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Difficulty: HardPreoperative and Postoperative Care

A 58-year-old man is examined in the hospital one week after undergoing a laparoscopic-assisted right hemicolectomy for a ruptured appendix with a localized abscess. He was initially recovering well but has developed worsening right shoulder pain and a mild, persistent cough over the last two days. His temperature is 39.0°C (102.2°F), blood pressure is 128/82 mmHg, pulse is 112/min, and respirations are 20/min. Pulse oximetry is 96% on room air. Cardiopulmonary examination reveals diminished breath sounds over the right posterior lung base. The abdomen is soft, with moderate focal tenderness in the right upper quadrant. The surgical incisions are healing well without erythema, fluctuance, or discharge. His leukocyte count is 18,500/mm^3. A portable chest radiograph demonstrates a small right-sided pleural effusion with an elevated right hemidiaphragm.

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

  1. Computed tomography scan of the abdomenAnswer
  2. B
    Computed tomography angiography of the chest
  3. C
    Thoracentesis and pleural fluid analysis
  4. D
    Encourage incentive spirometry and early ambulation
  5. E
    Administer intravenous furosemide

Answer

Computed tomography scan of the abdomen
The correct answer is a computed tomography (CT) scan of the abdomen. The patient's late postoperative fever, marked leukocytosis, right upper quadrant tenderness, and right shoulder pain (Kehr sign) following a right hemicolectomy for a ruptured appendix are classic for a right subphrenic abscess. Phrenic nerve (C3-C5) irritation from the diaphragmatic inflammation causes referred pain to the ipsilateral shoulder. This subdiaphragmatic inflammation also frequently causes a reactive (sympathetic) pleural effusion and an elevated hemidiaphragm, which explains his cough, diminished breath sounds, and radiographic findings. An abdominal CT scan is the most appropriate next step to diagnose the fluid collection and guide percutaneous drainage.

Step-by-Step Solution

1
Analyze the patient's postoperative timeline and systemic signs.
The patient is on postoperative day 7 with a high fever (39.0°C), tachycardia, and significant leukocytosis (18,500/mm^3).
To determine the most likely category of postoperative fever. A new fever occurring after postoperative day 5 is typically related to deep space abscesses, surgical site infections, or thromboembolic events.
2
Evaluate the localized signs and symptoms.
The patient has right upper quadrant tenderness, right shoulder pain, a right-sided pleural effusion, and an elevated right hemidiaphragm.
To identify the source of the infection. Right shoulder pain in the context of right upper quadrant inflammation indicates Kehr sign, which is caused by phrenic nerve irritation from a subdiaphragmatic source.
3
Synthesize findings to determine the next best step in management.
The clinical picture is highly specific for a right subphrenic abscess. An abdominal CT scan is required to confirm the diagnosis.
Imaging is necessary to visualize deep intra-abdominal space infections before definitive percutaneous drainage can be safely performed.

Key Concept

Diagnosis and management of postoperative intra-abdominal (subphrenic) abscess
Estimated Time:1m 30s
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Topics

Preoperative and Postoperative Care

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