Left Subphrenic Abscesses

Abscesses in the left subphrenic space may result from perforated anterior ulcers of the stomach or duodenal bulb, but they are seen particularly as complications of gastric or colonic surgery and of splenectomy.

The most consistent aspect of flow of fluid arising in the left upper quadrant is that it is preferentially directed upward to the subphrenic area, where an abscess typically coalesces56 (Figs. 3-86 through 3-88). This is a function of the negative intraabdominal pressure beneath the diaphragm related to respiration.

Figure 3-89 details the pathway from a perforation of the anterior wall of the stomach extending deep to the left lobe of the liver to abscess development in the immediate left subphrenic area. Coalescence of an abscess between the stomach and the left lobe of the liver is unusual. A similar direct cephalad extension is shown in an instance of colonic perforation in Figure 3-90.

Anastomotic leaks are being increasingly recognized as a source of postoperative left subphrenic abscesses. These may be small and loculated (Fig. 3-91) or extensive (Figs. 3-92 and 3-93).

When the volume of infected material in the left sub-phrenic space is considerable, one of two routes becomes available:

1. Spread may occur across the midline, beneath the free edge of the falciform ligament, to the right subhe-patic, right subphrenic, and then the right paracolic recesses. Figure 3-94 shows the pathways of infection across three quadrants of the abdomen, arising from a perforated ulcer of the stomach.

2. More often, the infected material simply overflows the strut of the phrenicocolic ligament. Ordinarily, inferior extension from the left subphrenic space tends to be arrested by this strong peritoneal reflection. However, large amounts simply proceed over it to the left paracolic gutter and then the pelvis (Figs. 3-95 through 3-97). From this site, contamination may rise up the paracolic gutter to the subhepatic and subphrenic spaces on the right.

Infection arising in the pelvis may extend upward to some degree within the shallow left paracolic gutter (Fig. 3-98), where the relatively slow flow may permit the development of adhesions and thereby coalesce into an abscess (Figs. 3-99 and 3-100). Medial displacement of the descending colon may result, and discrete gas shadows may be seen in the area of the infected fluid. Bulging of the posterolateral abdominal wall may be evident. The properitoneal fat line, radiologically referred to as the "flank stripe," is generally maintained. Loss of clear visualization of this implies extension of the infection across the peritoneal surface into the ab-

dominal wall. Livingston s description that fluid may well upward out of the pelvis . . . to pass into the left paracolic groove, to extend farther upward into the per-isplenic space" is generally not true. I have noted that an intact phrenicocolic ligament usually prevents spread to the left subphrenic area. This explains the repeatedly noted infrequency of left upper quadrant abscesses following generalized peritonitis. However, if the text continues on page 103

Fig. 3—68. Extension of intraperitoneal fluid into the lesser sac.

Contrast enema performed in a child following perforation of the rectosigmoid junction (R = rectum; S = sigmoid colon). Extravasation opacifies the paravesical fossae (pv) and the right paracolic gutter (RPG). Flow continues to Morison's pouch (MP), through the epiploic foramen to the lesser sac (LS). Extension up the left paracolic gutter (LPG) is impeded at the phrenicocolic ligament (PCL). (Courtesy of William Thompson, M.D., University of Minnesota School of Medicine, Minneapolis, MN.)

Fig. 3-69. Medial extension of posterior right subhepatic space into the lesser sac.

Postmortem CT following intraperitoneal injection of diluted contrast medium shows opaque fluid in the lesser and greater sacs. The right subhepatic space (SHS) extends continuously into the lesser sac (arrows) via the epiploic foramen (arrowheads). CL = caudate lobe (Courtesy of Yong Ho Auh, M.D., Asan Medical Center, Seoul, Korea

Fig. 3-69. Medial extension of posterior right subhepatic space into the lesser sac.

Postmortem CT following intraperitoneal injection of diluted contrast medium shows opaque fluid in the lesser and greater sacs. The right subhepatic space (SHS) extends continuously into the lesser sac (arrows) via the epiploic foramen (arrowheads). CL = caudate lobe (Courtesy of Yong Ho Auh, M.D., Asan Medical Center, Seoul, Korea

Fig. 3—70. Extension of intraperitoneal fluid into the lesser sac.

Following intraperitoneal (IP) injection of water-soluble contrast medium in vivo, CT demonstrates direct communication of fluid from Morison's pouch (MP) through the epiploic foramen (arrow) to the lesser sac (LS).

Fig. 3—70. Extension of intraperitoneal fluid into the lesser sac.

Following intraperitoneal (IP) injection of water-soluble contrast medium in vivo, CT demonstrates direct communication of fluid from Morison's pouch (MP) through the epiploic foramen (arrow) to the lesser sac (LS).

Fig. 3-71. Lesser sac abscess secondary to leak from ileoas-cending colostomy. Acute postoperative leakage from the anastomotic site has led directly to a large gas-producing infected collection within the lesser sac. Ready access from the adjacent site of leak was achieved before adhesions sealed off the foramen of Winslow. (Courtesy of Gary Ghahremani, M.D., Evanston Hospital, Evans-ton, IL.)

Fig. 3-72. Lesser sac abscess following perforation of a posterior gastric ulcer.

Erect plain film shows a large gas-containing abscess within the lesser sac displacing the transverse colon downward. (A smaller component extends beneath the left diaphragm.)

Fig. 3-72. Lesser sac abscess following perforation of a posterior gastric ulcer.

Erect plain film shows a large gas-containing abscess within the lesser sac displacing the transverse colon downward. (A smaller component extends beneath the left diaphragm.)

Fig. 3-73. Lesser sac abscess, following perforation of a posterior gastric ulcer.

Frontal (a) and erect lateral (b) views demonstrate a large gas-containing abscess behind the stomach. The collection is compartmentalized within the lateral compartment of the omental bursa by adhesions along the peritoneal fold of the left gastric artery.

Fig. 3-73. Lesser sac abscess, following perforation of a posterior gastric ulcer.

Frontal (a) and erect lateral (b) views demonstrate a large gas-containing abscess behind the stomach. The collection is compartmentalized within the lateral compartment of the omental bursa by adhesions along the peritoneal fold of the left gastric artery.

Fig. 3—74. Lesser sac abscess following gastric surgery.

CT demonstrates a gas-containing abscess (arrows) in the lesser sac, displacing the stomach and thickening its posterior wall. (Courtesy of Hiromu Mori, M.D., Oita Medical University, Oita, Japan.)

Fig. 3—75. Lesser sac abscess following surgery for a perforated gastric ulcer. CT demonstrates communication of oral contrast medium to retrogastric abscess collection in the lateral compartment of the lesser sac. The abscess is bounded laterally by the gastro-splenic ligament.

Essentials of Human Physiology

Essentials of Human Physiology

This ebook provides an introductory explanation of the workings of the human body, with an effort to draw connections between the body systems and explain their interdependencies. A framework for the book is homeostasis and how the body maintains balance within each system. This is intended as a first introduction to physiology for a college-level course.

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