A 42-year-old woman is evaluated on the surgical ward due to increasing restlessness and n… — USMLE Step 2 CK

A 42-year-old woman is evaluated on the surgical ward due to increasing restlessness and new-onset left shoulder pain. She underwent an uncomplicated laparoscopic Roux-en-Y gastric bypass for severe obesity two days ago. Her medical history is significant for obstructive sleep apnea and type 2 diabetes mellitus. She is currently receiving intravenous fluids, prophylactic subcutaneous enoxaparin, and patient-controlled analgesia with hydromorphone. Her temperature is $38.4^\circ\text{C}$ ( $101.1^\circ\text{F}$ ), pulse is $134/\text{min}$ , blood pressure is $122/78\text{ mmHg}$ , and respirations are $22/\text{min}$ . Pulse oximetry shows $95\%$ on room air. The patient appears extremely anxious. Physical examination reveals an obese abdomen with mild, diffuse tenderness but no rebound or guarding. The surgical incisions are clean, dry, and intact. Breath sounds are slightly decreased at the left lung base. The Jackson-Pratt drain in the left upper quadrant has accumulated $30\text{ mL}$ of serosanguinous fluid over the past 24 hours. Which of the following is the most appropriate next step in the management of this patient?

Computed tomography scan of the abdomen with oral contrastAnswer
B
Bedside chest radiography and increased incentive spirometry
C
Computed tomography pulmonary angiography
D
Empiric administration of intravenous piperacillin-tazobactam
E
Immediate return to the operating room for exploratory laparoscopy

Answer

The most appropriate next step in the management of this patient is a computed tomography scan of the abdomen with oral contrast.

Tachycardia greater than

120/\text{min}

is often the earliest and most sensitive indicator of an anastomotic leak following bariatric surgery. This patient presents on postoperative day 2 with significant tachycardia, fever, severe anxiety, and left shoulder pain. The shoulder pain is referred via the phrenic nerve (Kehr sign), indicating diaphragmatic irritation from leaked gastrointestinal contents. Because physical examination findings of peritonitis are notoriously masked in patients with severe obesity, an anastomotic leak must be aggressively ruled out. In a hemodynamically stable patient, the most appropriate next step is an abdominal computed tomography (CT) scan with oral contrast (or an upper gastrointestinal series with water-soluble contrast) to identify the presence and location of the leak.

Step-by-Step Solution

Analyze the patient's postoperative timeline and vital signs.

The patient is on postoperative day 2 following a Roux-en-Y gastric bypass and has marked tachycardia (

134/\text{min}

), fever (

38.4^\circ\text{C}

), and anxiety.

Tachycardia greater than

120/\text{min}

is typically the first and most sensitive clinical sign of an anastomotic leak in bariatric surgery patients, often preceding fever and abdominal pain.

Evaluate the localized symptoms and physical examination findings.

The patient has left shoulder pain and an obese abdomen with mild tenderness but no rebound or guarding.

Left shoulder pain represents Kehr sign, which is caused by subdiaphragmatic irritation from leaked enteric fluid. Severe obesity frequently masks the classic signs of rigid peritonitis.

Determine the appropriate diagnostic or therapeutic intervention based on hemodynamic status.

The patient is hemodynamically stable (BP

122/78\text{ mmHg}

); therefore, cross-sectional imaging is indicated.

In a stable patient with a suspected anastomotic leak, a CT scan of the abdomen with oral contrast (or an upper GI series) is the standard next step to confirm the diagnosis and guide surgical management. Immediate laparotomy is reserved for unstable patients.

Key Concept

Tachycardia is the most sensitive early indicator of an anastomotic leak following bariatric surgery. Hemodynamically stable patients require imaging with oral contrast to confirm the diagnosis, whereas unstable patients require immediate surgical exploration.

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