is exfoliated through the first incision with a forceps. From the second cut similarly penetrate into the first. From a new wound, the surgeon exfoliates the peritoneum and dissects it under the abscess at the bottom of it (method of K.S. Shakhov, 1960).
Rear approach
Skin incision 12-15 cm parallel and below the XII ribs, tissue dissection up to m.serratus post.inf. Dissect the tissue after the expansion of the wound to the transverse fascia. Detachment of the fascia, fiber and peritoneum from the lower surface of the diaphragm. The diaphragm is dissected, the PDA is drained.
Upper midline access with anterior PDA
Upper median incision to the transverse fascia 8 cm. Infiltration of preperitoneal tissues with novocaine. Detachment of the peritoneum with a finger up and to the sides. Opening of an abscess.
Transperitoneal subcostal approach
Apply with front PDA. Layered incision of the abdominal wall on the finger below the costal margin from the rectus muscle to l.axillaris media. After opening the abdominal cavity, PDA is searched. The lower edge of the liver is sutured to the lower lip of the wound to delimit the abdominal cavity. Tampons should be inserted into the outer corner of the wound in the abdominal cavity. Opening, drainage.
Extrapleural posterior access for posterior extraperitoneal abscesses
An incision of 10-15 cm behind along the XI rib. Resection of it (subtotal). They look for a transitional fold of the pleura, its mobilization. The diaphragm is exposed and dissected along the fibers to the peritoneum. If an abscess is found, the peritoneum is dissected, otherwise the peritoneum is exfoliated from the lower surface of the diaphragm and an abscess is found.
Extraperitoneal posterior access
Good for posterior extraperitoneal PDA. The incision is below and parallel to the XII rib, starting at 3 transverse fingers from the paravertebral line to the axillary. Dissect the tissues to the transverse fascia (if necessary, resect the XII rib). Further actions are the same as for the anterior approach. With retroperitoneal access, the most favorable conditions for PDA drainage are created.
Postoperative management of patients
After opening the PDA, its cavity is eliminated at different times. According to V.M. Belogorodsky (1964), this is 30-50 days. When using active supply and exhaust drainage, the cavity closes in an average of 20-27 days (Kapshin N.N., Bystritsky A.L.; 1980).
After the operation, patients must be given a position favorable for the outflow of pus. With posterior incisions - Fovlerian; at the front and side - on the side. The first dressing is best done after 5-7 days; tampons should be removed gradually.
In the postoperative period, physiotherapy exercises, breathing exercises, and early activation of the patient are very useful. Antibiotics are prescribed according to strict indications (Zaitsev V.T., Slyshkov V.P., Osmanov R.I.; 1984), one of which is the opening of the pleural cavity during surgery. Adequate anesthesia after surgery is necessary, which favors the manifestation of motor activity.
With the right choice of access and a well-performed operation, the prognosis is favorable. Mortality after surgery is usually due to concomitant diseases of the cardiopulmonary system. According to A.L. Bystritsky, mortality is 7.3% (Bystritsky A.L., Fainberg K.A., Golubev L.P.; 1986).
Bibliography
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A subdiaphragmatic abscess is an encysted collection of pus between the inferior surface of the diaphragm and the superior surface of the liver (right) or the fornix of the stomach and spleen (left). A right-sided subdiaphragmatic abscess is more common. The source of the subdiaphragmatic abscess is the foci of purulent inflammation of the abdominal organs (perforated and duodenal ulcers, inflammation of the biliary tract and pancreas, liver abscess, acute appendicitis, amoebic dysentery, festering echinococcus cyst), sometimes lungs and. The cause of the formation of a subdiaphragmatic abscess can also be open and closed abdominal trauma and thoraco-abdominal injuries. Most often, a subdiaphragmatic abscess is located intraperitoneally.
The clinical picture of a subdiaphragmatic abscess is often blurred, as it usually appears against the background of a serious illness. The most typical prolonged fever, chills, and appetite, weakness, depression of the psyche. The patient takes a forced semi-sitting position. The breath is gentle. With the abdomen, muscle tension and soreness in the right hypochondrium, with - an increase in the boundaries of the liver. In the blood, leukocytosis, acceleration. In more severe cases, the symptoms of a subdiaphragmatic abscess are pain in the right hypochondrium, aggravated by deep breathing, coughing, sudden movements, radiating to the shoulder girdle, right collarbone, shoulder blade, fever, leukocytosis. with a subdiaphragmatic abscess, it plays a decisive role (the dome of the diaphragm is raised, motionless; under it is gas and a horizontal liquid level).
Complications of a subdiaphragmatic abscess: reactive, breakthrough of pus into the pleural or abdominal cavity, into the pericardium. serious, without surgery usually ends in death.
The main method of treatment of subdiaphragmatic abscess is surgical. Diagnostic puncture is permissible only on, so that when pus is obtained from the subdiaphragmatic space, immediately proceed to the operation. Access to the subdiaphragmatic abscess through the chest is transpleural and extrapleural. After emptying the abscess, its cavity is drained and tampons with Vishnevsky's ointment and rubber drains are introduced. The first time tampons are changed on the 5-7th day.
In the postoperative period, the use of antibiotics, vitamins, control of the chest and abdominal cavity is indicated. It is necessary to change the dressings, which can get wet due to purulent discharge, as well as skin care: lubrication with sterile vaseline, Lassar paste.
Subdiaphragmatic abscess (subdiaphragmatic abscess) - a limited accumulation of pus in the subdiaphragmatic space between the diaphragm and the organs adjacent to its lower surface, mainly the liver on the right, the stomach and spleen on the left.
The subdiaphragmatic space above the liver is divided by the suspensory ligament of the liver (lig. suspensorium hepatis) into a large right and a smaller left halves isolated from each other.
The coronal ligament of the liver (lig. coronarium hepatis) delimits the subphrenic fissure at the back, and two triangular ligaments (lig. triaagulare dext. et sin.) - from the sides. Normally, under the left dome of the diaphragm, there is also a gap between the diaphragm and the stomach and spleen adjacent to its lower surface. These fissures communicate with the abdominal cavity, representing essentially a part of it; and only during the inflammatory process in some part of the subdiaphragmatic space, adhesions are formed very early, with which the area of inflammation is quickly delimited from the free abdominal cavity. The described sections of the subdiaphragmatic space do not communicate with each other, and therefore the suppurative process in one of them usually does not spread to others.
There are the following localizations of the subdiaphragmatic abscess: right upper anterior; right upper back; left upper back. In addition, extrahepatic subdiaphragmatic abscesses are isolated. In the upper floor of the abdominal cavity above the transverse colon and mesocolon: right lower hepatic; left lower anterior (pregastric); left lower-posterior (retrogastric). The subphrenic abscess develops predominantly in the right subphrenic space, with about half of all abscesses located in the right upper aad space. This is explained by the fact that during an inflammatory process in one of the organs of the abdominal cavity, the lymph, and with it the infection, rush to the centrum tendineum diafragmatis and, first of all, the right subdiaphragmatic space is infected.
Subdiaphragmatic abscess is usually observed in 30-50 years of age, 3 times more often in men than in women. However, a subdiaphragmatic abscess can develop in childhood and old age, but much less frequently.
Subdiaphragmatic abscess, as a rule, is a complication of inflammatory processes of the abdominal organs: perforated appendicitis, perforated gastric and duodenal ulcers, severe forms of acute cholecystitis and cholangitis. Less commonly, a subdiaphragmatic abscess develops with paranephritis, even more rarely with general purulent processes, pyemia. Finally, a subdiaphragmatic abscess can develop as a result of a breakthrough of an intrahepatic abscess, with liver injuries, after thoracoabdominal injuries.
A subdiaphragmatic abscess is a local abscess that has formed between the dome of the diaphragm and the adjacent organs of the upper floor of the abdominal cavity (liver, stomach and spleen).
A right-sided subdiaphragmatic abscess is more common. The source of a subdiaphragmatic abscess is the foci of purulent inflammation of the abdominal organs (perforated ulcer of the stomach and duodenum, inflammation of the biliary tract and pancreas, liver abscess, acute appendicitis, amoebic dysentery, festering echinococcus cyst), sometimes lungs and pleura. The cause of the formation of a subdiaphragmatic abscess can also be open and closed abdominal trauma and thoracoabdominal injuries. Most often, a subdiaphragmatic abscess is located inside the peritoneum.
The clinical picture of a subdiaphragmatic abscess is often blurred, as it usually appears against the background of a serious illness. In the initial stage of a subdiaphragmatic abscess, general symptoms may be observed: weakness, sweating, chills, fever, which are also characteristic of other abdominal abscesses. Sometimes the development of a subdiaphragmatic abscess begins violently with symptoms of acute peritonitis. And only after a while all the local symptoms are concentrated in the right hypochondrium. In cases where a subdiaphragmatic abscess develops with slowly increasing symptoms, physical methods of examining the patient are of great importance.
On examination, the protrusion is found forward and towards the liver area - the right costal is raised and, together with the lower part of the chest, is protruded forward and to the side. This area lags behind when inhaling. On palpation of the lower intercostal spaces on the right or left, a sharply painful point is detected, corresponding to the place of the closest position of the subdiaphragmatic abscess to the chest - Kryukov's symptom. Compression of the costal arch in the direction from front to back or from the sides causes severe pain. With a large abscess, the liver is displaced downward and limitedly mobile. All these symptoms are more or less clearly expressed in the later stages of the development of the process.
Subdiaphragmatic abscess very often develops as a complication of a number of diseases of the abdominal organs, for which the operation was performed. Therefore, when on the 6-10th day after the operation there is a gradual increase in temperature, chills appear, especially with developed complications in the pleura, increased heart rate, general weakness, weakness, high leukocytosis and other symptoms of acute purulent infection, the possibility of developing a subdiaphragmatic abscess should be suspected.
With the further development of the disease, symptomatology is reduced to an increasing picture of sepsis. It is accompanied by pain of varying degrees in the upper abdomen. Initially, the pain is dull, the patient cannot accurately determine its localization. Later, it becomes quite sharp with a return to the right shoulder and shoulder girdle. Often the right costal edge becomes painful when tapped. There is an increase in pain with a deep breath and a characteristic dry, painful cough, sometimes persistent painful hiccups. Shortness of breath appears. When the subphrenic abscess is located in the right upper-posterior part of the subphrenic space, patients complain of pain in the region of the right kidney.
A severe complication of a subdiaphragmatic abscess is a breakthrough of pus through the diaphragm with the formation of pleural empyema, pulmonary abscess, bronchopleural fistula, lung gangrene. Empyema may occur without rupture of pus through the diaphragm as a result of infection of a reactive effusion in the right pleural cavity. Much less often there is a breakthrough of the abscess into the free abdominal cavity with the subsequent development of peritonitis. Complications extremely aggravate the course of an abscess and are the main cause of mortality. They arise, as a rule, with untimely and belated recognition of a subdiaphragmatic abscess.
Diagnosis of a subdiaphragmatic abscess
Subdiaphragmatic abscess is differentiated from gastric ulcer and duodenal ulcer, purulent appendicitis, diseases of the liver and biliary tract, festering echinococcus of the liver.
Diagnostic methods:
- x-ray examination;
- Ultrasound of the abdominal cavity;
- CT scan.
Treatment of subdiaphragmatic abscess
Conservative antibiotic treatment is carried out only at the initial stages of the disease. The main method of treatment 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. The complex treatment of subdiaphragmatic abscess includes antibacterial, detoxification, symptomatic and restorative therapy.
Essential drugs
There are contraindications. Specialist consultation is required.
- (broad spectrum bactericidal antibacterial agent). Dosage regimen: in / in, adults and children over 12 years of age or weighing more than 40 kg - 1.2 g of the drug (1000 + 200 mg) with an interval of 8 hours, in case of severe infection - with an interval of 6 hours.
- (broad spectrum bactericidal antibacterial agent). Dosage regimen: in / in, adults and children over 12 years of age, the average daily dose is 1-2 g of ceftriaxone 1 time per day or 0.5-1 g every 12 hours. In severe cases or in cases of infections caused by moderately sensitive pathogens, the daily dose can be increased up to 4 g.
- (an antibiotic of the IV generation cephalosporin group). Dosage regimen: IV, adults and children weighing more than 40 kg with normal kidney function 0.5-1 g (for severe infections up to 2 g) or deep intramuscular injection with an interval of 12 hours (for severe infections - after 8 h).
- (antiprotozoal, antibacterial agent). Dosage regimen: intravenously for adults and children over 12 years of age, a single dose is 0.5 g. The rate of intravenous jet or drip injection is 5 ml / min. The interval between injections is 8 hours.
- (antimicrobial, bactericidal, antibacterial). Dosage regimen: in / in, as an infusion: ≤ 500 mg - for 20-30 minutes, > 500 mg for 40-60 minutes. The average daily dose is 2000 mg (4 injections). The maximum daily dose is 4000 mg (50 mg/kg). The dose is adjusted according to the severity of the condition, body weight and renal function of the patient.
- (antibacterial, bactericidal). Dosage regimen: for adults, 0.5 g intravenously every 6 hours or 1.0 g every 12 hours. The duration of the infusion is at least 60 minutes, the rate is 10 mg / min.
Definition
A subdiaphragmatic abscess is an abscess located in the pancreas between the diaphragm and the colon.
The subdiaphragmatic space is a section of the upper abdomen, bounded above, behind and laterally by the diaphragm, below - by the liver and spleen, splenic flexure of the colon, in front - by the anterior abdominal wall.
Spine and lig. falciforme divide the subphrenic space into two halves (right and left). Distinguish between intra- and extra-peritoneal subdiaphragmatic spaces.
Causes
The source of infection and the ways of its spread in a particular case cannot always be established. The most common sources are purulent processes in the abdominal region.
The most common sources are perforated ulcers of the stomach and duodenum, acute appendicitis, suppuration of the liver and gallbladder. Other sources may be the spleen, pancreas, paranephritic abscess, uterine appendages, colon, osteomyelitis of the rib. In newer statistics, indications of the postoperative origin of the subdiaphragmatic abscess predominate - mainly due to operations on the organs of the pancreas (stomach, duodenum, gallbladder, liver, pancreas).
Direct (open trauma), lymphogenous (pulmonary abscess, gangrene, bronchiectasis) and hematogenous infections of the subdiaphragmatic space are also possible.
The transfer of infection to the subdiaphragmatic space is favored by such factors as: movements of the diaphragm synchronous with breathing with fluctuations in pressure and the creation of the effect of pumping out to the subphrenic space, the outflow of exudate from the abdominal cavity in the supine position, according to the laws of hydraulics.
The use of antibiotics and sulfonamides masks the clinical picture, but does not prevent the occurrence of an abscess.
Most often, with this abscess, coli bacteria, streptococci and staphylococci are found. Less common are other pathogens, including anaerobic bacteria.
Intraperitoneal subphrenic abscesses are more common than extraperitoneal abscesses. More often they are right-handed. Bilateral subdiaphragmatic abscesses are rare.
Typical localizations of subdiaphragmatic abscesses are:
- between the right dome of the diaphragm and the bulge of the right lobe of the liver. Localization can be front and back;
- the space under the left dome of the diaphragm and the upper surface of the left lobe of the liver and the fundus of the stomach;
- the space between the left dome of the diaphragm, the spleen and the splenic fold of the colon.
Subdiaphragmatic abscesses can reach considerable sizes. They increase sharply with the formation of gases. Under the stress of pus, displacements of adjacent organs occur. So, for example, the diaphragm is shifted upward, the mediastinum - to the opposite side.
Symptoms
The symptoms of a subdiaphragmatic abscess are complex. It combines general phenomena, local symptoms and symptoms of the underlying disease. Most often, at present, a subdiaphragmatic abscess is a complication after surgery. Thus, its symptoms are superimposed on the phenomena of the postoperative period, and then a protracted one in this case. Antibiotic treatment greatly obscures the clinical picture. temperature, high leukocytosis, etc. But, despite the fact that the symptoms are not very pronounced, the general condition is still severe, the pulse is quickened, there is also tachypnea.The expected postoperative resolution of the abdominal status is delayed. the hypochondrium and sometimes in the epigastric region, where the abdominal wall can be stable.The skin in the areas of the projection of the subdiaphragmatic abscess is often pasty soft.These areas are painful on percussion.
Intercostal spaces are smoothed. Breathing on the corresponding side of the chest is slightly behind. One of the early symptoms is persistent vomiting. The third symptom complex is the clinical picture of the disease, a complication of which is a subphrenic abscess. Laboratory data are an indicator not only of the presence of a subphrenic abscess, but also of the underlying disease. There is usually a high leukocytosis, a shift to the left, lymphopenia, accelerated ESR, hypoproteinemia, a very short strip of Veltman.
The clinical picture is often complicated by an accompanying pleural effusion.
Diagnostics
Diagnosis of a subdiaphragmatic abscess is difficult. The most important thing to think about is the possibility of such a complication. A subdiaphragmatic abscess should always be considered when, after an acute inflammatory process in the abdomen and in the postoperative period after abdominal surgery, there is a slowdown in the recovery of the general condition, when it is inexplicable why intoxication occurs, when septic temperatures appear and pain or a feeling of heaviness in the subdiaphragmatic region. These symptoms suggest the presence of a subdiaphragmatic abscess. They are not pathological. X-ray data are also indirect signs. There is a high position of the diaphragm and restriction of its movement, and with the content of gases in the abscess - a water-air shadow. A reactive exudate is usually found in the pleural sinus. For smaller abscesses, tomographic examination is necessary.
Proof of the correctness of the diagnosis can only be the evacuation of pus from the subdiaphragmatic space through a diagnostic puncture. It is valid only when ready to carry out the immediate operation. Carrying out a puncture with the evacuation of pus and the introduction of antibiotics inside, as an independent therapeutic method, is associated with dangers, unreliability of the therapeutic result.
Complications of subdiaphragmatic abscesses are most often directed to the chest cavity (pleural empyema, pneumonia, abscessing pneumonia, bronchial fistula, breakthrough of pus into the pleura, into the pericardium) and, less often, to the abdominal cavity (breakthrough of pus into the free abdominal cavity, causing peritonitis, etc.). ).
In the differential diagnosis, one should keep in mind: pleural empyema, pneumonia, liver abscess, paranephritis, and typical abscesses in the epigastric region.
Subdiaphragmatic abscess is usually an acute disease, but it should be borne in mind that it can also occur chronically.
Prevention
Surgical treatment of subdiaphragmatic abscess. It consists of opening the abscess and draining it. It is carried out through three classical accesses: 1. Abdominal transperitoneal or abdominal extraperitoneal; 2. Transpleural; 3. Posterior retroperitoneal.
The best opportunity for viewing creates transpleural access. In view of the danger of infection of the pleura, it is necessary, in the absence of adhesions, to carry out a preliminary pleuroscopy - to sew the diaphragm to the parietal pleura. Extrapleural and extraperitoneal approaches are the safest. Drainage of large abscesses should preferably be connected to a suction system. In the postoperative period, antibiotics are used for general and local treatment according to the antibiogram.
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). Small 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
| PDA | Purulent pleurisy |
| History of abdominal disease | History of thoracic disease |
| With anterior PDA, dome-shaped dullness reaches II-III ribs along l. medioclavicularis | The highest point of dullness is in the axilla, and from there the level of dull sound decreases towards the spine and anteriorly (Garland's Triangle) |
| Above dullness, a distinct mobility of the edge of the lung with a deep breath | The pulmonary edge above the dullness is motionless |
| In the lower lobes of the lung - vesicular breathing, suddenly stops at the border of dullness | Breathing slows down gradually |
| Voice tremor increased | Voice trembling is weakened |
| Rubbing noise of the pleura over dullness | There is no pleural friction noise (appears with a decrease in effusion) |
| Between the dullness of the PDA and the heart - an area of \u200b\u200bnormal pulmonary sound (Grievous symptom) | With purulent pleurisy on the right, its dullness merges with the heart |
| Slight displacement of the heart (with a raised edge of the liver) | Often displacement of the heart according to the volume of the effusion |
| Pain and tenderness in the area of the lower ribs (s-m Kryukov) | May be higher, above the effusion, there are no ribs in the zone IX-XI |
| There are abdominal symptoms | No abdominal symptoms |
| Downward displacement of the liver (to the navel) | Liver displacement is rare and small |
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.
