Ten days after Splenectomy for blunt abdominal trauma, a 23- year-old man complains of upper abdominal and lower chest pain exacerbated by deep breathing. He is anorectic but ambulatory and otherwise making satisfactory progress. On examination his temperature is 38.20C and he has decreased breath sounds at left lung base. His abdominal wound appears to be healing well, bowel sounds are active and there are no peritoneal signs. Digital rectal examination is negative. WBC 12,500/mm3 with a shift to left. CXR show 'plate like' atelectasis of the left lung field. Abdominal radiograph shows a non-specific gas pattern in bowel and an air-fluid level in LUQ. Serum Amylase is 150 Somogyi units per dL. The most likely diagnosis is:
(Subphrenic abscess) Following Laparotomy it has been established that half of all patients develop some postoperative pulmonary collapse. This patient has pain in epigastrium, which exacerbates by deep breathing; hence, he will have some respiratory compromise adding to retained secretions.Leucocytosis, epigastric pain, local paralytic ileus in LUQ in the form of an air-fluid level there, with the reduced breath sounds at LLZ of lungs in a postoperative patient direct towards a infective subdiaphragmatic pathology, in turn affecting LLZ in form of Fleischner's plate atelectasis, i.e., most likely to be subphrenic abscess. However, the subsegmental or plate-like atelectasis as such appears about 24 hrs post-operatively and resolves in 2-3 days. Here the subdiaphragmatic abscess would be impoant.
Subphrenic abscess
Subfascial wound infection
Pancreatitis
Pulmonary embolism