Postoperative intra-abdominal abscess — FFICM MCQ

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ModerateSepsisPostoperative intra-abdominal abscessFFICM

A 58-year-old woman is on ICU 6 days after Hartmann's procedure. She has persistent fever, ileus and rising C-reactive protein despite antibiotics. Vasopressor requirement is low but not resolving. Abdominal examination is unreliable because she is sedated and ventilated. What is the most appropriate investigation?

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Correct answer: C — Contrast-enhanced CT abdomen and pelvis

The correct answer is C, contrast-enhanced CT abdomen and pelvis. In a sedated, ventilated post-laparotomy patient with unresolving fever, ileus, rising CRP and a persistent low-dose vasopressor requirement, clinical examination is unreliable and the leading differential is an intra-abdominal collection or anastomotic leak requiring source control. Contrast-enhanced CT is the only modality with the sensitivity and anatomical detail to identify collections, leaks, abscesses or bowel ischaemia and to guide percutaneous drainage or return to theatre. Surviving Sepsis Campaign guidance emphasises that failure to improve on antibiotics mandates rapid identification of a source amenable to control, and CT is the standard means of achieving this in the postoperative abdomen. Why the other options are wrong: B. Plain abdominal radiograph as definitive imaging: it lacks sensitivity for collections, leaks or ischaemic bowel and cannot characterise the retroperitoneum or pelvis, so it cannot be definitive in this context. D. Routine colonoscopy on ICU: insufflation risks disrupting a fresh anastomosis or staple line and perforating unstable bowel, and it does not assess extraluminal collections or leaks, which are the primary concern here. A. Serum amylase as the decisive test: it is neither sensitive nor specific for intra-abdominal sepsis after colorectal surgery and does not localise or characterise a source, so it cannot direct management. E. Wait until sedation is stopped: delaying investigation in a patient with ongoing sepsis and vasopressor need risks progression to uncontrolled septic shock; source control must be pursued urgently regardless of sedation status. Key point: Unresolving postoperative sepsis with an unreliable abdominal examination demands urgent contrast-enhanced CT to find and control the source, not delay or low-yield tests.

Reference: Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021 (Critical Care Medicine, 2021), Source Control recommendations, https://journals.lww.com/ccmjournal/fulltext/2021/11000/surviving_sepsis_campaign__international.21.aspx