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Postoperative Intra-abdominal Sepsis — FRCA Final MCQ

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HardIntensive Care MedicinePostoperative Intra-abdominal SepsisFRCA Final

A 75-year-old woman (ASA III) is in the ICU on day 3 after emergency sigmoid colectomy with primary anastomosis for perforated diverticulitis. Despite resuscitation and intravenous piperacillin–tazobactam, she develops worsening abdominal distension, rising serum lactate and new cardiovascular and renal dysfunction. CT shows extravasation of enteric contrast from the anastomosis with diffuse intraperitoneal contamination, but no localised collection suitable for percutaneous drainage. In line with current NICE sepsis guidance, which intervention should be prioritised?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Undertake urgent relook laparotomy for operative source control

Explanation lettering: C = shown as A · D = shown as C · E = shown as D · A = shown as E

C is correct. The CT demonstrates an anastomotic leak with diffuse contamination, while progressive organ dysfunction indicates uncontrolled postoperative intra-abdominal sepsis. Because there is no collection suitable for percutaneous drainage, urgent operative source control should be prioritised. NICE advises early surgical involvement and performance of an appropriate source-control intervention as soon as possible. Piperacillin–tazobactam already covers typical intra-abdominal anaerobes, so adding metronidazole is generally redundant. Empirical escalation to meropenem should be guided by microbiology, resistance risk and local policy and cannot correct an ongoing leak. Antifungal treatment may be considered in selected high-risk patients but is not a substitute for source control. Diagnostic peritoneal lavage adds no useful information because CT has already established the diagnosis and it would not control the contamination.

Reference: National Institute for Health and Care Excellence. NG253, Suspected sepsis in people aged 16 or over: recognition, assessment and early management, section 1.11, Finding and controlling the source of infection. 2025. https://www.nice.org.uk/guidance/ng253/chapter/finding-and-controlling-the-source-of-infection