During morning rounds, the surgical team evaluates a 61-year-old female who reports increa… — USMLE Step 2 CK

During morning rounds, the surgical team evaluates a $61$ -year-old female who reports increasing lower pelvic discomfort and a sense of general malaise. She is currently on her fifth day of recovery following an elective sigmoid resection for complicated diverticular disease. Her recovery had been progressing appropriately; her bowel function returned on the third day, and she was successfully transitioned to a soft diet. However, this morning she felt nauseous and refused breakfast.

Her temperature is $39.2^\circ\text{C}$ ( $102.6^\circ\text{F}$ ), blood pressure is $118/74\text{ mmHg}$ , pulse is $114/\text{min}$ , and respiratory rate is $18/\text{min}$ . Physical examination reveals a well-approximated midline abdominal incision with no surrounding erythema, induration, or purulent drainage. However, there is moderate deep tenderness in the left lower quadrant with mild voluntary guarding. Pulmonary auscultation is clear bilaterally. Laboratory studies show a leukocyte count of $17,500/\text{mm}^3$ with $85\%$ neutrophils.

Which of the following is the most appropriate next step in the management of this patient?

Computed tomography scan of the abdomen and pelvis with contrastAnswer
B
Bedside removal of surgical staples to explore the superficial fascial layers
C
Immediate transfer to the operating suite for an exploratory laparotomy
D
Commencement of intravenous piperacillin-tazobactam with serial abdominal examinations
E
Compression ultrasonography of the deep veins of the legs

Answer

Computed tomography scan of the abdomen and pelvis with contrast

The correct approach is obtaining a CT scan of the abdomen and pelvis with contrast. This patient is presenting with classic signs of a deep organ-space surgical site infection (such as an intra-abdominal abscess or localized anastomotic leak). This typically manifests on postoperative days 4 through 7 (often remembered as the 'Wound' phase of postoperative fever) with fever, tachycardia, leukocytosis, and focal abdominal tenderness. Because she is hemodynamically stable and her abdominal exam shows localized tenderness rather than generalized peritonitis, diagnostic imaging is indicated. A CT scan will not only confirm the presence of a fluid collection but can also evaluate the integrity of the anastomosis and determine if the abscess is amenable to minimally invasive, image-guided percutaneous drainage.

Step-by-Step Solution

Analyze the timing of the patient's postoperative fever.

The fever is occurring on postoperative day 5, which corresponds with the typical timeline for deep space infections, anastomotic leaks, or deep surgical site infections.

Different etiologies of postoperative fever have predictable timelines (e.g., wind/atelectasis early on, water/UTI by day 3, wound/SSI by day 5-7).

Correlate the timeline with the physical examination and laboratory findings.

The patient exhibits focal deep left lower quadrant tenderness, leukocytosis, and tachycardia, but lacks superficial wound erythema or diffuse peritonitis.

This constellation of findings localizes the source to an intra-abdominal process (likely an abscess or localized leak near the sigmoid anastomosis) while ruling out a superficial wound infection.

Determine the optimal diagnostic modality for the suspected condition.

A CT scan of the abdomen and pelvis is selected.

In a hemodynamically stable patient with a suspected intra-abdominal abscess, a CT scan provides definitive diagnosis, anatomical localization, and a roadmap for percutaneous image-guided drainage, effectively avoiding an unnecessary open operation.

Key Concept

Patients who develop fever, leukocytosis, and deep focal abdominal tenderness approximately 4 to 7 days following abdominal surgery should be suspected of having an intra-abdominal abscess or anastomotic leak. The most appropriate initial step in hemodynamically stable patients is a CT scan of the abdomen and pelvis to diagnose and potentially guide percutaneous drainage.

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