A 42-year-old lady underwent a laparoscopic cholecystectomy, which was uneventful other than some spillage of bile and gallstones during dissection. Postoperatively the patient was fine but she started complaining of right shoulder tip pain and developed high grade fever on the 3rd postoperative day. Her pulse was found to be 110/min and RR 20/min. The most likely diagnosis is
right subdiaphragmatic abscess
The likely diagnosis is a right subdiaphragmatic (subphrenic) abscess. Spilled infected bile and dropped gallstones left in the subhepatic and subphrenic spaces act as an infected nidus. Diaphragmatic irritation, supplied by the phrenic nerve (C3, C4, C5), refers pain to the right shoulder tip through supraclavicular nerves of the same roots. Shoulder tip pain with swinging high-grade fever on the third to fifth postoperative day, pulse 110 per minute and tachypnoea is classic. Confirm on ultrasound or CT; treat with antibiotics and drainage.
Ascending cholangitis would give Charcot's triad including jaundice, absent here, and implies a retained ductal stone. Liver abscess causes tender hepatomegaly with intercostal tenderness rather than isolated shoulder tip pain, and is uncommon after cholecystectomy. DVT with pulmonary embolism causes pleuritic pain, hypoxia and a respiratory rate well above 20 per minute, without high swinging fever.
Key point: Postoperative fever plus shoulder tip pain means a subphrenic collection until proven otherwise - pus somewhere, pus nowhere, means pus under the diaphragm.
Important Questions from Hepatobiliary & Pancreatic Surgery
Which among the following are complications of liver trauma?
1. Liver abscess
2. Biliary fistula
3. Portal thrombosis
4. Liver failure
Select the correct answer using the code given below.
Which of the following are local complications of acute pancreatitis?
1. Pseudocyst
2. Pleural effusion
3. Ileus
4. Acute fluid collection
Select the correct answer using the code given below.
Which of the following are risk factors for the development of pancreatic cancer?
1. Cigarette smoking
2. Diabetes mellitus
3. Caucasian ethnicity
4. Male gender
Select the correct answer using the code given below.
Which of the following are options for management of a pancreatic pseu- docyst?
1. Pancreaticoduodenectomy
2. Cystogastrostomy
3. Percutaneous drainage
4. Endoscopic drainage
Select the correct answer using the code given below :
- Which of the following statements regarding hepatic adenomas are correct? 1. They are almost exclusively seen in females aged 25-50 years 2. They are associated with use of oral contraceptive pills 3. They do not have any malignant potential 4. Majority are detected incidentally on imaging Select the correct answer using the code given below :
