A 35-year-old man suffers severe polytrauma including traumatic brain injury (GCS 6), pulmonary contusions, splenic laceration, and open femur fracture. He undergoes damage control surgery with splenectomy and external fixation. On ICU day 4, he develops worsening hypoxemia (PaO2/FiO2 ratio 150), bilateral infiltrates on chest X-ray, normal pulmonary capillary wedge pressure, petechiae, and altered mental status beyond his head injury. Fat globules are noted in urine. Platelet count drops from 245,000 to 89,000/μL. Evaluate the diagnosis and management priority.
Q2
A 42-year-old woman undergoes bilateral prophylactic mastectomy with immediate reconstruction using tissue expanders. On postoperative day 10, she develops fever, erythema, and swelling of the right breast with purulent drainage. Cultures grow methicillin-resistant Staphylococcus aureus (MRSA). Despite IV vancomycin and surgical drainage, infection persists with exposed tissue expander. She has strong psychological investment in reconstruction and fears permanent disfigurement. Her oncologist notes she is BRCA1-positive with 60% lifetime breast cancer risk. Evaluate the management approach balancing medical and psychosocial factors.
Q3
A 70-year-old man with COPD (FEV1 45% predicted) undergoes emergency laparotomy for mesenteric ischemia with bowel resection. Postoperatively, he remains intubated due to respiratory failure and develops acute kidney injury (creatinine 3.2 mg/dL from baseline 1.1), requires vasopressors for blood pressure support, and has an open abdomen with planned second-look operation. On day 3, he develops new-onset atrial fibrillation with rapid ventricular response. Evaluate the optimal management strategy considering his multiple competing issues.
Q4
A 58-year-old man undergoes right hemicolectomy for colon cancer. On postoperative day 6, he develops fever (38.7°C), leukocytosis (16,500/μL), and purulent drainage from the midline incision. Wound cultures grow Escherichia coli and Bacteroides fragilis. He has been receiving cefazolin prophylaxis. Despite opening the wound and initiating piperacillin-tazobactam, fever persists and a new pelvic fluid collection is seen on CT. Analyze the clinical scenario to determine the underlying problem.
Q5
A 48-year-old woman undergoes laparoscopic cholecystectomy. Postoperatively, she develops hypotension (85/50 mmHg), tachycardia (125/min), oliguria (15 mL/hr), and abdominal distension. Hemoglobin drops from 13.5 to 8.2 g/dL over 6 hours. Drain output shows 50 mL of serosanguinous fluid. She received appropriate fluid resuscitation. Analyze the findings to determine the most likely source of bleeding.
Q6
A 62-year-old man with cirrhosis (MELD score 18) undergoes urgent splenectomy for traumatic splenic rupture following a motor vehicle accident. On postoperative day 4, he develops worsening encephalopathy, jaundice (total bilirubin rising from 2.5 to 6.8 mg/dL), INR increases from 1.8 to 3.2, and ascites. He received appropriate perioperative antibiotics and thromboprophylaxis. Analyze the most likely underlying cause of his deterioration.
Q7
A 55-year-old woman undergoes thyroidectomy for papillary thyroid cancer. On postoperative day 1, she develops perioral tingling, carpopedal spasm, and a positive Chvostek sign. Laboratory studies show calcium 6.8 mg/dL (normal 8.5-10.5), phosphate 5.2 mg/dL (normal 2.5-4.5), and albumin 4.0 g/dL. ECG shows prolonged QT interval. What is the most appropriate immediate management?
Q8
A 72-year-old man with history of coronary artery disease undergoes emergency exploratory laparotomy for perforated duodenal ulcer. Intraoperatively, after closure of the perforation, he develops severe hypotension (70/40 mmHg), new ST-segment elevations in leads V1-V4, and decreased cardiac output. Troponin returns markedly elevated. The surgical field is dry and well-controlled. How should management proceed?
Q9
A 45-year-old woman develops sudden onset dyspnea and pleuritic chest pain on postoperative day 3 following total abdominal hysterectomy. Vital signs show temperature 37.2°C, blood pressure 110/70 mmHg, heart rate 115/min, respiratory rate 28/min, and oxygen saturation 89% on room air. ECG shows sinus tachycardia and right axis deviation. What is the most appropriate initial diagnostic test?
Q10
A 68-year-old man undergoes elective sigmoid colectomy for diverticular disease. On postoperative day 5, he develops fever (38.9°C), tachycardia (110/min), and abdominal distension. His white blood cell count is 18,000/μL with left shift. CT scan shows fluid collection near the anastomotic site with air bubbles. What is the most appropriate next step in management?
Surgical complications US Medical PG Practice Questions and MCQs
Question 1: A 35-year-old man suffers severe polytrauma including traumatic brain injury (GCS 6), pulmonary contusions, splenic laceration, and open femur fracture. He undergoes damage control surgery with splenectomy and external fixation. On ICU day 4, he develops worsening hypoxemia (PaO2/FiO2 ratio 150), bilateral infiltrates on chest X-ray, normal pulmonary capillary wedge pressure, petechiae, and altered mental status beyond his head injury. Fat globules are noted in urine. Platelet count drops from 245,000 to 89,000/μL. Evaluate the diagnosis and management priority.
A. Sepsis from missed abdominal injury; return to OR for re-exploration
B. Transfusion-related acute lung injury; diuresis and transfusion avoidance
C. Disseminated intravascular coagulation; aggressive factor replacement
D. Acute respiratory distress syndrome; increase PEEP and lung-protective ventilation
E. Fat embolism syndrome; supportive care and definitive fracture fixation when stable (Correct Answer)
Explanation: ***Fat embolism syndrome; supportive care and definitive fracture fixation when stable***
- This patient presents with the classic **Gurd’s triad**: respiratory distress (hypoxemia, infiltrates), neurologic symptoms (altered mental status), and a **petechial rash** 24–72 hours after a **long bone fracture**.
- Laboratory findings of **thrombocytopenia** and **fat globules in urine** further confirm the diagnosis, with management prioritizing **supportive care** and stabilization before definitive orthopedic intervention.
*Sepsis from missed abdominal injury; return to OR for re-exploration*
- While common in trauma, sepsis typically presents with **hemodynamic instability**, fever, or leukocytosis, rather than the specific petechial rash seen here.
- Re-exploration is unnecessary unless there is evidence of **peritonitis** or a clear source of infection that cannot be managed medically.
*Transfusion-related acute lung injury; diuresis and transfusion avoidance*
- **TRALI** presents with acute hypoxemia and bilateral infiltrates shortly after blood administration, but does not explain the **petechiae** or fat globules.
- Unlike circulatory overload, TRALI management focuses on **supportive ventilation** rather than aggressive **diuresis**, which might worsen the patient's condition.
*Disseminated intravascular coagulation; aggressive factor replacement*
- **DIC** can cause a drop in platelets and widespread bleeding, but it is usually a consumptive process resulting in prolonged **PT/PTT** and elevated **D-dimer**.
- While fat embolism can trigger secondary coagulopathy, the primary pathology here is the embolism itself, and factor replacement is only indicated for active, severe hemorrhage.
*Acute respiratory distress syndrome; increase PEEP and lung-protective ventilation*
- While the P/F ratio of 150 meets criteria for **ARDS**, this diagnosis alone fails to account for the **petechial rash** and systemic fat globules.
- Lung-protective ventilation is part of the treatment for fat embolism, but the question asks for the most comprehensive diagnosis and management strategy for all clinical features.
Question 2: A 42-year-old woman undergoes bilateral prophylactic mastectomy with immediate reconstruction using tissue expanders. On postoperative day 10, she develops fever, erythema, and swelling of the right breast with purulent drainage. Cultures grow methicillin-resistant Staphylococcus aureus (MRSA). Despite IV vancomycin and surgical drainage, infection persists with exposed tissue expander. She has strong psychological investment in reconstruction and fears permanent disfigurement. Her oncologist notes she is BRCA1-positive with 60% lifetime breast cancer risk. Evaluate the management approach balancing medical and psychosocial factors.
B. Remove expander, place antibiotic beads, attempt salvage with shorter delay
C. Switch to alternative antibiotic regimen and hyperbaric oxygen therapy
D. Continue antibiotics indefinitely with serial debridements to salvage the expander
E. Remove infected expander immediately and attempt immediate replacement with new device
Explanation: ***Remove expander, complete antibiotic course, delay reconstruction 6 months***
- The presence of **purulent drainage**, **MRSA**, and an **exposed expander** indicates a severe biofilm-associated infection that necessitates **removal of the foreign body** for definitive source control.
- A delayed reconstruction (typically **3 to 6 months**) allows the soft tissue to heal and the infection to fully resolve, providing the best long-term aesthetic and clinical outcome despite the patient's psychological concerns.
*Remove expander, place antibiotic beads, attempt salvage with shorter delay*
- **Antibiotic beads** are more commonly used in orthopedic osteomyelitis and are not standard practice for addressing **infected breast expanders** in soft tissue.
- Shortening the delay period significantly increases the risk of **recurrent infection** and subsequent failure of the revised reconstruction, especially with **MRSA** involvement.
*Switch to alternative antibiotic regimen and hyperbaric oxygen therapy*
- **Hyperbaric oxygen therapy** is not an indicated primary treatment for acute **periprosthetic MRSA infections** and cannot overcome the presence of a macroscopic nidus like an expander.
- Medical management alone is insufficient to clear **biofilm** on a synthetic device once purulence and exposure have occurred.
*Continue antibiotics indefinitely with serial debridements to salvage the expander*
- Indefinite antibiotic suppression is inappropriate for a **surgical site infection** where the device is **exposed**, as it risks secondary complications and antibiotic resistance.
- **Salvage attempts** in the setting of persistent drainage and MRSA are highly likely to fail and can lead to extensive **skin flap necrosis**, worsening the eventual cosmetic result.
*Remove infected expander immediately and attempt immediate replacement with new device*
- Immediate replacement of a device into a **purulent/infected pocket** is contraindicated as the new expander will likely become colonized by the remaining bacteria.
- This approach carries a very high rate of **failure and sepsis**, which would ultimately result in worse **psychosocial trauma** and scarring for the patient.
Question 3: A 70-year-old man with COPD (FEV1 45% predicted) undergoes emergency laparotomy for mesenteric ischemia with bowel resection. Postoperatively, he remains intubated due to respiratory failure and develops acute kidney injury (creatinine 3.2 mg/dL from baseline 1.1), requires vasopressors for blood pressure support, and has an open abdomen with planned second-look operation. On day 3, he develops new-onset atrial fibrillation with rapid ventricular response. Evaluate the optimal management strategy considering his multiple competing issues.
A. Amiodarone for rate control without anticoagulation (Correct Answer)
B. Rate control with diltiazem and hold anticoagulation given surgical risks
C. Digoxin for rate control and prophylactic dose anticoagulation
D. Immediate cardioversion to restore sinus rhythm
E. Rate control with metoprolol and systemic anticoagulation
Explanation: ***Amiodarone for rate control without anticoagulation***
- **Amiodarone** is the preferred agent because it provides effective rate control with minimal **negative inotropic effects**, which is crucial for a patient currently requiring **vasopressors** for shock.
- **Anticoagulation** must be withheld due to the high risk of hemorrhage associated with an **open abdomen**, recent bowel resection, and the planned upcoming surgical procedure.
*Rate control with diltiazem and hold anticoagulation given surgical risks*
- **Diltiazem**, a calcium channel blocker, is contraindicated here as it causes significant **vasodilation** and myocardial depression, which would worsen the patient's **hypotension**.
- While withholding anticoagulation is appropriate, the choice of rate control agent is unsuitable for a patient in **distributive/post-surgical shock**.
*Digoxin for rate control and prophylactic dose anticoagulation*
- **Digoxin** has a slow onset of action and is primarily excreted by the kidneys, making it difficult to manage in the setting of **acute kidney injury (AKI)**.
- Prophylactic anticoagulation may still pose a significant risk in the setting of an **open abdomen** and imminent **second-look surgery**.
*Immediate cardioversion to restore sinus rhythm*
- Electrical **cardioversion** is typically unsuccessful or short-lived when the underlying **critical illness**, metabolic derangements, and inflammatory state remain uncorrected.
- It is generally reserved for patients with pulse-associated **hemodynamic collapse** that does not respond to pharmacological measures.
*Rate control with metoprolol and systemic anticoagulation*
- **Beta-blockers** like metoprolol can exacerbate **respiratory failure** in COPD and further compromise blood pressure in **vasopressor-dependent** patients.
- **Systemic anticoagulation** is strictly contraindicated given the massive **bleeding risk** from recent major surgery and an open abdominal wound.
Question 4: A 58-year-old man undergoes right hemicolectomy for colon cancer. On postoperative day 6, he develops fever (38.7°C), leukocytosis (16,500/μL), and purulent drainage from the midline incision. Wound cultures grow Escherichia coli and Bacteroides fragilis. He has been receiving cefazolin prophylaxis. Despite opening the wound and initiating piperacillin-tazobactam, fever persists and a new pelvic fluid collection is seen on CT. Analyze the clinical scenario to determine the underlying problem.
A. Unrecognized anastomotic leak causing ongoing contamination (Correct Answer)
B. Retained foreign body (sponge) causing persistent infection
C. Clostridium difficile superinfection from antibiotic use
D. Resistant organism requiring broader antibiotic coverage
E. Undrained intra-abdominal abscess requiring intervention
Explanation: ***Unrecognized anastomotic leak causing ongoing contamination***
- The presence of **enteric organisms** (*E. coli* and *B. fragilis*) in a wound infection following bowel surgery, combined with a new **pelvic fluid collection**, is highly suggestive of a breakdown at the surgical site.
- Failure to respond to **source control** (wound opening) and **broad-spectrum antibiotics** (piperacillin-tazobactam) indicates a continuous supply of contaminated material from the GI tract.
*Retained foreign body (sponge) causing persistent infection*
- While it can cause persistent sepsis, it is statistically less common than an **anastomotic leak** in a patient with a new pelvic collection on postoperative day 6.
- A retained object typically presents as a discrete mass on imaging rather than a generalized **pelvic fluid collection** associated with fecal flora.
*Clostridium difficile superinfection from antibiotic use*
- This typically presents with **profuse watery diarrhea**, abdominal cramping, and leukocytosis, rather than a purulent wound infection and pelvic collection.
- It would not explain the growth of **Bacteroides fragilis** or the physical collection seen on the **CT scan**.
*Resistant organism requiring broader antibiotic coverage*
- **Piperacillin-tazobactam** provides excellent coverage for both the **gram-negative rods** and **anaerobes** identified in the culture.
- Persistent fever in the presence of an abscess usually indicates a failure of **source control** rather than an inadequacy of the chosen antibiotic spectrum.
*Undrained intra-abdominal abscess requiring intervention*
- While an abscess is present, it is often a **sequela** of a primary issue like an **anastomotic leak** which provides the constant contamination.
- Merely draining the collection without identifying the underlying leak may result in the development of a **fecal fistula** or recurrent sepsis.
Question 5: A 48-year-old woman undergoes laparoscopic cholecystectomy. Postoperatively, she develops hypotension (85/50 mmHg), tachycardia (125/min), oliguria (15 mL/hr), and abdominal distension. Hemoglobin drops from 13.5 to 8.2 g/dL over 6 hours. Drain output shows 50 mL of serosanguinous fluid. She received appropriate fluid resuscitation. Analyze the findings to determine the most likely source of bleeding.
A. Liver bed oozing from dissection
B. Mesenteric vessel injury during port placement (Correct Answer)
C. Inferior vena cava injury during dissection
D. Trocar site bleeding from abdominal wall vessel injury
E. Cystic artery bleeding from clip dislodgement
Explanation: ***Mesenteric vessel injury during port placement***
- Significant **hemorrhage** resulting in a large hemoglobin drop (13.5 to 8.2 g/dL) and **hemodynamic instability** (hypotension/tachycardia) without corresponding drain output suggests bleeding into a space not captured by the drain.
- Injury to **mesenteric or retroperitoneal vessels** during trocar insertion can lead to massive **intraperitoneal bleeding** and abdominal distension that remains concealed until the patient decompensates.
*Liver bed oozing from dissection*
- Oozing from the **liver bed** typically results in a slow, self-limiting blood loss rather than rapid **hemodynamic collapse**.
- This type of bleeding is usually localized and would likely be visible through the **surgical drain** if one is placed near the gallbladder fossa.
*Inferior vena cava injury during dissection*
- Injury to a major vessel like the **inferior vena cava (IVC)** would cause catastrophic, immediate bleeding that is typically recognized **intraoperatively**.
- It is highly unlikely for such a high-pressure or high-volume venous injury to manifest as a delayed **postoperative drop** in hemoglobin after an initially stable period.
*Trocar site bleeding from abdominal wall vessel injury*
- Bleeding from **abdominal wall vessels** (like the epigastric arteries) usually presents with a visible **hematoma** at the port site or external bleeding.
- While it can cause significant blood loss, it rarely causes the massive **abdominal distension** and profound shock seen in this patient compared to intra-abdominal sources.
*Cystic artery bleeding from clip dislodgement*
- Dislodgement of the **cystic artery clip** usually causes bleeding into the subhepatic space, which would typically be evacuated by the **serosanguinous drain**.
- While it causes hypotension, the **minimal drain output** (50 mL) in the presence of a 5-point hemoglobin drop strongly points toward a source distal to the immediate surgical field.
Question 6: A 62-year-old man with cirrhosis (MELD score 18) undergoes urgent splenectomy for traumatic splenic rupture following a motor vehicle accident. On postoperative day 4, he develops worsening encephalopathy, jaundice (total bilirubin rising from 2.5 to 6.8 mg/dL), INR increases from 1.8 to 3.2, and ascites. He received appropriate perioperative antibiotics and thromboprophylaxis. Analyze the most likely underlying cause of his deterioration.
A. Surgical stress-induced hepatic decompensation (Correct Answer)
B. Intra-abdominal abscess formation
C. Acute hepatic vein thrombosis (Budd-Chiari syndrome)
D. Sepsis from inadequate antibiotic coverage
E. Portal vein thrombosis from hypercoagulable state post-splenectomy
Explanation: ***Surgical stress-induced hepatic decompensation***
- Patients with **advanced cirrhosis** (MELD > 15) have very limited hepatic reserve, and the physiologic stress of **major trauma** and **surgery** can precipitate **acute-on-chronic liver failure**.
- This manifests as worsening **synthetic function** (elevated INR), impaired clearance of bilirubin and ammonia leading to **jaundice** and **encephalopathy**, and new-onset or worsening **ascites**.
*Intra-abdominal abscess formation*
- While a potential postoperative complication, an abscess typically presents later with **fever**, **leukocytosis**, and localized abdominal pain rather than rapid systemic liver failure.
- It would not primarily cause a significant, acute rise in **INR** and **total bilirubin** without underlying septic shock.
*Acute hepatic vein thrombosis (Budd-Chiari syndrome)*
- This condition usually presents with severe **right upper quadrant pain**, hepatomegaly, and massive ascites, but is highly uncommon in the immediate postoperative period after splenectomy.
- It is a rare vascular complication compared to the more frequent **portal vein thrombosis** or general physiologic decompensation in cirrhotic patients.
*Sepsis from inadequate antibiotic coverage*
- The clinical scenario notes the patient received **appropriate perioperative antibiotics**, making primary sepsis less likely than direct metabolic failure.
- While sepsis can trigger decompensation, the absence of reported fever, hemodynamic instability, or a specific source points toward **stress-induced failure**.
*Portal vein thrombosis from hypercoagulable state post-splenectomy*
- Splenectomy increases the risk of **portal vein thrombosis (PVT)** due to altered hemodynamics and postoperative thrombocytosis, which can cause portal hypertension and ascites.
- However, isolated PVT usually causes pre-hepatic portal hypertension; the global failure of **synthetic function** (rising INR and bilirubin) is more characteristic of diffuse **hepatic decompensation**.
Question 7: A 55-year-old woman undergoes thyroidectomy for papillary thyroid cancer. On postoperative day 1, she develops perioral tingling, carpopedal spasm, and a positive Chvostek sign. Laboratory studies show calcium 6.8 mg/dL (normal 8.5-10.5), phosphate 5.2 mg/dL (normal 2.5-4.5), and albumin 4.0 g/dL. ECG shows prolonged QT interval. What is the most appropriate immediate management?
A. Calcitriol (active vitamin D) administration
B. Magnesium sulfate replacement
C. Recombinant parathyroid hormone injection
D. Oral calcium carbonate supplementation
E. Intravenous calcium gluconate infusion (Correct Answer)
Explanation: ***Intravenous calcium gluconate infusion***
- The patient exhibits severe **symptomatic hypocalcemia** evidenced by **carpopedal spasm**, **positive Chvostek sign**, and **QT interval prolongation** on ECG.
- Immediate **IV calcium gluconate** is the therapy of choice to rapidly stabilize cell membranes and prevent life-threatening **cardiac arrhythmias** or seizures.
*Calcitriol (active vitamin D) administration*
- While useful for long-term management of **hypoparathyroidism**, its onset of action is too slow for acute **symptomatic** relief.
- It is typically used as an adjunct alongside oral calcium once the patient has been stabilized with **intravenous** therapy.
*Magnesium sulfate replacement*
- **Hypomagnesemia** can cause functional hypoparathyroidism, but this patient's clinical picture is a direct result of surgical trauma to the **parathyroid glands**.
- Magnesium would only be the priority if labs confirmed **low magnesium** as the primary driver of the hypocalcemic state.
*Recombinant parathyroid hormone injection*
- This is an expensive, specialized treatment typically reserved for **chronic hypoparathyroidism** that is refractory to conventional therapy.
- It is not indicated for the **acute emergency management** of postoperative tetany or ECG changes.
*Oral calcium carbonate supplementation*
- Oral supplementation is appropriate for **asymptomatic** or mild hypocalcemia, but it is insufficient for a patient with **carpopedal spasms**.
- **Gastrointestinal absorption** is too slow to provide the rapid increase in serum ionized calcium required to correct **neuromuscular irritability**.
Question 8: A 72-year-old man with history of coronary artery disease undergoes emergency exploratory laparotomy for perforated duodenal ulcer. Intraoperatively, after closure of the perforation, he develops severe hypotension (70/40 mmHg), new ST-segment elevations in leads V1-V4, and decreased cardiac output. Troponin returns markedly elevated. The surgical field is dry and well-controlled. How should management proceed?
A. Complete the operation and arrange urgent postoperative cardiac catheterization
B. Administer thrombolytics intraoperatively and complete the procedure
C. Place intra-aortic balloon pump intraoperatively and complete the procedure
D. Complete the operation rapidly and transfer to ICU for cardiology consultation (Correct Answer)
E. Abort the operation, leave temporary closure, and emergent cardiac catheterization
Explanation: ***Complete the operation rapidly and transfer to ICU for cardiology consultation***
- The patient is experiencing a **perioperative myocardial infarction**; the safest approach involves finishing the surgery quickly to ensure **fascial closure** and preventing further surgical stress.
- Management then shifts to the **ICU** for stabilization and **cardiology evaluation** to determine the need for intervention while balancing surgical bleeding risks.
*Complete the operation and arrange urgent postoperative cardiac catheterization*
- While **cardiac catheterization** may be required, it is not the immediate first step for a patient who just underwent major abdominal surgery due to **bleeding risks** from periprocedural anticoagulation.
- Initial stabilization and **risk assessment** by a cardiologist in the ICU must happen before moving to the cath lab.
*Administer thrombolytics intraoperatively and complete the procedure*
- **Thrombolytic therapy** is strictly contraindicated in the setting of recent major surgery, such as a **laparotomy**, due to the high risk of life-threatening hemorrhage.
- Percutaneous interventions or medical management are preferred over **fibrinolysis** in surgical patients.
*Place intra-aortic balloon pump intraoperatively and complete the procedure*
- An **intra-aortic balloon pump (IABP)** is typically not indicated as a primary response unless there is **cardiogenic shock** refractory to vasopressors or mechanical complications of MI.
- Insertion in the OR during an abdominal surgery is logistically difficult and usually secondary to standard **hemodynamic support**.
*Abort the operation, leave temporary closure, and emergent cardiac catheterization*
- Aborting the operation when the perforation is already closed is inappropriate, as **permanent closure** is more stable for a critically ill patient.
- **Emergency catheterization** is rarely performed immediately post-laparotomy for a **perforated viscous** due to the extreme risk of bleeding from necessary therapeutic anticoagulation.
Question 9: A 45-year-old woman develops sudden onset dyspnea and pleuritic chest pain on postoperative day 3 following total abdominal hysterectomy. Vital signs show temperature 37.2°C, blood pressure 110/70 mmHg, heart rate 115/min, respiratory rate 28/min, and oxygen saturation 89% on room air. ECG shows sinus tachycardia and right axis deviation. What is the most appropriate initial diagnostic test?
A. Chest X-ray
B. Arterial blood gas
C. CT pulmonary angiography (Correct Answer)
D. Ventilation-perfusion scan
E. D-dimer assay
Explanation: ***CT pulmonary angiography***
- **CT pulmonary angiography (CTPA)** is the current gold standard and first-line diagnostic imaging for **pulmonary embolism (PE)** in hemodynamically stable patients.
- This patient has a high clinical suspicion (Wells score) due to recent **major surgery**, **tachycardia**, and **hypoxemia**, making definitive imaging necessary [1].
*Chest X-ray*
- **Chest X-ray** is often normal in PE or may show non-specific findings like **Westermark sign** or **Hampton’s hump** [1].
- Its primary role is to rule out alternate causes of acute dyspnea such as **pneumothorax** or pneumonia rather than confirming PE.
*Arterial blood gas*
- **Arterial blood gas (ABG)** typically shows **hypoxemia**, **hypocapnia**, and **respiratory alkalosis** due to hyperventilation [2].
- While useful for assessing the severity of respiratory distress, it lacks the **specificity** required to diagnose a pulmonary embolism.
*Ventilation-perfusion scan*
- A **V/Q scan** is generally reserved for patients with **renal failure** or **contrast allergy** where CTPA is contraindicated.
- It provides a probability of PE rather than direct visualization and is less definitive than **multi-detector CT** imaging.
*D-dimer assay*
- **D-dimer** has a high negative predictive value but is non-specific and is frequently elevated in **postoperative states**, inflammation, or malignancy.
- In patients with a **high pretest probability**, a negative D-dimer is insufficient to rule out PE, making immediate imaging the preferred step.
Question 10: A 68-year-old man undergoes elective sigmoid colectomy for diverticular disease. On postoperative day 5, he develops fever (38.9°C), tachycardia (110/min), and abdominal distension. His white blood cell count is 18,000/μL with left shift. CT scan shows fluid collection near the anastomotic site with air bubbles. What is the most appropriate next step in management?
A. Broad-spectrum antibiotics and close observation
B. CT-guided percutaneous drainage of the collection
C. Immediate exploratory laparotomy with resection (Correct Answer)
D. Colonoscopy to evaluate the anastomosis
E. Total parenteral nutrition and bowel rest
Explanation: ***Immediate exploratory laparotomy with resection***
- The patient presents with clinical signs of **sepsis** (tachycardia, fever, leukocytosis) and a CT scan confirming an **anastomotic leak** with extraluminal air.
- In the presence of **systemic toxicity** and peritonitis, the standard of care is urgent surgical intervention to control the source of infection and perform a **Hartmann’s procedure**.
*Broad-spectrum antibiotics and close observation*
- While antibiotics are part of the supportive care, **conservative management** alone is insufficient for a gross anastomotic leak with systemic instability.
- Delaying surgery in a patient with signs of **sepsis** significantly increases the risk of multiple organ failure and mortality.
*CT-guided percutaneous drainage of the collection*
- This procedure is only indicated for small, **localized abscesses** in clinically stable patients without evidence of generalized peritonitis.
- It does not address the underlying **anastomotic dehiscence** or the ongoing contamination of the peritoneal cavity seen in this case.
*Colonoscopy to evaluate the anastomosis*
- Acute colonoscopy is **contraindicated** in the setting of a suspected leak and peritonitis due to the risk of worsening the perforation with insufflation.
- The diagnosis is already clearly suggested by the **CT scan findings** and the patient's deteriorating clinical status.
*Total parenteral nutrition and bowel rest*
- **Bowel rest** and TPN are supportive measures for managing small fistulas, but they are not primary treatments for acute **postoperative sepsis**.
- This approach ignores the urgent need for **source control** to manage the infected fluid and air leak.
