Special considerations Subphrenic abscess

Special considerations: Subphrenic abscess

This refers to the presence of pus immediately beneath the diaphragm. Patients may complain of shoulder tip pain. The diaphragm also develops at the same level as the C5 dermatome. If the parietal peritoneum under the diaphragm is irritated, - pain is referred to the shoulder tip. This also explains why patients frequently complain of shoulder tip pain following laparoscopic or robotic surgery . In the era preceding that of cross-sectional imaging via CT , the adage ‘pus somewhere, pus nowhere, pus under the diaphragm’ was useful. The pelvis is the most common site of abscess formation because the vermiform appendix is often pelvic in position and the Fallopian tubes are also frequent sites of infection. A pelvic abscess can also occur as a sequel to di ff use peritonitis and is common after anastomotic leakage following colorectal surgery . Clinical features The most characteristic symptoms are pelvic pain, diarrhoea and passage of mucus in the stools. The patient may complain of lower back pain or a pressure sensation in the pelvis. This symptom can be quite severe in intensity . The abscess may discharge into the anal canal as the pelvic collection points through an anastomotic leak (the point of least resistance). Rectal or vaginal examination can be extremely uncomfortable for the patient. Investigation and management If any uncertainty exists, the presence of pus should be confirmed by ultrasonography or CT scanning. Pelvic abscesses can be drained transanally or transgluteally . The past vogue for transintestinal drainage is no longer practised because of the high incidence of complications such as fistulae. Laparotomy may sometimes be indicated.