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Difficulty: MediumPreoperative and Postoperative Care

A 59-year-old man presents to the emergency department with a two-day history of fever, left-sided chest pain, and persistent hiccups. Ten days ago, he underwent an emergent laparotomy with splenectomy following a motor vehicle collision. His temperature is 39.1°C (102.4°F), blood pressure is 118/76 mmHg, pulse is 112/min, and respirations are 22/min. Pulse oximetry shows 94% on room air. Physical examination reveals decreased breath sounds at the left lung base. The abdomen is soft but tender to deep palpation in the left upper quadrant. The surgical incision is well-healed without erythema or discharge. Laboratory studies show a leukocyte count of 18,500/mm³. A chest radiograph demonstrates a left-sided pleural effusion with basilar atelectasis. Which of the following is the most appropriate next step in management?

  1. Computed tomography of the abdomenAnswer
  2. B
    Diagnostic thoracentesis
  3. C
    Administration of intravenous furosemide
  4. D
    Initiation of empiric antibiotics and observation
  5. E
    Computed tomography pulmonary angiography

Answer

Computed tomography of the abdomen
The correct next step is to obtain a computed tomography scan of the abdomen. This patient presents with classical features of a left subphrenic abscess on postoperative day 10 following a splenectomy. An intra-abdominal abscess typically presents 1 to 2 weeks after surgery with swinging fevers and leukocytosis. Inflammation adjacent to the diaphragm can cause irritation of the phrenic nerve (leading to persistent hiccups) and referred pain to the shoulder or pleura. Furthermore, the local inflammatory response often leads to a reactive, sterile pleural effusion and basilar atelectasis on the affected side. A CT scan of the abdomen is the most sensitive and specific test to diagnose a subphrenic abscess and can simultaneously guide percutaneous drainage.

Step-by-Step Solution

1
Analyze the timing of the patient's presentation.
The patient is postoperative day 10, which increases the probability of a deep space surgical site infection, such as an intra-abdominal abscess.
Postoperative fever timing ('5 Ws') helps narrow the differential diagnosis.
2
Evaluate the clinical signs and symptoms.
The combination of fever, left upper quadrant tenderness, hiccups, and left-sided pleural effusion points to inflammation near the left hemidiaphragm.
Hiccups result from diaphragmatic irritation, and reactive pleural effusions frequently occur adjacent to subphrenic fluid collections.
3
Determine the optimal diagnostic modality.
A CT scan of the abdomen is selected to visualize the intra-abdominal anatomy and identify any fluid collections.
CT imaging is the gold standard for diagnosing a subphrenic abscess and planning potential percutaneous drainage.

Key Concept

Patients who develop fever, left upper quadrant pain, hiccups, and a reactive left pleural effusion several days after splenic or gastric surgery should be evaluated for a subphrenic abscess using a computed tomography scan of the abdomen.
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Topics

Preoperative and Postoperative Care

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