Most common cause of infection and collection of fluid in the left subhepatic space?
Ans. c (Complicated acute pancreatitis) (Ref. Bailey and Love 26th/pg. 998).Left inferior (posterior) intraperitoneal space OR Left subhepatic space/lesser sac: The most common cause of infection here is complicated acute pancreatitis. In practice, a perforated gastric ulcer rarely causes a collection here because the potential space is obliterated by adhesions.ABDOMINAL ABSCESS# There are four peritoneal and three extraperitoneal spaces in which pus may collect.# Three of these spaces are on either side of the body, and one is approximately in the midline.# Left superior (anterior) intraperitoneal ('left subphrenic') = common came of an abscess here is an operation on the stomach, the tail of the pancreas, the spleen or the splenic flexure of the colon.# Right superior (anterior) intraperitoneal ('right subphrenic') = Common causes here are perforating cholecystitis, a perforated duodenal ulcer, a duodenal cap 'blow out' following gastrectomy and appendicitis.# Right inferior (posterior) intraperitoneal ('right subhepatic') lies in Rutherford Morison's pouch. It is the deepest space of the four and the commonest site of a subphrenic abscess which usually arises from appendicitis, cholecystitis, a perforated duodenal ulcer or following upper abdominal surgery.# Extraperitoneal. There are three of these:- Right and left extraperitoneal which are terms given to perinephric abscesses;- Midline extraperitoneal which is another name for the 'bare' area of the liver which may develop an abscess in amoebic hepatitis (commonest cause) or a pyogenic liver abscess.Educational Points:# The pelvis is the commonest site of an intraperitoneal abscess because the vermiform appendix is often pelvic in position and also the Fallopian tubes are frequent sites of infection. A pelvic abscess can also occur as a sequel to any case of diffuse peritonitis and is a common sequel of anastomotic leakage following large bowel and rectal surgery.# The most characteristic symptoms of a pelvic abscess are diarrhea and the passage of mucus in the stools.# It is no exaggeration to say that the passage of mucus, occurring for the first time in a patient who has, or is recovering from, peritonitis, is pathognomonic of pelvic abscess.# Left to nature, a proportion of these abscesses bursts into the rectum, after which the patient nearly always recovers rapidly. Laparotomy is almost never necessary.# Rectal drainage of a pelvic abscess is far preferable to suprapubic drainage (risks peritoneal infection).# Subdiaphragmatic abscess: remember the aphorism, 'pus somewhere, pus nowhere else, pus under diaphragm. 9# A swinging pyrexia is usually present, unless antibiotics or drugs (steroids) have interfered.# Ultrasound or CT scanning is the investigation of choice and permits early detection of subphrenic collections.# Ga67/Indium-111 white cell scanning may occasionally prove helpful when other imaging techniques have failed.
Perforation at the lesser curvature of stomach
Perforation of posterior duodenal wall ulcer
Complicated acute pancreatitis
Ruptured abscess of the left lobe of the liver
Liver