Case reports of transdiaphragmatic fistulas connecting subphrenic collections and empyemas are uncommon. We report the rare complication of a fistulous connection between a subphrenic collection and the bronchial tree.
- transdiaphragmatic fistula
- subphrenic abscess
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An 82 year old man was admitted following an episode of coffee ground vomiting. He had experienced a dull ache in the epigastrium for one week and had a history of a duodenal ulcer 20 years previously. He looked pale with a regular pulse of 100 bpm and there was mild epigastric tenderness. His haemoglobin was 123 g/l.
Gastroscopic examination showed a dilated stomach with fluid residue and the pylorus was narrowed to a pinhole; the duodenum could not be seen. He was started on lansoprazole and over the following week his condition stabilised. His haemoglobin fell to 107 g/l but he did not pass melaena.
He then became unwell with a pyrexia of 38°C, was tachypnoeic, and developed coarse crackles in the right lower chest. A diagnosis of right basal pneumonia was made and he was treated with intravenous cefuroxime and clarithromycin. Blood cultures were taken which subsequently grew a coagulase negativeStaphylococcus, thought to be a skin contaminant. His temperature settled and his chest radiograph showed only patchy shadowing at the right base. An abdominal ultrasound scan, requested because of an increase in the serum level of alkaline phosphatase, was normal. His condition improved over the next four weeks and his chest signs and symptoms resolved. He had no further vomiting and was discharged home.
Six weeks later he was re-admitted with a haemoglobin of 59 g/l. He was transfused with six units of blood and discharged home three days later with a haemoglobin of 134 g/l. A barium enema examination was ordered to investigate further the cause of his recurrent anaemia.
Two weeks later he was re-admitted with a one week history of a cough productive of purulent sputum. On examination he was apyrexial, had peripheral oedema, and the right base was dull to percussion and associated with decreased breath sounds. Abdominal examination was normal.
His haemoglobin was 125 g/l, white cell count 6.3 × 109/l, and chest radiography showed cardiac failure with upper lobe venous diversion and bilateral pleural effusions, with a homogenous opacity at the right base which was thought not to be entirely caused by the effusion.
He was started on co-amoxiclav and erythromycin but attempted intercostal aspiration of the pleural fluid was unsuccessful. A barium enema was performed and indicated early diverticular disease in the sigmoid colon and a tiny outpouching at the hepatic flexure with some possible tethering. The significance of this was uncertain but possible causes included the previous perforation of a colonic diverticulum.
Bronchoscopic examination of the right bronchial tree indicated some inflammatory changes in the right lower lobe. A foul faeculent smell was noted and the possibility of a transdiaphragmatic fistula was raised. An abdominal ultrasound examination demonstrated a 12 cm collection of fluid lateral to the liver, suggestive of a subphrenic abscess. Later that day a pigtail drainage catheter was inserted into the subphrenic collection and thick pus was drained.
Two days later a tubogram was performed to assess the size of the abscess cavity. A small subphrenic cavity was demonstrated before the patient started to cough up contrast medium. Radiography showed a fistula between the subphrenic cavity and the bronchial tree (fig1).
Pus from the subphrenic abscess cavity yielded heavy growths of methicillin resistant Staphylococcus aureusand Enterococcus spp. Both sputum and bronchial washings yielded methicillin resistant S aureus. The patient was treated with teicoplanin and the cavity drained externally. Subsequent tubograms over the following week showed that the fistula had closed and the abscess cavity became smaller.
Following drainage of the abscess the patient made a good recovery and his chest symptoms resolved. He was discharged home and was well when seen two months later.
Case reports of transdiaphragmatic fistulas connecting subphrenic collections and empyemas are uncommon.1-3 This elderly patient presented with chest symptoms and was found to have a subphrenic abscess by ultrasound scanning. These pathologies were not initially thought to be connected but opinion changed when the patient expectorated contrast medium which had been injected into the subphrenic abscess cavity.
It was decided that the best treatment option was to continue percutaneous drainage of the abscess and to administer antibiotics. This led to a satisfactory outcome and the transdiaphragmatic fistula closed spontaneously when the abscess cavity had drained for a few days.
It is not clear why this patient developed a subphrenic abscess but it must have arisen following his first hospital admission because the original ultrasound examination was normal. The possibilities include perforation of a colonic diverticulum or a duodenal ulcer. The barium enema findings suggested that a small diverticular perforation had occurred which had sealed spontaneously and the microbiology suggested a faecal origin to the abscess, so this seems the most likely explanation. Alternatively, the dyspeptic symptoms, the fall in haemoglobin, and the previous history of a peptic ulcer raises the possibility of a silent perforation of a duodenal ulcer with subsequent healing. Pyloric stenosis prevented this possibility being confirmed at gastroscopy. The erosion of an empyema through the diaphragm following an earlier chest infection seems unlikely.