Introduction
The subdiaphragmatic abscess is also known as a subphrenic abscess. It is rare and not frequently seen. The abscess results from internal infection of the organ caused by bacteria which leads to the accumulation of pus. In addition, the accumulation of pus can be due to inflammation of the organ.
As the name suggests, the subdiaphragmatic abscess is located between the diaphragm (a muscle located just below the lungs and heart, which helps to breathe) and the stomach. In 83 percent of the cases, subdiaphragmatic abscesses result from diseases of the abdomen or can occur as a complication of surgeries for abdominal illnesses. The abscess can be anywhere in the stomach, but it affects the right side of the abdomen more often than the left side of the abdomen.
What Are the Causes of Subdiaphragmatic Abscess?
A subdiaphragmatic abscess can be caused by several bacteria (Escherichia coli, Streptococcus, and Staphylococcus) present at the inflamed site. As a result of bacterial contamination, pus accumulates in the cavity, separating healthy tissue from infected tissue. The following are the causes of subdiaphragmatic abscess:
1) Local Inflammation - Localized inflammation may occur in:
- Gallbladder.
- Pancreas (pancreatitis).
- Appendix (appendicitis).
- Kidneys.
2) Abdominal Surgeries - Surgical excision of the following organs:
- Spleen (splenectomy).
- Bile duct removal (choledocholithotomy).
- Gallbladder (cholecystectomy).
3) Infection - Infections like
- Septicopyemia (severe infection in the bloodstream).
- Ulcer in the stomach.
- Condition of the intestines.
- Severe kidney dysfunction.
4) Trauma - Any injury can cause trauma to the abdominal cavity, resulting in pus formation.
Risk factors for subdiaphragmatic abscess are:
- Diabetes mellitus.
- Infectious complications of surgeries.
- Collection of pus in the lungs or empyema.
- Sepsis (an infection of the bloodstream).
What Are the Symptoms of Subdiaphragmatic Abscess?
The following are the symptoms of the subdiaphragmatic abscess:
- High fever with chills.
- Loss of appetite.
- Weight loss.
- Anemia (a condition where blood cannot meet the tissue's oxygen requirement).
- Malaise (lack of energy).
- Weakness.
- Nocturnal hyperhidrosis (night sweats).
- Chest pain.
- Occasional shoulder pain.
- Deep breathing.
- Coughing.
- Belching (expelling air out from the stomach through the mouth).
- Nausea and vomiting.
- Hiccups.
- Halitosis (bad breath from the mouth).
- Abdominal pain.
The following are the signs of the subdiaphragmatic abscess:
- Dyspnea (shortness of breath).
- Abdominal pain on touch.
- Anemia (a condition where blood cannot meet the tissue's oxygen requirement).
- Tachycardia (increased heart rate).
- Hypotension (low blood pressure).
- Low urine output.
- Increase in white blood cells, otherwise known as leukocytes, in the blood (leukocytosis).
- Stiffness of abdominal muscles.
What Are the Complication of Subdiaphragmatic Abscesses?
A subdiaphragmatic abscess is uncommon but fatal. Untreated abscesses can cause severe complications such as:
- Pyrexia (abnormal increase in the body temperature) of unknown origin.
- Tachycardia.
- Hypotension.
- Low urine output.
- Lung abscess.
- Bronchitis (inflammation of the bronchi).
- Inflammation of the membrane that encloses the abdomen (peritonitis).
- Accumulation of pus in groin areas (pelvic abscess).
- Respiratory diseases such as pneumonia and pleural effusion).
- Respiratory failure.
- Sepsis (blood poisoning due to bacterial infection).
- Shock.
- Multi-organ failure.
- Death.
When to See a Doctor?
If a person experiences severe abdominal pain, tachycardia, hypotension, stiffness of abdominal muscles, or shortness of breath, medical attention should be sought as soon as possible. The subdiaphragmatic abscess can have severe complications like sepsis, shock, multi-organ failure, and death. It can also be a sign of lung abscess. Hence, it is always better to consult a doctor rather than neglect such signs and symptoms.
How Is Subdiaphragmatic Abscess Diagnosed?
The following are the investigations that help to diagnose subdiaphragmatic abscess:
- Blood Tests: Complete blood count shows a rise in white blood cells, indicating inflammation. Blood culture shows bacteria (Escherichia coli, Streptococcus, and Staphylococcus), confirming a subdiaphragmatic abscess.
- X-Ray: Chest X-ray shows pus accumulation in the chest region and lung abnormalities, which is highly suggestive of the subdiaphragmatic abscess.
- Computed Tomography (CT Scan): CT scan confirms the location of the abscess. It helps visualize the exact location of fluid accumulation in the abdominal cavity. It also helps in the detection of left-side subdiaphragmatic spots.
- Magnetic Resonance Imaging (MRI): MRI helps to identify hidden intra-abdominal subphrenic abscesses when a CT scan fails to detect them.
What Are the Treatment Options for Subdiaphragmatic Abscess?
Patients suffering from a subdiaphragmatic abscess need general care and immediate hospitalization. The drainage of pus followed by antibiotics is the only treatment of choice in a subdiaphragmatic abscess. The following are the treatment options for subdiaphragmatic abscess:
- Surgery - Drainage of pus is the most preferred method in a subdiaphragmatic abscess as it prevents sepsis. The pus is exudated or drained with the help of abdominal surgery. The suction process allows the drainage of pus. Antiseptic agents help in cleaning the infected area properly. A majority of the patients recover after surgery without any complications. Respiratory exercises for deep breathing and painkillers are recommended after surgery to the patient for early recovery.
- Antibiotics - Broad-spectrum antibiotics, such as cephalosporins, can be administered against the bacteria at the diagnosis of suspected subdiaphragmatic abscesses. Combination therapy of antibiotics can also help improve the outcomes. Cephalosporins with Metronidazole are highly recommended in a subdiaphragmatic abscess. The following anti-bacterial drugs are given intravenously:
- Cefotaxime.
- Cefazolin.
- Ceftriaxone.
- Flucloxacillin.
- Trimethoprim-sulfamethoxazole.
- Clindamycin.
- Antifungal Drugs - Antifungal drugs are recommended in immunosuppressed patients. Azoles and Candida are the drugs of choice.
- Over-The-Counter Drugs - Painkillers and non-steroidal non-inflammatory drugs are given to patients suffering from abdominal pain. Antiemetics can be given to patients suffering from recurrent episodes of vomiting.
Conclusion:
Patients who have undergone surgeries for an abdominal disease should be more conscious of the symptoms and seek medical help immediately if a subdiaphragmatic abscess is suspected. The prognosis of a subdiaphragmatic abscess differs from person to person as it depends on the severity of the subdiaphragmatic abscess and how soon it is treated.
Studies indicate that the recovery is complete with surgical intervention at the right time, with a mortality rate of 10 to 20 percent. If a subdiaphragmatic abscess is left untreated, it can cause respiratory failure, abdominal infection, and more severe complications. Patients can recover entirely if the diagnosis and treatment are proper in a hospital setting.
