Global Journal of Medical Research, I: Surgeries and Cardiovascular System, Volume 22 Issue 2

Subdiaphragmatic Abscess: Complication of Emergency Laparotomy Dr. Abhijeet Dilip Kharche α , Dr. Sriranjani Iyer σ & Dr. Saileshwar Natarajan ρ Abstract- Intra-abdominal abscesses usually occur following any intra-abdominal surgery, trauma, Gastrointestinal infection or intestinal perforation. In particular, the diagnosis of sub- phrenic collection can be notoriously difficult. This fact is expressed by the well-known aphorism: 'Pus somewhere, pus nowhere else, pus under the diaphragm'. Sub-diaphragmatic abscesses form between the diaphragm and abdominal organs, such as the liver and spleen. Depending on the severity of the sub-diaphragmatic abscess and the cause, treatment method may vary for each case. The abscess may be treated with early percutaneous drainage and empiric intravenous antibiotics. When dealing with post-operative persistent pyrexia that does not react to antibiotics, surgeons must always be careful, and the likelihood of a sub- diaphragmatic abscess must always be considered. If not treated, thoracic and abdominal complications may prevail, in rare cases, death.We present a case of sub-diaphragmatic abscess in a patient with a perforated duodenal ulcer treated by ultrasound-guided percutaneous drainage with a good outcome. Keywords: sub-phrenic, abscess, drainage, post- operative. I. I ntroduction ntra-abdominal abscesses are common after surgery, trauma, severe gastrointestinal infection, intestinal perforation, or acute pancreatitis [1, 2]. Thirty percent of episodes are related to inflammatory illnesses of the abdominal organs caused by gastric/duodenal perforation, twenty percent to the liver/biliary system, and one-third to appendicitis [1, 3]. Between the diaphragm and abdominal organs like the liver and spleen, sub-diaphragmatic abscesses occur. Surgical drainage, percutaneous drainage, and endoscopic drainage are all options for abscess drainage. The mortality rate of a sub-diaphragmatic abscess is significant, and failing to recognize or postpone treatment might be harmful to the patient [4]. The sub-diaphragmatic purulent collection has a significant mortality rate, and if undetected or delayed, it can lead to intra-thoracic problems [5]. Fever with chills and rigors, upper quadrant pain, and leukocytosis are some of the symptoms. The best way to diagnose a Author α : Junior Resident, Department of General surgery, Rajiv Gandhi Medical College, Thane, Mumbai, Maharashtra, India. Corresponding Author σ : Senior Resident, Department of General surgery, Rajiv Gandhi Medical College, Thane, Mumbai, Maharashtra, India. e-mail: sriranjani1993@gmail.com Author ρ : Professor and Head, Department of General surgery, Rajiv Gandhi Medical College, Thane, Mumbai, Maharashtra, India. sub-phrenic abscess is to use imaging, particularly a CT scan [6]. The patient is at risk of developing chronic episodes of unrelenting fever, sepsis, peritonitis, and death unless treated. Early percutaneous drainage and empiric intravenous antibiotics may be enough to treat the abscess. Surgeons must always be cautious when dealing with post-operative persistent pyrexia that does not respond to antibiotics, and the possibility of a sub- diaphragmatic abscess must always be addressed. We report a case of sub-diaphragmatic abscess in a post-operative case of perforated duodenal ulcer treated with ultrasound guided percutaneous drainage, with a favorable post-treatment course. II. C ase R eport A 48-year-old male patient came with chief complaints of pain in the abdomen, breathing difficulties, fever, loss of appetite since four days. Patient is a post-operative day 14 case of pre-pyloric perforation and was previously explored and managed by modified graham’s patch repair. His pelvic drain was removed on post-operative day 3 and the abdominal drain in Morrison’s pouch was removed on post-op day 5 with minimal to nil drain output. The patient was discharged in a healthy state on post-op day 7 with no complaints. On routine post discharge follow up day 3, he had no complaints and his general and per abdomen examination were satisfactory. On post-operative day 11, patient started experiencing pain in right hypochondrium and fever. Pain was dull aching, and progressively increasing in nature with spikes of low- grade fever throughout the day. Gradually he further developed breathing difficulties and loss of appetite. Patient is a known chronic cigarette smoker. Patient did not have any comorbidities. At admission, on general physical examination, patient was febrile (38.6 degrees centigrade) with tachycardia (130/min), patient had right hypochondriac tenderness with localized guarding with a palpable lower margin of liver, Respiratory system showed decreased breath sounds on the right lower zone of the chest on auscultation. Per-Rectal examination showed no abnormalities. After initial resuscitation with Intravenous fluids, patient was investigated with routine laboratory investigations which revealed a marked inflammatory response, with a white blood cell count of 14,500 cells/ I 15 Year 2022 Global Journal of Medical Research Volume XXII Issue II Version I ( D ) I © 2022 Global Journals