Endoscopic ultrasound-guided transmural drainage for subphrenic abscess: report of two cases and a literature review.

BACKGROUND: An intra-abdominal abscess can sometimes become serious and difficult to treat. The current standard treatment strategy for intra-abdominal abscess is percutaneous imaging-guided drainage. However, in cases of subphrenic abscess, it is important to avoid passing the drainage route through the thoracic cavity, as this can lead to respiratory complications. The spread of intervention techniques involving endoscopic ultrasonography (EUS) has made it possible to perform drainage via the transmural route. CASE PRESENTATION: We describe two cases of subphrenic abscess that occurred after intra-abdominal surgery. Both were treated successfully by EUS-guided transmural drainage (EUS-TD) without severe complications. Our experience of these cases and a review of the literature suggest that the drainage catheters should be placed both internally and externally together into the abscess cavity. In previous cases there were no adverse events except for one case of mediastinitis and pneumothorax resulting from transesophageal drainage. Therefore, we consider that the transesophageal route should be avoided if possible. CONCLUSIONS: Although further studies are necessary, our present two cases and a literature review suggest that EUS-TD is feasible and effective for subphrenic abscess, and not inferior to other treatments. We anticipate that this report will be of help to physicians when considering the drainage procedure for this condition. As there have been no comparative studies to date, a prospective study involving a large number of patients will be necessary to determine the therapeutic options for such cases.

A case of left subphrenic abscess caused by gastric ulcer penetration that was successfully treated with endoscopic transgastric drainage.

A 65-year-old male visited our hospital because of fever and difficulty in walking. He was suffering from left-sided hypochondrial pain for a month. Laboratory tests performed on admission revealed a white blood cell count of 1700/µl and C-reactive protein level of 9.51mg/dl, which were suggestive of severe inflammation. Contrast-enhanced computed tomography revealed a subphrenic abscess around the spleen, which we considered to be caused by gastric penetration into the gastrosplenic ligament. Upper esophagogastroduodenoscopy revealed a gastric ulcer together with a fistula that connected to the left subphrenic abscess. We thus performed endoscopic transgastric drainage through the fistula. Antibiotics and a proton pump inhibitor were administered, and drainage was continued. The patient's clinical and inflammatory symptoms subsequently improved. We thus consider that endoscopic transgastric drainage is an appropriate treatment option for subphrenic abscesses.

[Perforation of the right ventricle of the heart as a complication of CT guided percutaneous drainage of a subphrenic abscess - a case report]. / Perforace pravé srdecní komory jako komplikace CT navigované perkutánní drenáze subfrenického abscesu kazuistika.

INTRODUCTION: CT guided percutaneous drainage is currently the gold standard in the treatment of abdominal fluid collections, having substituted open surgical drainage in many cases. It burdens the patient less than surgical drainage. Its efficiency is comparable to standard surgical drainage when properly indicated. It is readily available even in smaller hospitals. However, this method can also have many complications, which originate most often from an improperly targeted drainage catheter. CASE REPORT: The authors describe a case report of a 55 years old man with a right-sided subphrenic abscess. The right ventricle of the heart was perforated during a CT guided percutaneous drainage. The bleeding was minimal, but the patient suffered a profound septic shock as a result of massive bacteremia during direct communication of the contents of the abscess cavity with blood circulation. He was operated immediately. The right ventricle was sutured, and the subphrenic abscess was drained. There were no complications after the operation, and the patient was discharged on day 17 after the surgery. CONCLUSION: The CT guided drainage of an abdominal abscess or a fluid collection in a risk area should be preferably done in hospitals whose therapeutic portfolio also includes the handling of serious complications. KEY WORDS: heart injury drainage.

An Unexpected Case of Perforated Acalculous Cholecystitis Caused by a Fish Bone.

Gallbladder inflammation is most often determined by the presence of gallstones. Acalculous cholecystitis usually occurs in patients with multiple comorbidities or with an immunosuppressed status, and therefore its evolution is faster and more severe compared to acute calculous cholecystitis. The presence of a fish bone into the peritoneal cavity, through a gastrointestinal fistula is not very rare, but acute cholecystitis caused by a fish bone is unexpected. Here, we present the case of a 75-year old woman who had eaten fish two months before and presented at the Emergency Room with perforated acalculous cholecystitis and a right subphrenic abscess. The laparoscopic approach permitted the evacuation of the subphrenic abscess, bipolar cholecystectomy and removal of a fish bone from nearby the cystic duct. Postoperative evolution was uneventful, with hospital discharge after five days. The patient was in good clinical condition at two months follow-up.

Subphrenic abscess after cesarean section in term pregnancy complicated by chorioamnionitis.

BACKGROUND: Subphrenic abscess is rare after cesarean section. METHODS: Case report and review of the pertinent world literature CASE REPORT: A 22 year-old primigravida underwent a lower-segment cesarean section in the setting of chorioamnionitis, and had a good postoperative recovery initially. Eleven days after surgery, dyspnea and fever prompted a computed tomography scan, which revealed a large subphrenic abscess. The abscess resolved with percutaneous drainage and intravenous antibiotics. A placental swab, baby's skin swab, and abscess aspirate all grew group B Streptococcus. CONCLUSION: Although subphrenic abscess is rare in obstetric practice, it should be suspected in patients who remain unwell after chorioamnionitis.

A case of successful ablation of a gastrophrenic fistula with n-Butyl-2-Cyanocrylate.

A 79-year-old woman with a fistula between a subphrenic abscess and the fundus of the stomach was successfully treated with n-Butyl-2-Cyanoacrylate. Conservative management had failed. Clinical presentation, treatment progress and imaging findings by computed tomography scan, ultrasound, gastroscopy and fluoroscopy are presented, along with a brief review of the relevant literature.

Delayed recurrence of postoperative intra-abdominal abscess: an unusual case and review of the literature.

BACKGROUND: Although intra-abdominal abscess is one of the major complications of abdominal surgery, the literature documents only a few cases of recurrence after a long asymptomatic period. METHODS: Case report and literature review. RESULTS: A 66-year-old woman developed a primary subphrenic abscess secondary to anastomotic leakage after total gastrectomy. Percutaneous drainage succeeded in evacuating the abscess cavity, and broad-spectrum antibiotics apparently eradicated the infection. However, a recurrent subphrenic abscess appeared eight years later with no intervening signs or symptoms. CONCLUSIONS: The unexpected outcome in this case may call into question the appropriate follow-up period after treatment for subphrenic abscess. Our experience indicates that clinicians should be aware of the possibility of rare delayed recurrence of intra-abdominal abscess.

Retroperitoneal abscess with retained gall-stones as a late complication of laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is the golden standard, considering treatment of cholelithiasis. During the laparoscopic procedure one may often observe damage to the gall-bladder wall, as well as presence of gall-stones in the peritoneal cavity, as compared to classical surgery. These gall-stones may be associated with the occurrence of various complications following surgery. The study presented a rare case of a retroperitoneal abscess, as a consequence of retained gall-stones, in a female patient who was subject to laparoscopic cholecystectomy two years earlier.

Decreased sensitivity of early imaging with In-111 oxine-labeled leukocytes in detection of occult infection: concise communication.

Imaging with leukocytes labeled with indium-111 oxine is a sensitive technique for detecting sites of occult infection. Traditionally, imaging is performed 24 hr after injection. We undertook a prospective study of 35 patients (40 studies) with possible occult infection to see whether a 24-hr delay in imaging is really necessary. Patients were imaged at 1-4 hr and again at 24 hr after injection. The early images had a sensitivity of only 33%, compared with 95% for the 24-hr images. Of the seven studies that were positive on both early and delayed images, 71% had more intense uptake at 24 hr. There were no false-positive early images. We conclude that imaging 1-4 hr after injection with In-111 oxine-labeled leukocytes has a low sensitivity for detecting occult infection. However, a positive early image is specific for a site of infection.

Gallium imaging in pediatrics.

Gallium-67 citrate imaging was carried out in 59 children from 3 mo to 20 yr of age. Indications for the study included the search for occult inflammatory disease and the detection and staging of malignant disease. The Ga-67 citrate scan had a 96% reliability in confirming or excluding the site of purulent material as a cause of sepsis, and 76% reliability in detecting malignant disease. Tissue distributions in children differ from those in adults primarily in that the epiphyseal plates, spleen, and thymus may show increased activity normally and in the presence of sepsis. These variations are illustrated as possible sources of incorrect interpretation. "Cold" defects may be seen in sterile collections and avascular masses. Experience in this age group seems sufficiently encouraging to continue the use of gallium-67 citrate for the purposes described.

Dual radionuclide subtraction imaging of the spleen.

Dual radionuclide subtraction imaging of the spleen using 67Ga citrate and 99mTc is useful in further delineating lesions that are identified on either a routine radiogallium survey or on a conventional sulfur colloid liver-spleen image. Better anatomic localization of left subphrenic abscesses may be obtained. Differentiation of tumors and abscesses from less serious lesions such as cysts, infarcts, and hematomas is possible. We have found this technique to be generally applicable to any organ that can be selectively imaged using a technetium radiopharmaceutical, including the liver, bones, and kidneys. In addition, we are currently evaluating thallium-pertechnetate subtraction imaging in the evaluation of parathyroid adenomata.

Eclectic drainage of subphrenic abscesses.

In 196 cases of subphrenic abscess from 1964 through 1979, 56% were attributable to gastric, hepatic, and colonic disease or surgery. Posttraumatic abscesses in younger patients became more frequent. Synchronous suprahepatic and subhepatic abscesses or bilateral abscesses accounted for 19%. Streptococci, Escherichia coli, Klebsiella, and Bacteroides species were the most frequently isolated organisms. Although the overall mortality rate was 40%, the surgical mortality rate decreased from 33% initially to 17% recently. The mortality rate of transperitoneal drainage decreased from 41% to 16%. From 1980 through early 1983, a success rate of 84%, with no fatalities, was achieved in percutaneous radiologic drainage of 25 unilocular abscesses. At present, radiologically guided drainage should be considered for unilocular abscesses and some bilocular ones. Although extraperitoneal, extrapleural surgical drainage remains an expeditious form of treatment, it may give way to radiologic drainage. Transperitoneal drainage is preferable for multifocal abscesses and for many abscesses secondary to complications of intraabdominal surgery.

Anatomy and radiologic diagnosis of perihepatic abscesses.

The radiologic diagnosis of perihepatic abscess is one of the most important diagnoses the radiologist is called upon to make. The author defines, simply and accurately, the spaces around the liver, and simplifies the radiologic diagnosis of abscesses within these spaces. He establishes a radiologic routine which aids in this task.

Thoracic findings in gastrointestinal pathology.

A large variety of gastrointestinal and abdominal pathologic processes can be diagnosed or suspected by their direct effects on the chest. The chest radiograph, as often the first admission film, can aid the radiologist in recommending the appropriate follow-up examinations.

Repositioning catheters in surgically drained abscesses.

Primary percutaneous drainage of intraabdominal abscesses under local anesthesia is an accepted method of treatment, with low morbidity and mortality. This technique was extended to patients with recurrent or secondary abscesses after initial primary surgical drainage. Four patients had abscesses drained operatively but were reevaluated several weeks later for recurrent fever. Sinography demonstrated an inadequately drained abscess cavity. Under fluoroscopic control and using local anesthesia, new drains were inserted and repositioned to provide better drainage. Resolution of the abscess cavity was documented radiographically, with improvement in the patients' clinical status.

Specific but limited role of new imaging techniques in decision-making about intraabdominal abscesses.

Despite the very high accuracy rate of imaging studies (ultrasound, computed tomography, liver-lung-spleen scans and gallium-67 scans) in detecting intraabdominal abscesses, our experience with 80 recent cases indicate that these techniques have not significantly altered traditional methods of decision-making about when and where to drain such abscesses. In only 12.5 percent of cases were such decisions based on special imaging techniques alone, and most of these cases subphrenic abscesses were diagnosed late after surgery. In the remainder, physical examination and routine radiologic studies sufficed, with special imaging techniques primarily corroborating clinical evidence based on these methods. We conclude that the use of special imaging techniques alone in a search for the cause of fever early after abdominal surgery does not provide evidence upon which clinical decisions can be based unless there are already physical signs of an abscess.

Percutaneous imaging-guided abdominal and pelvic abscess drainage in children.

Percutaneous imaging-guided drainage is the first-line treatment for infected or symptomatic fluid collections in the abdomen and pelvis, in the absence of indications for immediate surgery. The technology and expertise needed to perform percutaneous abscess drainage are widely available and readily adapted for use in the pediatric population. Catheter insertion procedures include the trocar and Seldinger techniques. Imaging guidance for drainage is most commonly performed with ultrasonography (US), computed tomography, or US and fluoroscopy combined. Abscesses in locations that are difficult to access, such as those deep in the pelvis, subphrenic regions, or epigastric region, can be drained by using the appropriate approach-transrectal, transgluteal, intercostal, or transhepatic. Although the causes of abscesses in children differ slightly from those of abscesses in the adult population, the frequency of successful treatment with percutaneous abscess drainage in children is 85%-90%, similar to that in adults. With expertise in imaging-guided drainage techniques and the ability to adjust to the special needs of children, interventional radiologists can successfully drain most abscesses and obviate surgery. Successful adaptation of abscess drainage techniques for pediatric use requires attention to the specific needs of children with respect to sedation, dedicated resuscitation and monitoring equipment, avoidance of body heat loss, minimization of radiation doses, and greater involvement of family compared with that in adult practice.