Muhammad Umar Amin, Mobeen Shafique, Rabia Mahmood, Sajid Ali Mustafvi.
Idiopathic right sub-phrenic abscess containing gas.
Pak Armed Forces Med J Jan ;57(4):335-8.

A 33 years old male patient was admitted with complaints of low grade fever and pain in the right hypochondrium for 15 days. There was history of drug addiction (Marijuana) for 5-6 years. On examination, hepatic dullness was absent, breadth sounds and bowel sounds were normal and there was mild tenderness in right hypochondrium. His initial X-ray chest showed gas under the right hemidiaphragm and a slightly elevated right hemidiaphragm also. Considering it a case of pnemoperitoneum. X-ray abdomen, Right decubitus view was done which showed no free air rising in superior position thus excluding pneumoperitoneum. Since patient was not toxic the gas under right hemidiaphragm was thought to be present in transverse colon (Chilaiditi syndrome) in which transverse colon passes between the liver and rt hemi-diaphragm. Abdominal ultrasound revealed a complex abscess rt sub-phrenic area with air in it. CT Scan revealed presence of sub-phrenic abscess in rt anterolateral position compressing the rt lobe of liver medially and inferiorly. Air -fluid level was also seen in the abscess confirming infection by gas forming organisms. He was referred to surgeon who planed exploratory laparotomy of the patient. Approximately 150m1 of foul smelling greenish pus was drained from the abscess cavity and sample sent for culture and sensitivity. A drain was placed in the Morrison`s pouch and abdomen was closed. Post operatively, I/V antibiotics were continued. Pus culture revealed the growth of staphylococcus aureus, enterococci and gram negative rods.

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