A 54-year-old woman comes to the emergency department due to 2 days of abdominal pain. She has also had anorexia, nausea, hiccups, and shortness of breath. The patient was diagnosed with acute appendicitis and underwent a laparoscopic appendectomy 10 days ago. She had been recovering well until the abdominal pain returned. The patient has a history of type 2 diabetes mellitus and prior cholecystectomy for choleliths. Temperature is 39.3 C (102.8 F), blood pressure is 120/70 mm Hg, pulse is 94/min, and respirations are 24/min. BMI is 30 kg/m². No scleral icterus or skin rash is present. Breath sounds are decreased at the right base. The abdomen is mildly distended, and palpation of the right upper quadrant elicits pain. The abdominal surgical incisions are mildly tender without surrounding erythema or discharge. Bowel sounds are decreased. Leukocyte count is 24,000/mm³, and chest x-ray reveals a right pleural effusion. Which of the following is the most likely cause of this patient's current condition?

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This patient underwent a laparoscopic appendectomy 10 days ago and now has right upper quadrant pain, fever, leukocytosis, and pulmonary manifestations (shortness of breath, hiccups, right-sided effusion), suggesting a subphrenic abscess. Infections are the most common complication of appendectomy, and risk of intra-abdominal abscess is significantly greater with laparoscopic appendectomy than laparotomy. Manifestations typically include recurrent fever and abdominal symptoms (eg, pain, vomiting) several days after an abdominal operation. Diagnosis usually requires CT scan of the abdomen. Most patients are treated with drainage and intravenous antibiotics. (Choice A) Choledocholithiasis can cause fever, right upper quadrant pain, and leukocytosis: however, most patients are jaundiced (not anicteric), and a pleural effusion/hiccups would be atypical. (Choice B) Hospital-acquired pneumonia (HAP) is associated with fever, leukocytosis, and pulmonary infiltrate; however, most cases occur <5 days postoperatively. In addition, abdominal pain, abdominal distension, and reduced bowel sounds are not typical features of HAP. < (Choice D) Mechanical bowel obstructions are more common in individuals who have abdominal adhesions from previous abdominal surgery; however, adhesions typically take months to form, and bowel obstruction is not typically associated with pleural effusion and hiccups. (Choice E) Postoperative atelectasis is common up to 5 days after abdominal procedures and often presents with hypoxemia and dyspnea. Fever, significant leukocytosis, abdominal pain, and reduced bowel sounds are not typically associated with this condition. (Choice F) Pulmonary embolism is a common postoperative complication and may cause shortness of breath, pleural effusion, and fever. Abdominal pain, abdominal distension, and decreased bowel sounds are not typical. Educational objective: Patients who receive a laparoscopic appendectomy are at much greater risk for intra-abdominal abscess than those receiving laparotomy. Intra-abdominal abscess should be suspected when fever and abdominal symptoms (eg, pain, vomiting) return several days after an abdominal operation.

A 54-Year-Old Woman Comes to the Emergency Department Due to 2