The occurrence of an elevated right diaphragm following abdominal surgery presents a difficult diagnostic and therapeutic problem. Although the incidence of subphrenic infections has decreased due to the extensive use of multiple antibiotics, there may be masking or a more insidious onset of such a serious closed abscess when it does occur.

There is an increase of pulmonary complications causing elevation of the right diaphragm due to the extensive use of intravenous barbiturates, curare derivatives and positive pressure oxygen administration during abdominal surgery.

Any patient presenting symptoms of dyspnea, high fever and lower right chest or upper right abdominal pain in the first forty-eight hours after operation, especially upper abdominal pain, should have x-rays to determine the position of the right diaphragm, aspiration of the respiratory tract either by catheter suction or bronchoscopy, periodic carbon dioxide and oxygen inhalations, coughing encouraged and sodium iodide intravenously to help alleviate and diagnose the situation.

If after another forty-eight hours the symptoms and elevated right diaphragm persist, a thoracentesis is done for aspiration of pleural fluid. Antibiotics are continued all during this period with the hope that the infection, whether above or below the diaphragm, will subside.

By the seventh to tenth postoperative day, if purulent pleural fluid is aspirated from the right chest, if the symptoms of fever and pain persist along with the elevated right diaphragm or if a fluid level is seen subphrenically on x-ray, exploratory needle aspiration of the subphrenic spaces is performed at the point where the pain is localized. When the right diaphragm is elevated, it is safe to aspirate directly beneath it anteriorly with a large caliber needle. If subphrenic purulent material is aspirated, it may be drained through a stab wound along the course of the needle.

By following the procedures outlined for the diagnosis and treatment of the complications causing an elevated right diaphragm following abdominal surgery, antibiotics may be given to the fullest extent without masking infections directly above or below the area described.