COTW: Post-op Complications

As anyone with a bit of medical training will tell you, it's important to have a differential diagnosis when you examine a patient. You start with the primary complaint, which gives you a category of possible diagnoses, and then ask questions until you can narrow things down. Then you move on to the physical exam to confirm or rule out the list of differentials. So if someone comes in with "stomach pains" for example, you have a pretty good idea of the problem by the time you actually examine the patient. The same goes for a patient you have operated on already. As medical students, we all memorized the list of what causes post-op fevers with the "W" mnemonic: wind, water, walk, wound, wonder drugs (atelectasis, bladder infection, thrombophlebitis, wound infection, drug fevers...etc).

Well, needless to say, here in Kenya we have a greatly expanded differential. Post-op fevers are just as likely to be caused by malaria as a bladder infection, abdominal pain after surgery could be a bowel obstruction from worms or a volvulus (twisted bowels). Enter my case of the week.

N is a lady in her mid-30s who initially came to me in GYN clinic. Her primary complaint was infertility but this was unfortunately due to massive uterine fibroids--approximately the size of an 8 month pregnancy. The fibroids had gotten so large they were compressing her right ureter (tube that drains the kidney into the bladder). We decided the best course of action was just to perform a hysterectomy and I scheduled it for a few weeks. Last week she came in to the ER with severe upper abdominal pain, one week before her surgery. Because of the pain, we admitted her. It's an unlikely spot for fibroid pain, but her fibroids WERE pretty big, so it was decided that the best course of action was to just do her surgery early. By the morning of surgery her pain had resolved.

A visiting OB and I did the hyst, one of the largest uteruses I've seen here. It was a great case! For reference, a non-pregnant uterus should be about the size of a medium pear. We were careful to move the ureter out of the way and avoid injuring the bowel, normal procedures for a hyst. She did well, lost as little blood as we could have hoped for, and was moved to the recovery room.

The "offending organ"...finger is pointing to her RIGHT ovary which was displaced by a big fibroid in the right broad ligament, pushing everything normal into the left lower quadrant. Beneath the finger is the normal looking uterus.

Almost done with the surgery...most of the uterus and fibroid have been mobilized.

On the second day after the surgery, the other OB went in to see N and she was curled up on the bed in the fetal position with a painful and rigid abdomen. She had a fever of 100.5, and severe pain which started after she took some clear liquids for breakfast. An upright abdominal X-ray showed some free air, but she was only 2 days post-op. OK, medical folks, what's your differential? When the other OB told me about it, I had a moment of panic. Did we miss a bowel injury? Could this be related to her ureter? Was she bleeding internally?

Jason was on call that weekend and helped take her back for another surgery--her symptoms were severe enough to justify this. The uterus looked fine. They ran the bowel, no problems. But there was a lot of clearish-then greenish fluid. They eventually found the problem: a perforated duodenal ulcer! No relation to her surgery, but probably the cause of her presenting epigastric pain. Wow. She is now several days out from her second surgery and doing fine. Just reminds us here in the developing world (and everywhere)...keep a broad differential diagnosis!