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Subphrenic Suppuration and Its Complications H Postgrad Med J: first published as 10.1136/pgmj.39.449.138 on 1 March 1963. Downloaded from POSTGRAD. MED. J. (I963), 39, I38 SUBPHRENIC SUPPURATION AND ITS COMPLICATIONS H. C. NOHL, M.A., D.M., F.R.C.S. Thoracic Surgeon, Harefield Hospital, Hillingdon Hospital and West Middlesex Hospital THE diagnosis of subphrenic abscesses can be (ii) The right infra-hepatic space is synonymous with notoriously difficult. This fact is well Rutherford Morrison's kidney pouch. Its upper expressed border posteriorly is formed by the lower layer of the by the well known aphorism: 'Pus somewhere, coronary ligament. In front of it lies the liver and the pus nowhere else, pus under the diaphragm'. gallbladder, while below it communicates with the right Even more puzzling can be the features when paracolic gutter. complications, which occur relatively f.requently, dominate the clinical The situation 2. EXTRAPERITONEAL picture. This space lies between the two layers of the coronary of the subphrenic spaces, hidden under the rigid ligament and therefore is in contact with the bare area concavity of the ribs and therefore inaccessible to of the liver. palpation, is mainly responsible for the paucity of obvious clinical signs. The purpose of this The Left Subphrenic Spaces article is to stress the not so infrequent bizarre I. INTRAPERITONEAL presentation of subphrenic suppuration and draw (i) The left supra-hepatic space lies above the left by copyright. lobe of the liver and is limited behind by the upper layer the clinician's attention to this hidden area. of the left triangular ligament, while in front, over the edge of the liver, it communicates with the left anterior Anatomy infra-hepatic space. A knowledge of the anatomy of the subphrenic (ii) The left anterior infra-hepatic space is situated below the left lobe of the liver and in front of the lesser spaces is essential in the management of these omentum and stomach. Wooler (I956) points out that cases. The subphrenic region is generally con- the left lobe of the liver and the left triangular ligament sidered to lie between the diaphragm above and lie near the centre of the abdomen and that there is the transverse colon and mesocolon below. These therefore a wide communication between the supra- and the infra-hepatic spaces. http://pmj.bmj.com/ spaces have been variously described (Barnard, (ii) The posterior infra-hepatic space comprises the I908; Mitchell, 1940; Harley, 1949; Wooler, lesser sac. 1956), but Harley's description is both clear and practical. (For a full understanding of the 2. EXTRAPERITONEAL anatomical facts see Figs. I to 4.) This space constitutes the areolar tissue around the upper pole of the left kidney and suprarenal and the Both on the right and the left there are spaces above bare area of the esophagus. the liver (supra-hepatic) and below it (infra-hepatic). In conclusion it must be realized that all these spaces The supra-hepatic space on the right is separated from communicate with each other (Mitchell, 1940) and this on September 26, 2021 by guest. Protected that on the left by the falciform ligament, while the explains the not infrequent occurrence of multiple infra-hepatic compartments are divided into right and space infection. left by the ligamentum teres and ligamentum venosum. Altogether there are five intraperitoneal and two extra- AEtiology peritoneal spaces. The more detailed description of the subdiaphrag- In go900 of cases subphrenic suppuration is matic spaces as given by Harley are as follows: 'secondary' to infection elsewhere in the abdo- minal cavity (Harley). Perforated peptic ulcers, The Right Subphrenic Spaces appendicitis, abdominal operations and thoraco- I. INTRAPERITONEAL abdominal warwounds in that order account for (i) The right supra-hepatic space lies between the over 700/O of cases in that diaphragm and the liver and is bounded posteriorly by author's series. In the upper layers of the coronary and the right triangular Windsor's (1955) IOO patients, diseases of the ligaments. These separate it from the bare area of the stomach and duodenum also head the list (48%), liver. It is important to stress that this is a very large followed by appendicitis (23%)0 while liver and space, reaching from the anterior abdominal wall right biliary diseases come back to the posterior aspect of the liver. Abscesses a close third (22%). In the can therefore be situated anteriorly or posteriorly in older series, e.g. Barnard (I908) and Ochsner and this space. DeBakey (I938), appendicitis is the predominant Postgrad Med J: first published as 10.1136/pgmj.39.449.138 on 1 March 1963. Downloaded from Mlarch I943 NOHL: Subphrenic Suppuration and its Complications 139 4: 4 soct bC c4: o 4- .cjQ Wt o0" 0 0O cn 4- * by copyright. 0 C, 0 C, .:0o v 4- C) http://pmj.bmj.com/ CZ0u C) C) *) 0 r.-) on September 26, 2021 by guest. Protected C) C) C) 4-C F- 6 6 Postgrad Med J: first published as 10.1136/pgmj.39.449.138 on 1 March 1963. Downloaded from 140 POSTGRADUATE MEDICAL JOURNAL Mairch i963 cause of subphrenic suppuration. The reason for more negative especially during inspiration. the change in the incidence is probably that upper Overholt and Donches (I935) believe that in the abdominal surgery is now done far more frequently upright position the negative pressure in the than in former days. Only occasionally no de- subphrenic region is greater than in the pelvis and tectable cause can be found and these are then that this results in suction of infected fluid up- presumed to be 'primary' bloodborne infections. wards into the subphrenic spaces. Mitchell (1940) A number of extraperitoneal abscesses are con- investigated the spread of intraperitoneal effusions sidered to be primary, but the majority on the by injecting barium emulsion into the abdominal right side originate from infections in the liver and cavity of stillborn infants. It is doubtful whether this is especially so in tropical countries where his conclusions, which differ very much from those amrebiasis and hydatid disease are common. of other authors, are valid as the conditions of the experiments were far from physiological. Gravity Bacteriology is another factor which will determine the collec- The most common infecting organisms are tion of fluid in these spaces, as they form the escherichia coli, anaerobic streptococci and staphy- lowest area in the abdominal cavity with the lococcus pyogenes. In about half of the cases the patient in the recumbent position. Spalding infection is a mixed one. On rare occasions an (I946) makes the point that subphrenic abscesses actinomycotic infection may be the underlying are known to follow appendicectomy but hardly cause. The recognition of this type of infection is ever complicate conservatively treated cases. He important as only prolonged penicillin therapy will maintains that the normal upward movement of prevent a protracted illness. In patients who have fluid into the subphrenic spaces is accelerated lived in tropical countries entamaeba histolytica or by the presence of a pneumoperitoneum which echinococcus may be the causative organism. alters the intra-abdominal pressure differences. It The following case illustrates how a history of is far more likely that the pneumoperitoneum should this to opens up the subphrenic spaces. The following residence abroad bring diagnosis by copyright. one's mind: case illustrates the harmful effects of a pneumo- peritoneum. Case No. I. L. C., aged 35, a Hindu unable to speak English. Complained of pain in the right chest, Case No. 2. W. J., a 6o-year-old housewife, treated aggravated by a recent cough for five days. There was since 1953 for pulmonary tuberculosis with anti- also difficulty in breathing. On examination he was tuberculous chemotherapy and phrenic crush and found to be an ill-looking, dyspnceic man. Tempera- pneumoperitoneum. Sputum in I96I was still positive ture IOI0 F., respiration rate 30 per min. There was on culture and resistant to most of the anti-tuberculous diminished percussion note and air entry over the right drugs. In November i96i she developed appendicitis lower lung with tenderness on pressure over 12th rib. and a gangrenous appendix was removed; pelvic peri- The chest radiograph showed a raised right diaphragm tonitis was noted at the time of the operation. She with a small pleural effusion, which on aspiration developed a right supra-hepatic subphrenic abscesshttp://pmj.bmj.com/ yielded straw-coloured fluid. W.B.C. 23,200/CU. mm., (Fig. 5) which was treated conservatively with anti- E.S.R. 53 mm./hr. A subphrenic abscess was diag- biotics frorm November I96I to February I962. This nosed. At operation a liver abscess was found in the was ultimately drained after it had perforated into the bare area which was at the point of bursting. This chest. The patient died, drowning in pus which was drained and contained typical pus like 'anchovy spilled over into both bronchial trees. sauce' which revealed entameba histolytica. With a Comment. The presence of the pneumoperitoneum full course of emetine the recovery was quick and predisposed to subphrenic infection. The abscess complete. should have been drained when it became established. Comment. This was not a true subphrenic abscess A tracheostomy at the time of drainage of the abscess on September 26, 2021 by guest. Protected and if the diagnosis had been made correctly chemo- might have saved the patient. therapy alone would have been the right treatment. Location of Subphrenic Abscesses Spread of Infection to the Subphrenic Region The majority of abscesses occur on the right The way the subphrenic spaces become infected side, while in a quarter of the cases recorded by is still uncertain. In the majority of cases (64.9%) various authors the left-sided compartments were there is direct spread from a neighbouring focus involved (Ochsner and DeBakey, I938; Neuhof (Harley).
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