Image of the Day 24: Right Subdiaphragmatic Fluid Collection

30 years old lady, Para 3 presented with right hypochondriac region pain which is dull in nature, scoring of 3-5/10. non radiating, temporarily relief by pain medication and exacerbate by movement or deep inspiration. she also complaint of; on and off feverish sensation and dysmenorrhea. She otherwise denies jaundice or obstructive jaundice symptom, no cough, SOB or chest pain, no altered bowel habit

On examination, vital signs are stable. BP 134/93, PR 20, RR102/minute, temperature 36.9 Celsius, SPO2 100%. She is conscious and alert, good hydrational and perfusion status, not jaundice, no evidence of chronic liver disease. cardiovascular and respiratory system are unremarkable. Abdomen is soft and not distended, with tenderness on deep palpation over the right hypochondriac region and liver is palpable about two finger breadth. no other mass is palpable, no ascites and no surgical scar.

Bed side ultrasound shows sub diaphragmatic hypo-echoic image which most likely representing free fluid. Liver and gallbladder is otherwise normal and no free fluid at Morrison’s pouch and hepato-spleeno recess

Discussion

There is minimal amount of free fluid inside the peritoneal cavity and usually less than 100 ml. The distribution of fluid is influenced by the hydrostatic pressure, reflection of the mesentery, gravity and peritoneal recesses.

Sub diaphragmatic hydrostatic pressure is sub atmospheric and influence by the act of inspiration and expiration. It decreases during the inspiration due to enlargement of upper abdomen space causing by lateral movement of the ribs.

Differential diagnosis of Subdiaphragmatic fluid collection includes 1) Perihepatic tuberculous abscess, 2) actinomycosis, 3) echinococcosis, 4) Fitz-Hugh-Curtis syndrome, 5) cholecystits 6) perforated gall bladder or hollow viscous perforation 7) peritoneal carcinomatosis

Fitz-Hugh-Curtis syndrome is possible in this patient as she also complain of dysmenorrhea. This syndrome which name after Thomas Fitz-Hugh, Jr and Arthur Hale Curtis is a liver capsule inflammation due to rare complication of pelvic inflammatory disease. Diagnosis can be made by isolation of gonorrhea or Chlamydia from high vaginal swab or through laparoscopic finding of violin string adhesions of parietal peritoneum to liver.

This patient require further evaluation by the surgical team and CT abdomen may help in making diagnosis.