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Difficulty: EasyPreoperative and Postoperative Care

A 59-year-old man is evaluated for a high fever one week after undergoing an elective partial colectomy with primary anastomosis for recurrent diverticulitis. He reports feeling generally unwell and has experienced nausea and worsening deep abdominal discomfort since yesterday. His temperature is 39.0°C (102.2°F), blood pressure is 122/76 mmHg, pulse is 108/min, and respirations are 18/min. Physical examination demonstrates a slightly distended abdomen with localized tenderness in the left lower quadrant, but no generalized peritonitis. The surgical skin closure is intact, dry, and shows no surrounding redness or discharge. A complete blood count reveals a leukocyte count of 17,200/mm³. Which of the following is the most appropriate next step in management?

  1. Obtain a computed tomography scan of the abdomen and pelvisAnswer
  2. B
    Remove the surgical staples and pack the incision
  3. C
    Administer empiric broad-spectrum antibiotics and observe clinically
  4. D
    Perform bilateral duplex ultrasonography of the lower extremities
  5. E
    Encourage aggressive incentive spirometry and chest physiotherapy

Answer

Obtain a computed tomography scan of the abdomen and pelvis
This patient presents with a high fever, tachycardia, marked leukocytosis, and localized abdominal pain one week following a partial colectomy. This clinical picture strongly suggests a deep intra-abdominal space infection or an anastomotic leak. The most appropriate next step is to obtain a computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast. A CT scan will reliably identify the presence, size, and exact location of an abscess, which can often subsequently be managed with percutaneous image-guided drainage rather than immediate reoperation.

Step-by-Step Solution

1
Evaluate the timing and characteristics of the patient's postoperative fever.
The fever is occurring on postoperative day 7 and is associated with localized left lower quadrant abdominal tenderness.
The timeline of postoperative fever helps narrow down the differential diagnosis according to the '5 Ws'.
2
Identify the most likely etiology based on the surgical history and current symptoms.
An intra-abdominal abscess or anastomotic leak is highly suspected.
Colorectal surgery carries a high risk for deep space infections, which typically present 5 to 7 days postoperatively with systemic signs of infection and focal abdominal findings.
3
Determine the most appropriate next step in management to confirm the diagnosis.
A CT scan of the abdomen and pelvis is selected.
Cross-sectional imaging is required to visualize a deep intra-abdominal fluid collection and determine if it is amenable to percutaneous image-guided drainage.

Key Concept

Diagnosis of postoperative intra-abdominal abscess
Estimated Time:1m 0s
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Topics

Preoperative and Postoperative Care

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