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Zorluk: OrtaPreoperative and Postoperative Care

A 56-year-old man undergoes an emergent partial colectomy with primary anastomosis for ischemic colitis. Over the first four days following the procedure, his recovery is unremarkable and he transitions to a clear liquid diet. On the morning of his fifth hospital day, he reports new-onset lower abdominal discomfort, tenesmus, and frequent, small-volume loose stools. His temperature is 38.9°C (102°F), blood pressure is 128/82 mmHg, heart rate is 108/min, and respiratory rate is 16/min. Physical examination demonstrates a clean, well-approximated midline surgical incision without fluctuance, drainage, or erythema. There is localized tenderness in the suprapubic region. Digital rectal examination reveals a boggy, highly tender fullness anteriorly. Laboratory studies show a leukocyte count of 18,500/mm³. Which of the following is the most appropriate next step in the management of this patient?

  1. Contrast-enhanced cross-sectional imaging of the abdomen and pelvisCevap
  2. B
    Bedside opening of the surgical incision and wound exploration
  3. C
    Empiric escalation of broad-spectrum antimicrobial therapy
  4. D
    Urgent return to the operating room for exploratory laparotomy
  5. E
    Collection of stool specimens for bacterial culture and toxin assay

Cevap

Contrast-enhanced cross-sectional imaging of the abdomen and pelvis
The correct action is to obtain structural imaging. This patient's presentation of fever, leukocytosis, diarrhea, and a boggy anterior mass on digital rectal examination on postoperative day 5 is highly suggestive of a pelvic abscess. This is a form of deep-space surgical site infection. The localized fluid collection can irritate the adjacent rectum, leading to tenesmus and frequent loose stools. Before any intervention is performed, contrast-enhanced cross-sectional imaging (CT scan) must be obtained to confirm the diagnosis, define the anatomy of the abscess, and determine if it is amenable to minimally invasive image-guided percutaneous drainage.

Adım Adım Çözüm

1
Analyze the timing of the fever and associated symptoms.
Fever on postoperative day 5 accompanied by localized lower abdominal pain and tenesmus.
Timing and specific localizing signs help narrow the differential diagnosis of postoperative fever.
2
Evaluate the physical examination findings.
The incision is clean, ruling out a superficial wound infection, but the rectal examination shows a boggy, tender anterior fullness.
A tender pelvic mass in the setting of fever and recent abdominal surgery strongly suggests a deep space infection (pelvic abscess).
3
Determine the most appropriate management step.
Order a CT scan of the abdomen and pelvis.
Structural confirmation and localization are required to guide definitive management, which is typically CT-guided percutaneous drainage.

Anahtar Kavram

Diagnosis and management of intra-abdominal/pelvic abscess as a cause of postoperative fever.
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Preoperative and Postoperative Care

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