my mother in law recently died from a subphrenic abscess. She was
recovering from two operations, the first one a hip replacement
followed 7 days later by abdominal surgery due to a perforated
duodenal ulcer. The ulcer had an abscess which had burst causing some
septicaemia. She then spent three weeks in intensive care and on a
ventilator followed by another week in hospital before we were able to
bring her home. She was an otherwise healthy 68 year old with no
history of any illness apart from some mild hypertension that has been
present since two very difficult pregnancies in the 1960's.In the days
prior to her death she had never felt better and was doing housework
and cooking. On the day she died, she was feeling good, and only
seconds before her death she asked for a glass of water as she was
feeling sick. There were two nurses present at the time of her death.
She was having her dressings changed daily and they were there when
she said she felt sick. They immediately performed CPR and an
ambulance arrived within a few minutes - but it was all too late. She
was dead before the nurses even managed to lay her on the floor. We
are not interested in pursuing a case for negligence against anyone,
but we are unable to get a clear answer from anyone in the medical
profession. We know she did not suffer, but we were prepared for a
different cause of death - i.e. clot or major heart attack. However
this answer from the post mortem has only raised more questions. What
we are struggling to come to terms with is this - how could this
abscess recur following the surgical repair of her ulcer? What exactly
happens internally for this abscess to kill so quickly?

---

Request for Question Clarification by crabcakes-ga on 17 Jun 2004 13:35 PDT

Hi doasuwouldbedoneby,

 I'm sorry to hear of your unexpected loss. I hope that you can answer
at least some of the following questions for me:

Do you know if your mother-in-law had been on any anti-coagulants,
such as coumadin or IV heparin? You mention you would have expected
her passing possibly from a clot or heart attack - did she have any
clotting problems  whatsoever? Was she on any IV's in the hospital or
at home?

What antibiotics had she been taking for the abcess?

What other medications was she taking? Was she taking any
"Acid-blockers" such as Pepsid, Zantac, Prevacid, etc.? You say she
was up and walking prior to her death, do you know if she had normal
bowel function at the time? Any urinary incontinence?

Had she had any blood, plasma or platelet transfusions for either
surgery or following surgery?

Did you notice a yellowish tinge to her skin and the whites of her eyes at all?

Could you share any other post-mortem results with me?

Was she released from the hospital prior to her ulcer surgery?

Did she have "staples" for her incision, or stitches?

How many days prior to her death had she actually been seen by the physician?

Did the attending nurses take vital signs (Blood pressure, pulse,
respirations) at least once a day, and do you know if they were
normal?

Did she have any known medication allergies?

Thank you in advance for answering these questions - they will assist
me in preparing your answer.

Sincerely,
crabcakes

---

Clarification of Question by doasuwouldbedoneby-ga on 17 Jun 2004 17:22 PDT

Thank you for your request for clarification.
1.The only medication she was on prior to her hip operation was
atenelol - 50mg per day.
2. She had been given very strong antibiotics in intensive care and
then when she came out she tested positive for helicobacter pylori and
was given what looked like horse tablets for 7 days. I am sorry i do
not know the name of this drug, but it was designed specifically for
the helicobacter bug.
3. She had completely normal bowel function and was completely
continent at the time of her death. She had a catheter in following
surgery and that remained in situ until she came off the ventilator 3
weeks later.
4. She was given two blood transfusions during her stay in intensive
care. She was not given any platelets.
5. There was no discoloration to her skin or her eyes. Her liver
function was normal and her heart was very strong.
6.The only results we received from teh pm was the cause of death. We
have yet to receive a full copy of the report.
7. She was released from hospital 7 days after her hip replacement but
was taken back into hospital that night. They wanted to operate
immediately, but she was very dehydrated and they had to push IV
fluids into her before they were able to operate the following
morning.
8.She had stitches for her surgery - no staples.
9. Her own GP saw her on the Thursday morning and she died on Sunday night.
10. Nurses checked her temp, bp and pulse every day. They also
listened to her heart and checked her wound.All of her vital signs
were normal and she had no fever or pain in her chest. No
breathlessness either.
11. She had no lnown allergies. She had only been ill once before in
her life and that was when she was having her babies 40 years ago.

I am very grateful to you for taking such an interest in my question.
I am sure any answers you can give us will help us to understand how
she died.

At first we were very angry that she died, and were sure the nurses
and doctors should have been able to diagnose her problem, however
even if they had diagnosed it, we know that she would not have
consented to any more surgery - even if she had, she would not have
survived the anaesthetic as she had lost a lot of weight and was still
quite weak. If she had been told she needed to go back into hospital,
it would have knocked the fight out of her.

Thank you


8.

---

Clarification of Question by doasuwouldbedoneby-ga on 17 Jun 2004 17:24 PDT

oops i forgot to mention she had never had any problems with clotting
before and she was not on any anti coagulants that we are aware of. We
only thought it might have been a clot due to the sudden death - it
could only have taken 10 seconds for her to die.

Hello doasuwouldbedoneby,

I want to tell you and your spouse,again, that I am sorry for your
loss, and I understand your concern.

   Before you continue reading, please keep in mind that my answer
contains only *possible* causes of death, or circumstances that may
have contributed to the cause of death, and can in no way be construed
as a definitive cause.

First, let?s define a subphrenic abscess. This is a broad term for an
abscess below the diaphragm, and usually indicates a break or rupture
of the peritoneum. A perforation, either from bacterial infection or
scalpel, of the appendix, gall bladder, duodenum,  or bowel can lead
to an abscess. (An abscess is a collection of pus and decayed tissue,
results of invading bacteria.). Subphrenic abscesses can appear 2-21
days following surgery.

http://www.gpnotebook.co.uk/simplepage.cfm?ID=-13303782&linkID=32069&cook=yes

?Commonly these abscesses only show up two or more weeks after the infection.?
http://www.surgerydoor.co.uk/so/detail2.asp?level2=Abscess%20-%20Subphrenic

?Subphrenic abscesses are the commonest intra-abdominal abscess.?
http://www.gpnotebook.com/cache/-315293670.htm


?Although multiple causes of intra-abdominal abscesses exist, the
following are the most common: (1) perforation of a diseased viscus,
which includes peptic ulcer perforation, (2) perforated appendicitis
and diverticulitis, (3) gangrenous cholecystitis, (4) mesenteric
ischemia with bowel infarction, and (5) pancreatitis or pancreatic
necrosis progressing to pancreatic abscess.?

The causative organisms of an abdominal abscess are generally e.coli
and B.fragilis, although nosocomial bacteria can cause abdominal
abscess as well. (Nosocomial indicates something that was acquired
while in the hospital - a staph infection is the most well know form
of a nosocomial infection).  Patients who have been on antibiotic
therapy for other infections, such as your mother-in-law?s septicemia
and H. pylori infection, may develop a yeast abcsess, specifically
candida species.

?If a deeply seated abscess is present, many of these classic features
may be absent. The only initial clues may be persistent fever, mild
liver dysfunction, persistent GI dysfunction, or nonlocalizing
debilitating illness.
The diagnosis of an intra-abdominal abscess in the postoperative
period may be difficult because postoperative analgesics and
incisional pain frequently mask abdominal findings. In addition,
antibiotic administration may mask abdominal tenderness, fever, and
leukocytosis.? This statement presents us with an interesting
possibility; your mother-in-law probably was taking some form of pain
reliever and some form of antibiotic at the time of her passing. These
medications could have cloaked any presenting symptoms. It is possible
that the causative organism was an overgrowth of a resistant strain of
her septicemia, or a separate organism, that was not susceptible to
the antibiotics she was taking. Your mother-in-law was already in a
weakened state and may not have been able to effectively fight off a
new infection.

?In patients with subphrenic abscesses, irritation of contiguous
structures may produce shoulder pain, hiccup, or unexplained pulmonary
manifestations such as pleural effusion, basal atelectasis, or
pneumonia.
Many patients have a significant septic response, volume depletion,
and catabolic state. This syndrome may include high cardiac output,
tachycardia, low urine output, and low peripheral oxygen extraction.
Initially, respiratory alkalosis due to hyperventilation may occur. If
left untreated, this progresses to metabolic acidosis. Sequential
multiple organ failure is highly suggestive of intra-abdominal
sepsis.?  Your mother-in-law could have had a sudden septic response,
whose symptoms may have been masked by her medications, leading to
metabolic acidosis. Once septic shock sets in, and acidosis begins,
and is not medically interrupted, the organs begin to shut down. A
seemingly healthy body, can be rendered non-functional in a matter of
moments by a septic response. The body can not function without the
proper acid-base balance.
Septic response/shock can disrupt the normal blood flow to organ
systems, whereby the core organs may not receive an adequate oxygen
supply.
?Microcirculation is the key target organ for injury in sepsis
syndrome. A decrease in the number of functional capillaries causes an
inability to extract oxygen maximally, which is caused by intrinsic
and extrinsic compression of capillaries and plugging of the capillary
lumen by blood cells. Increased endothelial permeability leads to
widespread tissue edema of protein-rich fluid.
Redistribution of intravascular fluid volume resulting from reduced
arterial vascular tone, diminished venous return from venous dilation,
and release of myocardial depressant substances causes hypotension.?
http://www.emedicine.com/med/topic2702.htm

http://classes.kumc.edu/son/nurs420/unit6/signs_MODS.htm

?However, in patients who have undergone previous surgery, the
diagnosis is more difficult. The most consistent finding is fever
associated with tachycardia. Abdominal pain and tenderness are
difficult to evaluate because of the recent surgical incision and
post-operative ileus. An exception is pelvic abscess where tenderness
may be elicited on rectal or vaginal examination. Understandably, the
surgeon is reluctant to undertake a second operation without definite
evidence of the presence of an abscess.?
http://www.pchrd.dost.gov.ph/pcs_publications/number_03/pc970381.html


?The subphrenic space is arbitrarily defined as lying below the
diaphragm and above the transverse colon. About 55% of subphrenic
abscesses are right-sided, 25% are left-sided, and 20% are multiple.
Most subphrenic abscesses arise from direct contamination after
surgery, local disease, or injury. They develop from peritonitis
secondary to another cause, such as a perforated viscus; extension
from an abscess in an adjacent organ; or, most commonly, as a
postoperative complication of abdominal surgery, especially on the
biliary tract, duodenum, or stomach. The peritoneum may be
contaminated during or after surgery?
?Clinical manifestations usually begin subtly within 3 to 6 wk after
surgery but occasionally do not appear for several months. Fever,
nearly always present, may be the only evidence, although anorexia and
weight loss are common. Nonproductive cough, chest pain, dyspnea, and
shoulder pain may result from the effects of the infection on the
adjacent diaphragm, and rales, rhonchi, or a friction rub may be
audible. Dullness to percussion and decreased breath sounds are
present when basilar atelectasis, pneumonia, or pleural effusion
occurs.?
 
http://www.medilligence.com/knowbase/infecti12.htm

http://www.merck.com/mrkshared/mmanual/section13/chapter155/155b.jsp


Blood Clots
===========
Some medicines, as well as the effects of septicemia can trigger blood
clots. IV tubing can also occasionally form blood clots, some  can
even occlude an entire vein.
This News in Education site about blood clotting, gives a colorful
description: ?Living conditions in the bloodstream are great --
there's plenty to eat, central heating and air conditioning, waste
removal, water quality control facilities, and convenient means of
transportation.  It's worth the trouble to get in and exploit the
system.  Living creatures take advantage of an opportunity that
provides the things they require.  They adapt themselves, step by
step, to the environmental conditions found in or upon a host
organism.  Microorganisms have devised every means possible to gain
entry and evade the body's protection systems.  But the host fights
back by developing counter-measures just as sophisticated.  This
biological warfare has had an enormous impact on the course of
humanity.?
http://www.goerie.com/nie/itsaboutlife/clotting_and_disease.html


?The complications are those of any major abdominal operation:
infections of the chest, wound or urine and thrombosis (blood clots)
in the veins of the leg.?
http://www.surgerydoor.co.uk/medical_conditions/Indices/P/peptic_ulcer_surgery.htm

?If a portion of the forming blood clot breaks free inside the veins
of the leg, it may travel through the veins to the lung where it can
lodge itself in the tiny vessels of the lung. This cuts off the blood
supply to the portion of the lung that is blocked. The portion of the
lung that is blocked cannot survive and may collapse, which is called
a pulmonary embolism. If a pulmonary embolism is large enough and the
portion of the lung that collapses is large enough it may cause
death.?
http://www.jointreplacement.com/xq/ASP.default/pg.content/content_id.87/mn./newFont.2/joint_id./joint_nm./tp.search/qx/default.htm


DIC (Disseminated Intravascular Coagulation)
=============================================
DIC is a strange cycle of coagulation, often caused by sepsis, which
the body tries to combat by producing anti-coagulants in excessively
large amounts. Internal hemorrhage occurs, followed by shock, organ
shutdown, and death.

??an important primary cause of DIC in all patients. The clinical
condition is worsened by secondary fibrinolysis, which results in the
formation of FDP's (fibrinogen / fibrin degradation products or "D -
dimers) that interfere with normal fibrin formation and platelet
function.
Fibrin deposition in DIC may lead to further organ dysfunction. DIC is
a major cause of acute renal failure and it also contributes to
multiple system organ failure. The converse is also true with damaged
organs contributing to DIC.?

http://rnbob.tripod.com/dic.htm

http://www.hosppract.com/issues/2000/08/celevi.htm


Delayed Hemolytic Transfusion Reaction
======================================
Some patients have a delayed transfusion reaction. While rare,
alloantibodies to blood cell antigens can occur up to a month post
transfusion. This is a virtually unpreventable reaction, that happens
with little frequency, but it does happen. I have seen perhaps two
dozen reactions of this type in my 25 years in the health care field.
http://www.blood.co.uk/hospitals/library/shot/SHOT0001/shot01n.htm
?In some circumstances, the magnitude of a risk can be estimated from
characteristics of the donated units and the recipient population. For
example, we may know the frequency of certain rare antigens and
antibodies in the population and can estimate the likelihood that a
recipient will receive a unit that will cause an antigen-antibody
reaction, which in turn may or may not produce clinical symptoms?
http://www2.us.elsevierhealth.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=full&id=atmrv50009

?In truth, in most cases, we can't do anything to prevent a delayed
hemolytic reaction. Since the majority of DHTRs result from the
reappearance of an antibody that by definition, we could not detect,
you could say that we are all operating with the possibility that a
transfusion reaction could occur with any transfusion?
http://www.bbguy.org/Rxns/dhtrprev.htm

Here is a simple illustration of a ?coated? red blood cell. The body
develops antibodies in response to the foreign substance.
http://www.umm.edu/imagepages/9985.htm

As you can see, there are many possible contributing factors. Your
mother-in-law had recently had two surgeries, fairly close together,
both of which have their own risks. The fact that she had been treated
for H.pylori and had duodenal surgery greatly increases the
possibility of a subphrenic abscess. She had had two transfusions, was
probably taking medications that could have masked septic shock and
it?s symptoms,  and was in a state of recovery from two surgeries.
I am not surprised that the medical staff is giving vague answers. You
are not pursuing litigation, but many people do. I certainly don?t
want to sound cavalier, as I know you are in mourning, but sometimes
there *are* irreproachable  complications  following surgery. Delayed
transfusion reactions, even when all protocols have been followed, do
occur. On the other hand, errors areoccasionally made, and a small
nick of a scalpel has been implicated more than once in post-surgical
septicemia and death.
Anecdotally, I have seen cases very similar to your mother-in-law?s
case. Septic shock particularly can strike very quickly. I have seen
patients sitting up, feeling good, playing cards, and laughing, when
they were struck with septic shock, and quickly succumbed to the
bacterial infection.

Additional Reading:

You may be interested in reading two other answers of mine that cover H.pylori:

http://answers.google.com/answers/threadview?id=275889

http://answers.google.com/answers/threadview?id=356017


http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=81034069

A strange cause of subphrenic abscess is swallowing toothpicks! (You
can read the abstract without signing up for free membership)
http://www.highbeam.com/library/doc1.asp?docid=1P1:29236746

Bacterial Toxins
http://www.uni-wuerzburg.de/infektionsbiologie/hauck/overview.htm


Sudden Death
http://www.mywhatever.com/cifwriter/library/mortals/mort2467.html



I hope this has helped you understand what could have occurred to you
mother-in-law. Perhaps the Post Mortem will reveal pertinent
information!  If any part of my answer is unclear, or if I have
duplicated information you already had, please request an Answer
Clarification, before rating, and I will be glad to assist you
further.

Sincerely,
crabcakes

Search Terms
abdominal subphrenic abscess
DIC post septicemia
DIC abscess
Sequela subphrenic abcess
Post surgical complications

I would like to commend crabcakes for the answer they provided me
with. It was very speedy and very thorough. In the answer,
consideration was given to my circumstances and for that i am truly
grateful. It has been a very hard time for us and the fact that we now
can understand fully what may have happend is of great comfort. Many
facts have been provided that make the picture much clearer for us.
Thank you - from the bottom of my h eart.

You understand of course that what you are asking for here would be
mere speculation from non-medical professionals? First that the abcess
was the actual cause of death (directly or indirectly) and secondly
that any number of things related to that complication ultimately led
or contributed to her death?

tutuzdad-ga

Thank you for the stars and nice tip doasuwouldbedoneby! Both are
appreciated, and I am glad I was able to help you out!
Regards,
crabcakes