subphrenic abscess

A subphrenic abscess, also known as a subdiaphragmatic or infradiaphragmatic abscess, is a localized accumulation of pus in the subphrenic space(s).

Clinical presentation

The classical clinical presentation is:

  • fever
  • upper quadrant pain
  • chills
  • leukocytosis

Pathology

Etiology

Subphrenic abscess may be caused by:

  • perforation of hollow viscus (e.g. appendix, colon) 
  • inflammatory process (pancreatitis, cholecystitis, hepatic abscess, etc.)
  • trauma of internal organs (stab, gunshots, etc.)
  • a complication of surgical operations (splenectomy, cholecystectomy, gastrectomy, etc.), most commonly in 1-3 weeks after surgery
  • idiopathic

Radiographic features

A subphrenic abscess may be right-sided (between right hemidiaphragm and liver) or left-sided (between left hemidiaphragm and spleen), right-sided subphrenic abscesses are more common.

In general, there is an infradiaphragmatic localized collection of fluid with gas bubbles or gas-fluid level which has an enhancing wall. It is often combined with elevation of the hemidiaphragm and a pleural effusion.

Plain radiograph

Often the only finding on a plain radiograph is an elevation of the hemidiaphragm,also infradiaphragmatic collections of gas (if present) and/or pleural effusion may be detected.

Ultrasound

Non-homogeneous fluid-density mass in the infradiaphragmatic spaces which may contain echogenic debris and gas .

CT

CT is a good modality for the detection of a subphrenic abscess and estimating its volume. It allows the evaluation the condition of adjacent organs and a possible reason for the abscess (e.g. perforation) and its complications.

Treatment and prognosis

Without adequate treatment, a subphrenic abscess may lead to peritonitis, sepsis, and even death.

Treatment options include a combination of antibacterial therapy and surgical drainage.

Differential diagnosis