Teaching Case

Percutaneous drainage of a subphrenic abscess.

This man was admitted with a right subphrenic abscess, having had an uneventful surgical repair of a perforated duodenal ulcer a few weeks previously. This was drained under CT guidance and the patient discharged a few days later.
He was readmitted to hospital with right upper quadrant and right shoulder tip pain. Reaccumulation of the right subphrenic abscess and right lower lobe consolidation was confirmed at CT and insertion of a pigtail catheter was performed simultaneously. A tubogram performed to show cavity size unexpectedly revealed a right bronchoperitoneal fistula and the patient expectorated contrast during the examination. A water-soluble contrast meal found no evidence of a duodenal leak or fistula.
Bronchoscopy showed right middle lobe secretions and no other abnormality. A right postero-lateral thoracotomy was performed and a 5-cm abscess crossing the right hemi-diaphragm into the right subphrenic space was found and drained and adhesions and a fistula between the right lower lobe and right diaphragm were divided. He made and uneventful recovery and was discharged home.

Case reports of bronchoperitoneal fistula secondary to perforated duodenal ulcer are uncommon. In this case a subphrenic abscess secondary to perforated duodenal ulcer with erosion of the diaphragm and fistulous communication with the bronchial tree is likely to have occurred. Surgical debridement of the subphrenic abscess and division of the fistula was necessary in this case; however, a case report of conservative management of transdiaphragmatic fistula with percutaneous drainage of subphrenic abscess with successful outcome has been cited (1). Another case report has discussed bronchoperitoneal fistula secondary to chronic Klebsiella pneumoniae subphrenic abscess (2).
Bronchial fistulae can occur with structures within and outside the thorax, the commonest form being bronchopleural fistula usually after lobectomy or pneumonectomy for pulmonary malignancy. Stump failure due to dehiscence of sutures and infection is the commonest origin of a fistula. The principal causes of bronchial fistula are infection and carcinoma, with trauma and inflammatory processes being less common causes.
Formation of bronchial fistulas with abdominal viscera is rare and colobronchial fistula develops mostly due to abdominal sepsis and subphrenic abscess, with colonic carcinoma and Crohn’s disease being less common causes.