Subphrenic abscess

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

Most often it 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

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

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

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

Symptoms of acute or subacute purulent-septic process predominate; in particular, a high fever with chills is possible, the corresponding localization of pain. It is possible to identify a sympathetic effusion in pleural cavity from the appropriate 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 find out the anatomical features of the location of the abscess and choose the correct access. Ultrasound examination reveals the fluid content in the abscess cavity. X-ray examination reveals a limitation of the mobility of the diaphragm on the corresponding side, effusion in the corresponding pleural sinus.

Treatment

Conservative treatment (prescribing antibiotics, detoxification therapy, treatment of the disease that caused the abscess) is carried out either in case of doubt about the diagnosis, or as a preoperative preparation. After a definite diagnosis, the subphrenic abscess should be opened and drained. The access through which an abscess is opened is largely determined by its localization and the presence of concomitant complications.

Extraseral accesses

Whenever possible, the optimal choice is non-spinal (i.e., extrapleural and extraperitoneal access). According to a number of authors (published in works from 1938 to 1955), the mortality rate with extraverous access ranged from 11 to 20.8%, and with transserous (that is, transpleural or transperitoneal) - from 25 to 35.8%.

Anterior extraverous subcostal approach

The anterior extraperitoneal subcostal approach was proposed by P. Clairmont and is used to open anteroposterior right-sided subphrenic 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 cut 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 approaches

Transperitoneal approaches

Imaging-guided percutaneous puncture drainage

Notes (edit)

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Exacerbations of diseases of the abdominal organs can occur due to various reasons: inflammatory processes, pathogenic microflora, surgical interventions, injuries. Rare enough, but extremely dangerous complication subphrenic abscess is considered. Its symptoms are often hidden under the manifestations of diseases provoking suppuration, which complicates timely diagnosis.

What is an abscess in the subphrenic space?

Subphrenic abscess - the concentration of pus under the diaphragm and next to the abdominal organs - the stomach, liver, spleen, transverse colon. This section, located in the upper abdomen, is called the subphrenic space. Inside it there are intraperitoneal and retroperitoneal parts. In most cases, the abscess develops in the intraperitoneal region. Vertebral column and the sickle ligament of the liver divide it into right and left halves. The subphrenic abscess was assigned the ICD code 10 K65.

In the process of formation of an inflammatory infiltrate, the superficial areas of organs, the diaphragm and the greater omentum are involved. A fully formed abscess is enclosed in a capsule of connective tissue with an uneven outline. There is pus inside. In addition, gases may be present in the capsule, sometimes gallstones, sand are found. The liquid contents of the capsule contain various types of microorganisms. Most often it is anaerobic flora, E. coli, streptococci, white or Staphylococcus aureus... With enough large size abscess, pressure is exerted on nearby organs, disrupting their normal functioning. The increase is most often due to the accumulation of gases. Often, an abscess is accompanied by the formation of a pleural effusion.

Both men and women are susceptible to this secondary disease. Most of them are elderly people and old age... In men, malaise is more common.

Why is an abscess formed?

More than 80% of cases of the formation of a local abscess occurs due to acute inflammatory diseases of the abdominal organs. Pathological processes in nearby and neighboring organs become foci of infections. There are different ways for infection to enter the diaphragm: creating negative pressure in the dome of the diaphragm during breathing, intestinal peristalsis, lymph flow, blood vessels... The most common causes are contact with diseased organs.

Subphrenic abscess is considered a severe complication of the postoperative period. The accumulation of pus can be caused by a number of factors that often accompany surgery on organs located in the abdominal cavity:

• errors in the technique of hemostasis;
• local or diffuse peritonitis;
• extensive organ trauma with the destruction of anatomical connections;
• incompetence of the seams of the anastomosis;
• depressed systemic and immunological reactivity;
• infection;
• ineffectiveness of drainage.

The risk group includes people with malignant lesions of the abdominal organs. This is due to the low level immune defense the body from infections. Removing the spleen removes the main barrier to infections in the subphrenic region and significantly slows down the formation of leukocytes.

The cause of the formation of a purulent capsule can be thoracoabdominal injuries, both open (firearms, stab wounds) and closed (blows, squeezing). Encapsulated hematomas arising from injury are often prone to suppuration.

Where can the abscess be located?

According to the location, the subphrenic abscess can be right-sided, left-sided, or middle. A right-sided abscess is much more common. Localization on the right side is explained by the anatomical and topographic conditions that favor the creation of a limiting shell of the abscess. On the right are the internal organs prone to the formation of inflammatory processes.

Bilateral abscesses are very rare. They make up only 4-5% of the total.

A median abscess can form after resection of the stomach, which violates the anatomical structure of the subphrenic region.

It is extremely rare that an abscess forms in the retroperitoneal part of the department. The accumulation of fluid occurs in the upper areas, between the diaphragm and the extra-abdominal part of the liver.

Symptoms of an intra-abdominal abscess

Diagnosis of a subphrenic abscess is difficult. This is due to the fact that the manifestations of the pathological process are hidden under the symptoms of diseases, which are the main reason for the accumulation of pus under the diaphragm. In addition, the location of the purulent capsule, its size, the presence or absence of gassing microflora in the pus are important.

At surgical intervention signs of the development of an abscess are hidden under the phenomena characteristic of the postoperative period. The antibiotics given to the patient help to erase the symptoms. Therefore, the clinical picture is unclear. The following symptoms may indicate the presence of a complication:

• weakness;
• chills and fever;
• sweating;
• temperature increase;
• tachycardia;
• dyspnea;
• vomit.

The clinical picture largely depends on the degree of intoxication. The pulse, reaching 120 beats / min, indicates a strong poisoning of the body.

There is heaviness and pain under the ribs. The pains are localized on the side affected by the pathology and can be both acute and moderate. Strengthening occurs with sudden movements, coughing, sneezing, deep breaths. Sometimes the pain radiates to the shoulder, shoulder blade, neck. Breathing is usually fast. In this case, the chest at the site of the formation of the abscess lags slightly behind. Relief can come if you take a half-sitting position.

How is the diagnostic examination carried out?

A shift is recorded in the blood test leukocyte formula to the left. X-ray and ultrasound examinations, computed tomography can provide valuable information.

To detect an exacerbation, a standard examination is essential. The following external signs indicate the presence of an abscess:

• smoothing of intercostal spaces;
• protrusion with a large abscess;
• bloating;
• change in breath sounds;
• pain on palpation.

Subphrenic abscess treatment

When an abscess is detected under the diaphragm, surgery is the main method of treatment. Minimally invasive technologies are usually used. During the operation, the abscess is opened and drained. Then, antibiotics are prescribed, the choice of which depends on the data of bacteriological studies.

The prognosis of the disease is ambiguous, since possible complications enough. The mortality rate is about 20%.

Subphrenic abscess refers to severe complications, the clinic, the diagnosis and treatment of which is quite difficult. Compliance with preventive measures, including timely diagnosis and adequate treatment of inflammatory processes in the abdominal cavity, as well as the exclusion of postoperative infectious complications, significantly reduce the risk of pathology formation.

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

Subphrenic abscess is a relatively rare, but very serious complication of purulent-inflammatory processes of the abdominal cavity. The subphrenic abscess is located mainly intraperitoneally (between the diaphragmatic leaf 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, subphrenic abscesses are divided into right-sided, left-sided and median. Most often, there are right-sided subphrenic abscesses with anteroposterior localization.

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

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

Causes of subphrenic 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 subphrenic abscess is postoperative peritonitis (local or diffuse), which developed after gastrectomy, resection of the stomach, suturing of a perforated gastric ulcer, splenectomy, resection of the pancreas. The development of a subphrenic abscess is facilitated by the occurrence of extensive surgical tissue trauma, disruption of the anatomical connections of the organs of the subphrenic space, anastomoses failure, bleeding, and immunosuppression.

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

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

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

Symptoms of a subphrenic abscess

V initial stage subphrenic abscess symptoms may occur general: weakness, sweating, chills, remitting or intermittent fever, characteristic of other abdominal abscesses (interintestinal, appendicular, Douglas space abscess, etc.)

A subphrenic abscess is characterized by the appearance of a feeling of heaviness and pain in the hypochondrium and lower part chest from the affected side. Pain can be of varying intensity - from moderate to acute, aggravated with active movement, deep breathing and cough, radiate to the shoulder, scapula and collarbone. Hiccups, shortness of breath, and a painful dry cough also appear. Breathing is rapid and shallow, the chest on the side of the abscess lags behind when breathing. A patient with a subphrenic abscess is forced to take a semi-sitting position.

Diagnostics of the subphrenic abscess

The detection of a subphrenic abscess is facilitated once it has fully matured. For the purpose of diagnosis, use is made of data from anamnesis and examination of the patient, the results of X-ray, ultrasound, laboratory studies, CT.

Palpation of the upper abdomen with a subphrenic abscess shows pain and muscle tension abdominal wall in the epigastric region or in the hypochondrium. Revealed smoothness and expansion of the intercostal spaces, protrusion of the hypochondrium, with a right-sided abscess - an increase in the liver.

If the subphrenic abscess does not contain gas, chest percussion reveals dullness of sound above the border of the liver, decrease or absence of mobility of the lower edge of the lung. When gas accumulates in the cavity of the subphrenic abscess, areas of different tones are revealed ("percussion rainbow"). On auscultation, there is a change in breathing (from weakened vesicular to bronchial) and a sudden disappearance of respiratory murmurs at the border of the abscess.

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

The main importance in the diagnosis of subphrenic abscess is given to chest radiography and fluoroscopy. A subphrenic abscess is characterized by a change in the region of the legs of the diaphragm, a higher standing of the dome of the diaphragm on the affected side and a limitation of its mobility (from minimal passive mobility to complete immobility). The accumulation of pus with gasless subphrenic abscesses is seen as a darkening above the diaphragm line, the presence of gas as a band of enlightenment with a lower horizontal level between the abscess and the diaphragm. Determined by effusion in the pleural cavity (reactive pleurisy), a decrease in the airiness of the lower parts of the lung.

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

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

Subphrenic abscess treatment

The main method of treating subphrenic abscess in operative gastroenterology is surgical opening and drainage of the abscess.

Surgery for a subphrenic abscess is performed by transthoracic or transabdominal access, which provides adequate drainage conditions. The main incision is sometimes supplemented with a counterperture. Slow emptying of the subphrenic abscess and revision of its cavity are performed. For quick cleansing of the subphrenic abscess, use the method of supply-aspiration drainage with double-lumen silicone drains.

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

Prediction and prevention of subphrenic abscess

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

Preventing the formation of a subphrenic abscess allows timely recognition and treatment inflammatory pathology abdominal cavity, exclusion of intraoperative injuries, thorough sanitation of the abdominal cavity during destructive processes, peritonitis, hemoperitoneum, etc.

St. Petersburg medical Academy Postgraduate education Department of Transfusiology and Hematology Subphrenic abscess (etiology, clinical picture, diagnosis, treatment) St. Petersburg 1999 List of abbreviations used PD - subphrenic PDA - subphrenic abscess PDP - subphrenic space CT - computed tomography Ultrasound - ultrasound procedure Subphrenic abscess (PDA) still remains a disease that is not clear enough in its origin, difficult to diagnose, difficult to prevent and treat. Its comparative rarity does not allow a practitioner to accumulate significant material in the work with PDA patients. This abstract is based on the materials of articles published over the past 15 years in the Soviet and Russian medical press, and is intended to summarize 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. The PDA found during the autopsy was described at one time by Thylesius (1670), Grossius (1696), Weit (1797), Gruveillier (1832). In 1845 Barlax first described clinical picture PDA in a woman. She complained of sudden pain in her side. Examination revealed tympanitis, amphoric breathing with a metallic shade at the angle of the left scapula, and a splash noise was also heard there, indicating an accumulation of fluid, which was a zone of dullness below the tympanitis area. The analysis of these data allowed the author to make an accurate diagnosis of PDA in vivo for the first time. The section confirmed the presence of an abscess source - two perforated stomach ulcers. Subsequently, a whole series of works on PDA appeared, in which for the first time a prominent place was occupied by the issues of diagnostics. Leyden (1870) and Senator (1884) described clear signs of PDA. Jaffe (1881) suggested the term "subphrenic abscess" itself. Gerlach (1891) established the anatomical boundaries of the abscess. Novack (1891) described his postmortem 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 offered transpleural access to the PDA, and N.V. Pariyskiy performed the operation of extrapleural opening of the abscess. By the end of the 19th century, there are works in which the use of X-rays for the diagnosis of PDA is discussed. For this purpose, they were first used by Beclere in 1899, and in Russia by J.M. Rosenblat in 1908. Later, 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 question 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 corrected). 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 70-90 years in the USSR and Russia, interest in this problem remained stable. In many articles of these years, the emphasis is not on the treatment of PDA, but on their diagnosis. modern methods(echography, CT). These methods greatly facilitated the diagnosis of PDA, even small and deep-seated ones. At the same time, many issues of prevention and maximum early detection(and, therefore, treatment) PDA. Over the years, the frequency of PDA was relatively small - 0.01% (Belogorodsky V.M., 1964). However, in last years with the deterioration of social and hygienic conditions in Russia, with a decrease in living standards, a worsening criminogenic situation, it is necessary to predict an increase in the incidence of PDA (trauma to the abdominal cavity, surgery for peptic ulcer disease, stomach and colon cancer, 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 is an accumulation of pus in the space between the diaphragm and the underlying organs. More often, its development is observed between the diaphragmatic leaf 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 (subphrenic space). Located directly under the diaphragm, this abscess, to one degree or another, disrupts the shape and function of the diaphragm and adjacent organs. The localization of the abscess in the PDP 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, omentum, abscesses of the abdominal wall, etc.). Statistical data The question of the frequency of PDA disease has not yet been given an exact scientifically substantiated, statistically reliable answer, despite the large number of works devoted to this pathology. The main reason for this is the sufficient 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 have 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 emergence of PDA, the leading role belongs to the microbial flora. According to most authors, streptococcus, staphylococcus, E. coli are most often found in pus PDA. Often in cultures from PDA pus, the growth of non-clostridial anaerobic flora is noted. Most often, the source of infection in PDA is local pyoinflammatory 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 PDA. But statistics show that PDA develops most often after gastrectomies, subtotal gastric resections, operations for cancer of the pancreas and left half colon(Gulevsky B.A., Slepukha A.G., 1988) SN Malkova (1988) even identifies a "risk group" for the development of PDA - these are patients who have undergone gastrectomy or subtotal gastrectomy for cancer, especially in combination with paragastric operations (splenectomy, pancreas resection). The reason for this is massive surgical tissue trauma, bleeding, failure of anastomoses (especially esophageal-intestinal), decreased immunity against the background of cancer intoxication, leukopoiesis disorders, splenectomy and postoperative anemia. Technical errors during surgery (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 and without any special technical difficulties operations (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 fester and turn into abscesses of the PDP. With open injuries, the occurrence of PDA is observed mainly when the periaphrenic region is damaged (gunshot wounds, stab and cut wounds). Only 10% of PDA patients (Belogorodsky V.M., 1964; Gulevsky B.A., Slepukha A.G.; 1988) had no 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 (unoperated 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 much more often joins 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 corpuscles is observed. Retroperitoneal PDA begins with cellular infiltration of tissue and the development of lymphadenitis. At the heart of PDA of traumatic genesis is suppuration of infected accumulations of blood and bile. This is stage I of PDA development. The inflammation can stop there. By De Bakey - this happens about 70% of the time. Otherwise, exudate appears in the peritoneal crevices, and periadenitis appears retroperitoneally. PDA is delimited from the abdominal cavity by adhesions and fascia. The abscess gradually increases and can reach significant values. PDA have different shape , more often rounded. The shape depends on the location of the abscess. The organs adjacent to the diaphragm exert pressure on the lower surface of the abscess, which can flatten it. The main content of PDA is pus. Occasionally, foreign bodies are found in pus - pieces of feces, gallstones, sand, parasites. Gas in PDA appears as a result of the vital activity of microbes, primarily gas-forming bacteria. The presence of pus and gas in the PDA leaves its own, special imprint on the clinical and anatomical picture of PDA. These are mainly symptoms of the presence of air (gas) and liquid and their movement. Sometimes at this stage, the development of PDA stops, but more often its volume increases with the appearance of gas. In this case, PDA has an effect on neighboring organs and tissues, which respond with reactive inflammation (pleurisy). Hollow organs are compressed, deformed, the lungs are compressed, the liver and spleen are displaced. Sometimes pus lyses the surrounding adhesions and walls of nearby organs, which leads to their penetration or perforation, and pus enters the adjacent cavities and then through the abdominal wall and the wall of the chest cavity to the outside. If the abscess is not emptied, then a dense fibrous capsule develops around the PDA at the site of loose adhesions and adhesions, with the appearance of which stage III of complete (encapsulated) PDA develops. The picture here is similar to stage II, but usually the severity of the purulent-inflammatory process decreases, the body temperature decreases, the volume of the abscess decreases due to the absorption of the liquid part of the pus, gas. At this stage, pus may also be emptied through adjacent cavities and organs, after which internal and external fistulas remain. Occasionally, in such cases, complete emptying of the abscess gradually occurs and spontaneous healing may occur, and dense scars develop at the site of the abscess, sometimes with petrification of the abscess membranes and pus particles. More often at this stage, purulent intoxication, exhaustion, amyloidosis of internal organs, and sometimes sepsis occur. In such cases, even a technically correct operation cannot always prevent the death of the patient. Classification of PDA Distinguish between intra- and extraperitoneal PDA, which are divided into left-, right-sided and median. These abscesses, in turn, differ in location in relation to the fornix of the diaphragm. Right-sided: anteroposterior, upper-posterior, central, posterior-lower. Left-sided: upper, lower anterior, posterior lower, peri-splenic. In addition, there are lower extraperitoneal right- and left-sided abscesses. The data of different authors on the frequency of PDA of different localization differ sometimes quite significantly. So, for example, V.M. Belogorodsky (1964) observed 163 right-, 72 left-sided and 5 bilateral abscesses. SM Malkova (1986) writes that in her work there were 52% left-sided, 19% right-sided and 29% median PDA. Taking into account the data of recent works (Aliev S.A., 1991; Gulevsky B.A., Slepukha A.G., 1988; Nepokoynitsky E.O., Rodina L.I., 1988), one should, apparently, talk about approximately equal occurrence left and right PDA; in any case, the difference in their frequency does not exceed 10-12%. By the nature of the content, PDA are gas-free (contain only pus) and gas. PDA Diagnosis PDA Symptoms The first and main symptom of PDA is pain. Pain in PDA is, as a rule, localized. The majority of patients note acute pains, "sharp", "burning". At the onset 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 almost throughout the course of the disease. The pain may decrease and / or increase with movement, coughing, breathing, exertion. A characteristic irradiation is in the shoulder girdle, scapula, collarbone from the side of the same name PDA. This is a consequence of irritation of the endings of n.phrenici, the fibers of which are distributed in the tendon center, therefore, irradiation is more often observed when PDA is localized under the center of the diaphragm. Body temperature in PDA patients is usually elevated. Hectic fever is sometimes the only symptom of developing PDA. According to EI Bakuradze, fever is the leading symptom of PDA (Belogorodsky V.M., 1964). It is accompanied by chills, sweating, pallor of the face, dry tongue, a feeling of heaviness in the lower chest. The pulse in these patients, as a rule, is speeded up. Inspection and palpation allow you to establish changes that could speak of PDA. In the first place is 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 sore side. When moving, patients avoid unnecessary body movements, keeping straight or, for example, with right-sided PDA, bending forward and to the right. Many symptoms, and the most characteristic ones, are determined by examining the chest. Already upon examination, one can detect an expansion of the chest. Langenbuch (1897) compared its shape to a bell (however, now no one describes such drastic changes). Less significant changes are quite common. The smoothness of the intercostal spaces, their expansion are noted; protruding them, respectively, PDA; protrusion of false ribs on the sore side (it is more pronounced with the accumulation of pus in the peripheral parts of the RAP). At the onset of the disease, when examining the abdomen, it is not possible 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 later 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 associated with impaired circulation in this area. Feeling the chest and abdomen near the diaphragm reveals muscle tension corresponding to the localization of the PDA (clearer from 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 in the upper part of the lumbar fossa. Unlike paranephritis, palpation of the lumbar region in front will be painless (more precisely, the kidney region). The most important symptom of PDA, obtained on palpation, is sensitivity and especially soreness in the area of ​​its location. In this case, a diffuse zone of soreness is sometimes noted, corresponding to the location of the abscess. Compression of the chest (Fakson) is recommended to detect tenderness. For topical diagnosis, it is necessary to identify the zone of pain corresponding to the PDA. Characterized by pain in the costal arch (opposite the IX - XI ribs), first noted by M.M. Kryukov (1901). This symptom is now called Kryukov's symptom. Sometimes there are zones 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 liquid and gas in places where they should not be, effusion in the pleural cavity, compression of lung tissue, hepatoptosis. These symptoms are outlined in early stage , clearly manifested in stages II and III. Non-gas PDA On chest percussion, dullness above the normal border of the liver can be detected; this dullness is less intense than hepatic dullness. 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 PDA patients (without sputum), explaining this by irritation of the sensitive nerve endings of the diaphragmatic pleura. Pleural effusion is also common in early PDA. Exudative pleurisy of a different genesis can complicate the diagnosis. It is important to note that even large pleurisy does not displace the edge of the liver downward, 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, the results of percussion will be - from pulmonary sound to absolute dullness (especially clearly from the front). With auscultation, you can listen to various changes - from weakened vesicular to bronchial breathing. At the border of the abscess, breathing sounds suddenly disappear. The dullness of the percussion sound over the PDA does not change with respiratory movements, but when the position of the body changes, the dull band shifts. With the position of the patient 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 together with an abscess above it gives rise to a ballot of the liver. If you tap the chest from behind at the angle of the patient's right scapula, 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 is lowered and well palpated. When examining the left half of the chest, the same ratios 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 behind in the lower part of the chest is also observed with retroperitoneal PDA. The bluntness zone does not reach a great height. The accumulation of pus in the retroperitoneal space smoothes the upper lumbar fossa, and sometimes even protrudes it. In these cases, tenderness, pastiness of soft tissues on palpation and the absence of pain in the front (in contrast to paranephritis) are determined. Gas-containing PDA Sometimes frontal percussion of the chest reveals not dullness below the pulmonary tone, but tympanitis. This is a sign of gas in the abscess cavity (gas PDA). With percussion, 3 areas of different tones are revealed - a clear tone of the lung, tympanitis of gas and dullness of pus. The PDA gas is displaced by changing the position of the body. It is always at the top of the PDA (Deve symptom). The ratio of gas and liquid is well detected on fluoroscopy. 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, there is a four-stage sound during percussion - pulmonary tone, dullness of exudate, tympanic sound of gas, dull tone of pus and liver (LD Bogalkov). X-ray methods of PDA diagnostics 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 diaphragm line (like a protrusion of the liver's shadow) with gasless 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, lifted 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 reveal changes in neighboring organs: displacement of the longitudinal axis of the heart, deformation 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 "matured" and has not taken shape, or because the picture obtained during the study is incorrectly assessed. Due to edema and infiltration of the diaphragm during PDA, it thickens up to 8-17 cm. The contours of the dome of the diaphragm become indistinct and blurred. The most characteristic radiological sign of PDA is changes in the area of ​​the diaphragm legs. V.I.Sobolev (1952) found that with PDA the legs of the diaphragm become more clearly visible. This symptom appears very early in PDA, therefore it is valuable for early diagnosis. Due to the presence of gas in the hollow organs of the BP, differential diagnostics 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 the pulmonary abscess and the tuberculous cavity is similar to the PDA gas, the only difference is that they are located above the diaphragm. Great importance in the diagnosis of PDA have repeated X-ray examinations. Patients who have postoperative period signs of an incipient complication appear, even if they are mild, should be X-rayed. Especially valuable are serial images, in which not only PDA is detected, its shape and localization are determined, but also the dynamics of the process, changes in the size of the abscess are visible. Re-examinations after evacuation of pleural effusion, which often masks PDA, are important. The X-ray method can be used to monitor the abscess cavity. PDA is often poorly emptied even through drains due to anatomical features. Fluoroscopy allows you to determine the reasons for the delay in the patient's recovery, if any. In recent years, computed tomography (CT) has been introduced into clinical practice. This method is very good for PDA diagnostics. Its resolution is 95-100% (Bazhanov E.A., 1986). With CT, there is a need to differentiate fluid in the abdominal and pleural cavity, 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 organs and the movement of fluid. The fluid in the pleural cavity is located posterolaterally, in the abdominal cavity - anteriorly and medially, which corresponds to the anatomy of the PD and pleural sinuses... With the help of CT, PDA can also be excluded if the picture is not entirely clear. In the article by E.A. Bazhanov (“Computed tomography in the diagnosis of subphrenic abscesses // Surgery, -1991g-№3, p.47-49) of the observed 49 patients, 22 had PDA diagnosed after CT, in the remaining 27 it was confirmed and found during surgery. Other instrumental methods PDA diagnostics Let us briefly touch on other, besides X-ray, methods of PDA diagnostics. The most important, widespread in recent times method - ultrasonography (echography, ultrasound). Its resolution with respect to PDA is very high and approaches 90-95% (Dubrov E.Ya .; 1992; Malinovsky N.N., 1986). Small left-sided PDA is visualized somewhat worse, especially when surrounded by adhesions of the abdominal cavity. The value of the method is its harmlessness, non-invasiveness, possibility dynamic observation and monitoring the postoperative state of the purulent cavity. Under the control of ultrasound, puncture drainage of abscesses can be performed (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 PDA treatment is not recognized by everyone (Belogorodsky V.M., 1986; Tyukarkin, 1989). The possibilities of laparotomy are also limited in case of severe adhesive process in the abdominal cavity. B.D. Savchuk (Malinovsky N.N., Savchuk B.D .; 1986) notes the efficiency of isotope scanning with Ga67 and Zn111. 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 abscesses of the abdominal cavity. Laboratory diagnostics PDA These studies occupy a huge place in the diagnosis and control of the PDA course. There are no specific changes in the analyzes for PDA. In blood tests, changes are noted that are 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 movement, and the appearance of tympanitis or dullness under the diaphragm. In a patient with PDA, during percussion, attention is drawn to the appearance of dullness in places unusual for her. It is detected above the normal borders of the liver, sometimes reaching the II-III ribs in front and the middle of the scapula in the back. This picture can be observed with exudative pleurisy. Differential diagnosis in basal pleurisy is much more difficult. Its distinctive 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 organ disease | History of organ disease | | abdominal cavity | chest cavity | | With the front PDA dullness | The highest point of dullness | | Dome-shaped, comes | in the armpit, and from there | | up to II-III ribs on | the level of dull sound decreases | | l.medioclavicularis | to the spine and anteriorly | | | (Garland's Triangle) | | Above dullness distinct | Pulmonary margin above dullness | | mobility of the edge of the lung when | motionless | | deep breath | | | In the lower lobes of the lung - | Breathing weakens gradually | | vesicular breathing, on | | | border of stupidity suddenly | | | breaks off | | | Voice jitter enhanced | Voice jitter weakened | | The noise of friction of the pleura over | The noise of friction of the pleura is absent | | bluntness | (appears with a decrease | | | effusion) | | Between the dullness of the PDA and the heart - | With purulent pleurisy on the right, | | area of ​​normal pulmonary | dullness merges with the heart | | sound (symptom of Grievous) | | | Slight displacement of the heart (with | Often displacement of the heart | | raised edge of the liver) | according to the volume of effusion | | Pain and soreness in the area | May be higher, above the effusion, in | | lower ribs (with-m Kryukov) | zone IX-XI ribs do not exist | | Symptoms from the abdominal | Symptoms from the abdominal | | cavity is | cavity is not | | Displacement of the liver down (up to | Displacement of the liver is rare and | | navel) | small | With gangrene of the lung, there is an extensive infiltration of the lung tissue, causing a dullness of the percussion sound, which may resemble a picture of gas-free PDA. Severe general condition, heat body; pronounced pulmonary phenomena and fetid sputum make it possible to correctly diagnose lung gangrene. In pulmonary abscesses, unlike PDA, patients have prolonged remitting fever, dullness of percussion sound, weakening of breathing in the absence of wheezing, symptoms of a cavity with gases and pus in the lung. After opening the abscess in the bronchus, purulent sputum is secreted for a long time. Differential diagnosis in these cases, it 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 PDA breakthrough into the pleural cavity. Acute pyopneumothorax is preceded by a long-term lung disease (tuberculosis, lung abscess). Distinctive signs of liver abscess - subacute course of the disease, remitting fever, pain in the right hypochondrium, aggravated by coughing and inhalation, weakening of respiratory excursions of the diaphragm, hepatomegaly with the normal location of the anterior edge of the liver, changes in the boundaries of the liver when changing the position of the body, pain in the suprahepatic region, absence reactive pleurisy. The most accurate differential diagnosis is possible by ultrasound and CT. Differential diagnosis of PDA and liver echinococcus is very difficult, and the true diagnosis can often be established only on the operating table. In the event of the death of the parasite, the contents of the cyst undergo melting, sweat and suppuration, which resembles PDA. Echinococcus differs from PDA in gradual development, slow growth, prolonged course, hepatomegaly; eosinophilia in the blood, positive reactions of Weinberg and Cazzoni (both with a live and a dead parasite). Diseases of the retroperitoneal space can produce 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 posterior and posterolateral parts of the trunk, fever, and swelling of the skin. Pain with 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, therefore, phenomena from the soft tissues of the back appear earlier and occur more often than with PDA. The outlines of the back are smoothed, the diseased half of it bulges out, which is especially clear when examining a sitting patient. With paranephritis, soreness is more pronounced in the angle between the XII rib and the long muscles of the back. 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 dietary disorders | Not associated with dietary disorders | | Filmed with drugs | Not filmed with drugs | | Obesity as a predisposing | Previous purulent | | condition | disease, injury (operation) | | Symptoms of Kera, Ortner, Murphy | Symptoms of Kera, Ortner, Murphy | | (+) | (-) | | Areas of hyperesthesia on the skin | There is a zone of hyperesthesia on the skin | | right shoulder girdle no | right forearm | | Normal standing and mobility | High standing of the diaphragm and | | diaphragm | restriction of its movements | | The course of the disease is periodic, with | The course is more or less | | remissions | long-term, no remissions | | Soreness in the right | (+) Kryukov symptom | | hypochondrium | | Table 3 Differential diagnosis of PDA and diaphragmatic hernia | PDA | Diaphragmatic hernia | | History of PD disease | History of trauma, | | (more precisely, its organs) | preceding the onset of the disease | | The disease develops by type | The disease flows over the years and | | inflammation in greater or lesser | manifested by pain and phenomena | | term | violations of the intestinal passage | | Sometimes severe inflammatory | Inflammatory phenomena are not | | phenomena in BP | | | High position of the diaphragm, | Dullness over the diaphragm at | | dullness with percussion | being in a dense hernia | | (gasless abscess), tympanitis | organs. Tympanitis on the diaphragm, | | with gas abscess | sometimes under it dullness from | | | contents of hollow organs | | | (stomach) | | X-ray: under high | X-ray: under | | standing diaphragm | diaphragm blackout - at | | hemispherical form of gas and under | the presence of a hernia of the liver, | | him the horizontal level of pus | peristalsis of the restrained | | | organ, sometimes the level of fluid. | | | Helps contrast | | | study with the basis | | X-ray constancy | Typically (!) Inconstancy | | paintings | 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 replace surgery conservative methods can not. Therefore, this section will consider surgical techniques, more precisely, different approaches for opening the PDA. The operation of opening the PDA is far from a safe intervention associated with anatomical features location of abscesses and gave a long time a great mortality. Question about best operation with PDA, it actually boils down to the issue of safe access to it. Most ways surgical treatment The PDA was proposed in the late 19th and early 20th centuries. At this time, a number of the simplest, shortest and safest accesses to PDA are renewed. 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 lying on its side, the leg lying on the table bends and attaches to it. Anesthesia during operations, as a rule, is general. The incision is usually 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. Emptying the PDA should 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 a finger, open the pockets and bays widely, removing the bridges between them. Further, it is necessary to ensure good drainage of the abscess cavity. Previously, the most commonly used tampons with Vishnevsky ointment, introduced into the cavity, sometimes tampons and drainage were introduced. In recent years, the most popular (as more effective) method has been used for supply-aspiration drainage of the PDA cavity, in particular, with double-lumen silicone drainages (according to N.N. Kashinin, A.L. Bystritsky; 1980). With this method of treatment, the abscess cavity is cleared faster, and the patient's stay in the hospital is reduced. The most common access to the PDA of the more common localization Chrezpleural access for the upper anterior and posterior abscesses A skin incision 10-12 cm long is made above the PDA location, preferably at its lower edge. The tissue is dissected in layers to the ribs. 1-2 ribs are resected subperiosteally. After that, sutures are applied along the edges of the wound, bringing together and stitching the periosteum and costal pleura from the diaphragmatic. Sewn with a needle, or with interrupted sutures, or intermittent. After suturing, an incision is made in the area bounded by the sutures, while the stitched pleura is cut, the diaphragm is cut deeper and the abscess is emptied. Tampons (drains) 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 a delicate 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 suture 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 with lines along the X edge, parallel to the supposed edge of the pleural sinus. The skin, subcutaneous tissue is dissected, the 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 is easily peeled off the chest wall, diaphragm and pushed up. Pleural tears are immediately sutured. The incision along the fibers exposes the intraperitoneal fascia and the diaphragmatic peritoneum above the abscess. The diaphragm is dissected along the wound, its upper edge is sutured with catgut with the muscles of the chest. An abscess is punctured, and, having received pus, it is opened. If pus is not received, the peritoneum is peeled to the sides and punctures are made in different directions until the abscess is found and then it is emptied with an incision. Revision of a half, smoothing of walls, tamponade (drainage). Posterior approach Skin incision along the XI rib, starting from the long muscles of the back. The XI rib is exposed and resected (if necessary, the end of the XII) and the intercostal muscles are bluntly separated. Having mobilized the sinus (see above the mobilization technique), 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 PDP is opened. Autopsy, drainage. If there is no abscess in the incision area, the peritoneum is peeled off the lower surface of the diaphragm until the abscess is found. Extraperitoneal subcostal access. Anterior and lateral approach A 10 cm long skin incision parallel to the costal arch, starting from the lateral edge of the rectus abdominis muscle to l.axillaris ant. (front approach) or by l.medioclav. to l.axillaris media. The tissues are dissected to the aponeurosis and the fibers of the transverse muscle. An incision is made in its presenting part, the costal arch is pulled up and anteriorly. The surgeon slides his finger along the transverse fascia upward, peeling it off the inner surface of the transverse muscle and the lower surface of the diaphragm. Having determined the fluctuation, the surgeon opens the abscess with an upward movement of the finger. If the abscess is not palpable, a puncture is done. Lack of access - delayed pus if the edge of the costal arch is pressed against the liver. This may require the imposition of a counteropening. Outside the wound by 5-6 cm, a second incision is made in the skin, tissue and superficial fascia, after which, through the first incision, the tissues of the abdominal wall are stratified with a forceps. From the second incision, the first is similarly penetrated. From the new wound, the surgeon exfoliates the peritoneum and cuts it under the abscess at the bottom of it (the method of KS Shakhov, 1960). Posterior approach Skin incision 12-15 cm parallel and below the XII rib, tissue dissection to m.serratus post.inf. The tissue is dissected after the expansion of the wound to the transverse fascia. Detachment of the fascia, tissue and peritoneum from the lower surface of the diaphragm. The diaphragm is dissected, the PDA is drained. Upper median approach 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 upward and to the sides. Lancing of an abscess. Transperitoneal subcostal approach Apply with anterior PDA. Layer-by-layer incision of the abdominal wall on the finger below the costal margin from the rectus muscle to the l.axillaris media. After opening the abdominal cavity, the PDA is found. The lower edge of the liver is sewn to the lower lip of the wound to delimit the abdominal cavity. In the outer corner of the wound in the abdominal cavity, tampons should be inserted. Autopsy, drainage. Extrapleural posterior access for posterior extraperitoneal abscesses A 10-15 cm incision posterior along the XI rib. Its resection (subtotal). Find the transitional fold of the pleura, mobilize it. 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 the abscess is found. Extraperitoneal posterior access Good for posterior extraperitoneal PDA. The incision is below and parallel to the XII rib, starting 3 transverse fingers from the paravertebral line to the axillary. The tissue is dissected to the transverse fascia (if necessary, resecting the XII rib). Further actions are the same as in the anterior approach. With the retroperitoneal approach, the most favorable conditions for PDA drainage are created. Postoperative management of patients After opening the PDA, its cavity is eliminated in different terms... According to V.M. Belogorodsky (1964), this is 30-50 days. When using active supply and exhaust drainage, the cavity closes on average in 20-27 days (Kapshin N.N., Bystritsky A.L .; 1980). After the operation, patients need to be given a position favorable for the outflow of pus. For back cuts - Fowler; with front and side - on the side. The first dressing is best done in 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 during the operation of the pleural cavity. Adequate pain relief after surgery is necessary, which favors the manifestation of physical activity. With the correct 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, the mortality rate is 7.3% (Bystritsky A.L., Fainberg K.A., Golubev L.P .; 1986). References 1. Aliev S.А. Diagnostics and treatment of subphrenic abscesses // Surgery, - 1991 - №3 p.47-49 2. Bazhanov Е.А. Computed tomography in the diagnosis of subphrenic abscesses // Bulletin of surgery - 1986 - № 11, p. 26-29 3. Belogorodsky V.М. Subphrenic abscess. 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A subphrenic abscess is an abscess that forms in the subphrenic space, which is located in upper section abdominal cavity, on the right - between the lower surface of the diaphragm and the upper surface of the liver, and on the left - between the lower surface of the diaphragm, stomach and spleen.

In essence, a subphrenic abscess is one of the types of limited or enclosed peritonitis, that is, it is a secondary disease that complicates the course of any primary disease, which is most often located in the abdominal cavity. In most cases, right-sided subphrenic abscesses are observed.

Subphrenic abscess causes... The reason for these abscesses is the spread of a purulent-infectious process into the subphrenic space from neighboring organs: the stomach (with its perforated ulcer), appendix(with appendicitis), liver (with abscess), biliary tract(with cholecystitis), the spleen (with its abscesses), with purulent pleurisy, some penetrating wounds of the abdominal cavity or operations on its organs.

Spreading purulent process occurs either directly by the flow of pus from the primary focus, or by the lymphogenous route. It should be borne in mind that one of the most common causes of the appearance of a subphrenic abscess is acute appendicitis, and in these cases, a subphrenic abscess usually appears 2-3 weeks after the onset of appendicitis. With the development of an abscess in the subphrenic space, pus gradually pushes the diaphragm upward, and the liver downward.

Subphrenic abscess signs and symptoms: pain and a feeling of pressure in the right (or left) half of the upper abdomen or lower chest, often hiccups, high temperature with large fluctuations, chills and sweats, sometimes - a general serious condition, leukocytosis. However, in many cases, the onset of abscess formation and its course may be less acute and with little noticeable signs.

With large subphrenic abscesses, shortness of breath, smoothing of the intercostal spaces and lag of the patient's side during breathing, some downward displacement of the liver is observed. When tapping in the lower part of the chest, dullness is determined, and when listening - weakened or bronchial breathing, sometimes pleural friction murmur. There is no voice trembling in the area of ​​dullness.

If there is gas in the abscess cavity, a tympanic sound is heard when tapping. With pressure on the lower ribs, on the intercostal space, or on the edge of the liver, soreness can be determined. Fluid may also appear in the pleural cavity. When an abscess is located close to the peritoneum, signs of irritation may occur: nausea, vomiting, bloating, and slight tension in the abdominal wall. Valuable data for diagnosis can be provided by x-ray examination sick.

It is difficult to recognize a subphrenic abscess and should be distinguished from purulent pleurisy and lung abscess. Whenever, after surgery, for example for a perforated stomach ulcer, appendicitis, cholecystitis, or if the right hypochondrium is damaged, a high persistent temperature, leukocytosis, etc. occurs, you should think about the possibility of a subphrenic abscess.

Subphrenic abscess complications: opening the abscess in abdominal cavity with the onset of general purulent peritonitis or its opening through the diaphragm into the pleural cavity with the development of purulent pleurisy; sometimes there is an opening of an abscess into the lung with emptying it through the bronchus. Development of sepsis is also possible.

Subphrenic abscess urgent care ... At the slightest suspicion of a subphrenic abscess, the patient must be immediately hospitalized in the surgical department of the hospital. Transport in a lying position.