[A case of subphrenic abscess in a very elderly patient relieved by conservative treatment].

A patient in her 90s with rheumatoid arthritis was admitted to the hospital. She was brought to the emergency department with a complaint of a fever and diagnosed with a urinary tract infection on admission, and antimicrobial therapy was started. On day 8 of admission, abdominal ultrasonography revealed a right subphrenic abscess due to cholecystitis with perforation. The patient consulted with the Department of Surgery, but drainage was deemed difficult due to the anatomical location of the gallbladder, and conservative treatment with antibiotics was continued. After two months of intravenous antimicrobial therapy, the abscess shrank, and the patient was discharged from the hospital after switching to oral antimicrobial therapy. At a follow-up visit two weeks after discharge, the abscess was confirmed to have disappeared, the oral antimicrobial therapy was discontinued, with no abscess recurrence noted. The principle of treatment for subphrenic abscess is the administration of broad-spectrum antimicrobial agents that cover enterobacteria and anaerobes, and drainage at appropriate times. Indeed, drainage is performed in most of the reported cases of subphrenic abscesses. However, in very elderly patients or those in whom puncture is difficult, conservative treatment while carefully checking imaging findings and other potentially involved factors may be an option.

Drainage of a Subphrenic Abscess Followed by Two-Stage Gastrectomy and Adjuvant Hyperthermic Intraperitoneal Chemotherapy (HIPEC) for Perforated Gastric Carcinoma: A Case Report.

BACKGROUND Perforated gastric cancer accounts for less than 1% of patients who present with an acute abdomen and for up to 16% of all gastric perforations. A two-stage laparoscopic procedure may be the therapeutic strategy of choice in selected patients, and adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) can reduce the incidence of peritoneal recurrence. A rare case of subphrenic abscess and gastric perforation due to carcinoma of the gastric fundus, followed by two-stage gastrectomy and adjuvant HIPEC is presented. CASE REPORT A 65-year old man presented with a left subphrenic abscess secondary to perforated gastric carcinoma. Laparoscopic drainage of the abscess was performed. Ten days later, following recovery from sepsis, the patient underwent total laparoscopic gastrectomy, and adjuvant HIPEC followed by a Roux-en-Y esophagojejunostomy. Histopathology showed an intestinal-type gastric adenocarcinoma. The tumor was staged as pT4aN0. The postoperative course was uneventful except for transient atrial fibrillation. The patient was discharged home on postoperative day 11. Systemic adjuvant chemotherapy was begun one month later. At six-month follow-up, the patient had no discomfort on eating or any other symptoms. CONCLUSIONS In this case, a two-stage laparoscopic treatment for perforated gastric carcinoma combined with adjuvant HIPEC was feasible and safe and may be considered at the time of laparoscopic gastrectomy in selected patients with perforated gastric carcinoma.

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.

Risk factors and clinical outcomes for spontaneous rupture of pyogenic liver abscess.

OBJECTIVE: To evaluate the risk factors and clinical outcomes in patients with spontaneous rupture of pyogenic liver abscess (PLA). METHODS: A total of 602 patients diagnosed with PLA between January 2004 and July 2013 were retrospectively analyzed. Among them, 23 patients experienced a spontaneous rupture of liver abscess (SRLA). RESULTS: The prevalence of SRLA was 3.8%. Using multivariate analysis, liver cirrhosis (OR 4.651, P = 0.009), gas-forming abscesses (OR 3.649, P = 0.026), abscess ≥6 cm in diameter (OR 10.989, P = 0.002) and other septic metastases (OR 1.710, P = 0.047) were risk factors for SRLA. Regarding the site of rupture, 20 (87.0%) patients had a localized rupture, specifically, subphrenic abscess in 3 (13.0%), peri-hepatic abscess in 10 (43.5%), localized peritoneal abscess in 3 (13.0%) and empyema in 4 (17.5%); and the other 3 (13%) had peritonitis. Ruptures resulting in peritonitis require urgent surgery, whereas localized ruptures were managed with surgical or percutaneous drainage in addition to appropriate antibiotics. The in-hospital mortality rate of SRLA was 4.3%. CONCLUSION: Patients with cirrhosis, having abscess ≥6 cm in diameter, gas-forming abscesses and other septic metastases in those with PLA should be monitored closely and may need early intervention for SRLA.

Safety of an intercostal approach for imaging-guided percutaneous drainage of subdiaphragmatic abscesses.

OBJECTIVE: The objective of our study was to test the hypothesis that an intercostal approach to imaging-guided percutaneous subdiaphragmatic abscess drainage is as safe as a subcostal approach. MATERIALS AND METHODS: A cohort of 258 consecutive patients with one or more subdiaphragmatic abscesses referred for imaging-guided (CT or ultrasound) percutaneous drainage was identified. Demographic characteristics and clinical outcomes were compared between patients who underwent drainage catheter placement via an intercostal approach versus those who underwent drainage catheter placement via a subcostal approach. RESULTS: Percutaneous drainage was performed for 441 abscesses in 258 patients in 409 separate procedures (214 via an intercostal approach, 186 by a subcostal approach, and nine by a combined approach). The total number of pleural complications was significantly higher in the intercostal group (56/214 [26.2%]) than the subcostal group (15/186 [8.1%]; p < 0.001). These complications included a significantly higher pneumothorax rate in the intercostal group than the subcostal group (15/214 [7.0%] vs 0/186 [0%], respectively; p < 0.01) and a higher incidence of new or increased pleural effusions (38/214 [17.8%] vs 14/186 [7.5%]; p < 0.01). The incidence of empyema was low and similar between the two groups (intercostal vs subcostal, 3/214 [1.4%] vs 1/186 [0.5%]; p = 0.63). A few of the complications in the patients who underwent an intercostal-approach drainage were clinically significant. Four of the 15 pneumothoraces required thoracostomy tubes and eight of 38 (21.1%) pleural effusions required thoracentesis, none of which was considered infected. CONCLUSION: An intercostal approach for imaging-guided percutaneous drainage is associated with a higher risk of pleural complications; however, most of these complications are minor and should not preclude use of the intercostal approach.

Empyema and psoas abscess in a previously undiagnosed diabetic patient.

A 48-year-old man presented with a 2-month history of polyuria, polydypsia, chest pain, fever, cough and extreme weight loss. He was diagnosed with diabetic ketoacidosis and investigations revealed widespread infection with an empyema complicated by bronchopleural fistula, and iliopsoas, suprapubic and periarticular abscesses. Streptococcus milleri was cultured from all sites. A multidisciplinary medical and surgical approach was required for treatment. This case highlights the immunosuppression, and life-threatening complications arising from undiagnosed diabetes mellitus.

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.

Post-traumatic hepatic artery pseudo-aneurysm combined with subphrenic liver abscess treated with embolization.

A 23-year-old man with post-traumatic hepatic artery pseudo-aneurysm and subphrenic liver abscess was admitted. He underwent coil embolization of hepatic artery pseudo-aneurysm. The pseudo-aneurysm was successfully obstructed and subphrenic liver abscess was controlled. Super-selective trans-catheter coil embolization may represent an effective treatment for hepatic artery pseudo-aneurysm combined with subphrenic liver abscess in the absence of other therapeutic alternatives.

[Cholangitis with subphrenic abscess after complicated cholecystectomy due to occluded plastic stents]. / Cholangitis mit Ausbildung eines subphrenischen Leberabszesses nach komplizierter Cholezystektomie auf dem Boden verschlossener Plastikstents.

A 62-year-old lady presented with fever and abdominal pain. History revealed cholecystectomy two years ago due to cholecystolithiasis, complicated by perforation of the common bile duct, leading to hepaticojejunostomy, jejunocholedochostomy, endoscopic retrograde insertion of two plastic stents and percutaneous drainage of bilioma. The patient was lost to follow-up until she presented two years later in the emergency room. ERC was performed. Both stents were occluded. After extraction dirty bile popped out. Injection of contrast medium showed stones in the remaining common bile duct and dilatation of the intrahepatic bile ducts and the interposed jejunum. After stone extraction a subphrenic intrahepatic fluid collection became visible when injecting contrast medium in the intrahepatic bile ducts. Pus was aspirated. The abscess was drained with a nasobiliary tube. Antibiotics were given. Temperature and CRP normalized. The nasobiliary tube was removed when the biliary fluid was clear. Recovery was uneventful with complete resolution of symptoms.

[Continuous low-flow vein-vein hemofiltration in peritonitis: changes in the severity of endotoxicosis as a criterion for the efficiency of the technique].

The efficiency of intermittent and continuous hemofiltration was comparatively evaluated in the complex treatment of 27 patients having multiple organ dysfunction along with pyoseptic complications of abdominal diseases. Based on the study of a broad spectrum of markers of toxicosis and the severity of organ dysfunction, it was concluded that the efficiency of the procedure should be objectively evaluated to optimize the time of its performance.

[Subphrenic abscess during the course of acute brucellosis: diagnosis and treatment with percutaneous sonographically-guided drainage]. / Ascesso sub-frenico in corso di brucellosi acuta: diagnosi e trattamento mediante drenaggio percutaneo eco-guidato.

Abscess formation during the course of acute brucellosis is a rare event. A case of subphrenic abscess, the first to our knowledge, is described. A 49 years-old male patient with fever and a mild increase in ALT and gamma-GT was referred to our Institution. Routine blood exams tested negative and antibodies against Brucella spp. Were also negative. CT examination of abdomen was normal. After 8 days, US examination showed a liquid area under the right diaphragma and US-guided puncture revealed an abscess; pus culture showed the presence of Brucella melitensis. Seven days later theWright reaction became positive. After percutaneous catheter drainage of the abscess, fever disappeared and US follow-up showed reconstitution of subphrenic space. Our study confirm that sonography is a valid method to demonstrate abdominal abscess and that US-guided percutaneous puncture and drainage are useful tools in diagnosis and treatment of fluid abdominal collections