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Difficulty: HardPreoperative and Postoperative Care

A 42-year-old woman is evaluated in the surgical telemetry unit on postoperative day 6 following a laparoscopic Roux-en-Y gastric bypass. Over the past 4 hours, she has reported rapidly worsening left shoulder pain and severe diffuse abdominal pain. She has no history of trauma to her shoulder. Her temperature is 39.1°C (102.4°F), blood pressure is 82/50 mm Hg, pulse is 134/min, and respirations are 26/min. Pulse oximetry is 94% on room air. She is diaphoretic, mottled, and appears in significant distress. Abdominal examination reveals a rigid, board-like abdomen with diffuse guarding and severe rebound tenderness. The laparoscopic port sites are clean, dry, and intact. A peripheral intravenous line is established, and rapid infusion of isotonic crystalloid is initiated, but her blood pressure remains 84/52 mm Hg. Which of the following is the most appropriate next step in management?

  1. Immediate surgical explorationAnswer
  2. B
    Computed tomography of the abdomen and pelvis with oral contrast
  3. C
    Computed tomography pulmonary angiography
  4. D
    Upper gastrointestinal series with water-soluble contrast
  5. E
    Intravenous broad-spectrum antibiotics and admission to the intensive care unit

Answer

Immediate surgical exploration
The correct answer is immediate surgical exploration. This patient is presenting with septic shock and a rigid abdomen (peritonitis) on postoperative day 6 following a gastric bypass. The combination of tachycardia, fever, severe abdominal pain, and left shoulder pain (Kehr sign) is highly suspicious for a gastrojejunal anastomotic leak with intraperitoneal contamination. Because the patient is hemodynamically unstable (hypotension unresponsive to initial fluid resuscitation) and has clinical signs of diffuse peritonitis, immediate surgical exploration is the most appropriate next step to achieve source control. Diagnostic imaging is contraindicated due to her instability.

Step-by-Step Solution

1
Identify the patient's hemodynamic status.
The patient is hypotensive (84/52 mm Hg) despite initial fluid resuscitation and tachycardic, indicating septic shock.
Hemodynamic instability dictates whether diagnostic imaging is safe or if immediate surgery is required.
2
Analyze the physical examination findings.
The patient has a rigid, board-like abdomen with severe rebound tenderness, indicating diffuse peritonitis.
Peritonitis in the setting of recent abdominal surgery strongly suggests a perforated viscus or anastomotic leak.
3
Interpret the left shoulder pain.
The left shoulder pain is Kehr sign, which represents referred pain from diaphragmatic irritation.
Fluid or gastric contents from a leak in the left upper quadrant (gastrojejunal anastomosis) irritates the left hemidiaphragm, referring pain via the phrenic nerve to the shoulder.
4
Determine the most appropriate next step in management.
Immediate surgical exploration is indicated.
In a hemodynamically unstable patient with an acute surgical abdomen, delaying definitive care for imaging is contraindicated; immediate operative source control is required.

Key Concept

Hemodynamically unstable patients with signs of an acute surgical abdomen (peritonitis) following recent abdominal surgery require immediate surgical exploration, bypassing diagnostic imaging.
Estimated Time:1m 15s
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Topics

Preoperative and Postoperative Care

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