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Pulmonary embolus
3%
3/86
Acute myocardial infarction
1%
1/86
Atelectasis
6%
5/86
Subphrenic abscess
83%
71/86
Pneumonia
5%
4/86
Select Answer to see Preferred Response
The patient described above has a subphrenic abscess. Subphrenic abscesses can present as a complication of a splenectomy with elevated white blood cells, fevers, pleuritic pain, and left shoulder pain. Subphrenic abscesses can present as complications from acute pancreatitis, trauma, post-splenectomy, and other abdominal surgeries. These abscesses are essentially infected fluid accumulations between the diaphragm, liver, and spleen. The postoperative fevers seen with a subphrenic abscess usually present 3-5 days after the operation. Subphrenic abscesses are unique on presentation in that they have left shoulder pain, which is referred pain from phrenic nerve irritation. Other common presenting signs are cough, tachypnea, diminished breath sounds, dullness to percussion, and fevers. Majeski discusses abdominal abscesses. Management of patients with abdominal abscesses has changed over time. Surgical incision and drainage is not always necessary, and percutaneous drainage has shown favorable outcomes. Ultrasonography, computed tomography and radionuclide scintigraphy can all be helpful aids in the management of patients with abdominal abscesses. Salzano et al. report on the role of computed tomography (CT) scans in assessing subphrenic abscesses after post traumatic splenectomy. Thirteen patients with left subphrenic abscesses after splenectomy were included in the study. CT was found to be an irreplaceable tool for rapid and easy diagnosis, along with follow-up surveillance of subphrenic abscesses. The CT scan was also used for guided drainage of the abscesses (first-line treatment). Illustration A is a CT scan of the upper abdomen demonstrating a right-sided subphrenic abscess. Illustration B is an overview image depicting an artist's rendition of a subphrenic abscess. Illustration C demonstrates an ultrasound image of free fluid in the left upper quadrant. The asterisk denotes the free fluid that is between the spleen and diaphragm (arrowheads). Incorrect Answers: Answers 1-3,5: None of these diagnoses would account for the constellation of post-operative symptoms that this patient is experiencing.
3.3
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