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Difficulty: MediumPreoperative and Postoperative Care

A 58-year-old man is evaluated on postoperative day 7 for fever and abdominal pain. He underwent an emergent exploratory laparotomy and partial ileocecal resection for a perforated appendix. His recovery was initially uncomplicated; his urinary catheter was removed on postoperative day 2, and he has been tolerating a soft diet since day 4. Today, he reports nausea, anorexia, and a persistent dull ache in his right lower abdomen. His temperature is 39.2°C (102.6°F), blood pressure is 114/76 mm Hg, pulse is 112/min, and respiratory rate is 18/min. Physical examination reveals a midline surgical incision that is clean, dry, and well-approximated with intact surgical staples. There is no surrounding erythema, induration, or discharge. His abdomen is mildly distended with localized tenderness in the right lower quadrant, but no rebound or guarding is present. Laboratory studies show a leukocyte count of 18,000/mm318,000/\text{mm}^3. Which of the following is the most appropriate next step in management?

  1. Computed tomography scan of the abdomen and pelvisAnswer
  2. B
    Removal of surgical staples and bedside opening of the incision
  3. C
    Initiation of empiric broad-spectrum antibiotics and observation
  4. D
    Lower extremity venous duplex ultrasonography
  5. E
    Plain radiography of the abdomen

Answer

Computed tomography scan of the abdomen and pelvis
The correct answer is to perform a CT scan of the abdomen and pelvis. This patient presents with a high fever, leukocytosis, and localized right lower quadrant abdominal pain on postoperative day 7 following an emergent laparotomy for a perforated appendix. This clinical picture is classic for a deep space surgical site infection, specifically an intra-abdominal abscess. In operations involving heavy contamination (like perforated appendicitis or colonic spillage), bacteria can persist in dependent areas of the peritoneum or deep tissue spaces, eventually forming a walled-off abscess typically 5 to 7 days postoperatively. Because the midline incision is clean and lacks signs of superficial infection, opening the incision is not indicated. A CT scan of the abdomen and pelvis with intravenous contrast is the modality of choice; it not only confirms the diagnosis but can also evaluate the feasibility of image-guided percutaneous drainage, which is the definitive treatment alongside targeted antibiotics.

Step-by-Step Solution

1
Analyze the timing of the postoperative fever.
The fever occurs on postoperative day 7.
Timing helps narrow the differential diagnosis (the '5 Ws'). POD 5-7 fevers are commonly related to surgical site infections (Wound) or deep space infections like abscesses.
2
Correlate with physical examination and surgical history.
The patient had a contaminated surgery (perforated appendicitis) and now has localized right lower quadrant pain, but a clean midline incision.
This presentation points away from a superficial wound infection and strongly toward a deep intra-abdominal space infection.
3
Determine the optimal diagnostic modality.
Select computed tomography (CT) scan of the abdomen and pelvis.
CT is highly sensitive for identifying deep intra-abdominal fluid collections and can facilitate image-guided percutaneous drainage.

Key Concept

Patients who develop a fever and localized abdominal symptoms roughly a week after contaminated abdominal surgery should be evaluated for an intra-abdominal abscess using a CT scan of the abdomen and pelvis.
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Topics

Preoperative and Postoperative Care

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