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2009-04-29-08 Subdiaphragmatic abscess and jejunal atresia © Volkov www.thefetus.net/

Subdiaphragmatic abscess and jejunal atresia

Andrey Volkov, MD, PhD*; V. Katñhupeev MD, PhD**; A. Dadayan, MD***.

*     Department of Obstetrics and Gynecology ¹ 1 of Rostov Medical University, Rostov on Don, Russia;
**    Department of Pediatric Surgery of Municipal Hospital ¹ 20, Rostov on Don, Russia;
***   Department of Pediatric Surgery and Orthopedy of Rostov Medical University, Rostov on Don, Russia.

 

 

Case report

 

A 22-year-old primigravida, with a non contributive history, presented to our department at 33 weeks of pregnancy, Her first and second trimester exams were reported to be normal. At 33 weeks, our ultrasound revealed a moderate polyhydramnios and an enlarged bowel of the fetus. Its growth was normal.

At 37 weeks the ultrasound revealed another oval lesion (90.8 x 42.3 cm) localized in the right part of the abdominal wall of the fetus under the diaphragm (Fig. 1, 2). The lesion was of inhomogeneous structure: within a hypoechoic content there was a hyperechoic movable debris changing its position with the change of the position of the mother (Fig. 3, 4). Next to the lesion a hyperechoic focus 7 x 9 mm (intraabdominal calcification) was found (Fig. 5). The lesion compressed the liver to the left. The fetus also had a hydrocele (Fig. 6).

 

The neonate was delivered at 38 weeks. Postnatal abdominal X-ray revealed the jejunal obstruction. Ultrasonography found a calcified focus within the left lobe of the liver (Fig. 7). The neonate underwent an operation at the first day after delivery. During the operation additionally to the jejunal obstruction, an abscess of 50 ml, bordered by diaphragm and diaphragmatic surface of the right lobe of the liver was found. The presence of the absence explained the prenatal ultrasonographic finding of the hypoechoic subdiaphragmatic lesion with movable debris inside the lesion. The proximal distended part of the obstructed bowel had to be resected with consequent anastomosis 30 cm distal to the angle of Treitz. The bowel rotation was normal. The wall of the resected 10 cm of gut was dark, carrying signs of necrosis.

 

Postoperative course was normal (Fig. 8) and the baby was discharged at the day 25 after the operation.

 

 

Images 1, 2: 37 weeks of pregnancy; the images show transverse scan of the subdiaphragmatic area of the fetal abdomen. A hypoechoic ovoid structure with a hyperechoic debris inside can be seen on the right side of the abdomen, compressing the liver to the left side. Postnatally the structure turned out to be the subdiaphragmatic fetal abscess.

 

 

Images 3, 4: 37 weeks of pregnancy; the images show transverse scan of the subdiaphragmatic area of the fetal abdomen in different positions of the mother. Note that the debris within the hypoechoic ovoid structure changed its position with the movement of the mother (compare the image 3 and 4). Postnatally the structure turned out to be the subdiaphragmatic fetal abscess. The image 4 also shows dilated loop of bowels. The jejunal obstruction was an initial diagnosis suspected at 33 weeks, before the ovoid structure representing the subdiaphragmatic abscess appeared.

 

Images 5, 6: 37 weeks of pregnancy; the image 5 shows transverse scan of the fetal abdomen at the lever of the liver. The ovoid structure representing the subdiaphragmatic abscess can be seen on the right side of the liver. Within the liver a hyperechoic calcification can be seen (arrow). The image 6 shows hydrocele of the fetus.

 

Images 7, 8: Postnatal ultrasonography of the neonate. The image 7 shows intrahepatic calcification. The image 8 was done at the 25th day after the operation. The calcification within the liver has disappeared and no signs of subdiaphragmatic abscess were find.

 

 

 

 

 

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