Differential Diagnosis

The patient presents with abdominal pain, fever, and elevated inflammatory markers 2 weeks after a laparotomy for a gastrinoma. The following differential diagnoses are considered:

• Single most likely diagnosis
  • Post-operative intra-abdominal infection or abscess: The patient's symptoms of abdominal pain, fever, and elevated CRP and WCC are consistent with an intra-abdominal infection. The recent laparotomy and manipulation of the duodenum increase the risk of infection.
• Other Likely diagnoses
  • Cholangitis: The elevated bilirubin, ALP, and ALT suggest biliary obstruction or inflammation, which could be due to a stone, stricture, or tumor. The recent surgery and manipulation of the duodenum may have caused a bile duct injury.
  • Pancreatitis: The elevated amylase and abdominal pain could indicate pancreatitis, which may be related to the recent surgery or a complication of the gastrinoma.
  • Wound infection: The patient's fever and elevated inflammatory markers could be due to a wound infection, which is a common complication of abdominal surgery.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Bile duct injury or leak: A bile duct injury or leak can lead to severe consequences, including peritonitis and sepsis. The patient's elevated bilirubin and ALP increase the suspicion for a bile duct injury.
  • Hemorrhage or bleeding: Post-operative hemorrhage is a life-threatening complication that requires prompt recognition and treatment. The patient's tachycardia and abdominal pain could be indicative of bleeding.
• Rare diagnoses
  • Gastrinoma recurrence or metastasis: Although rare, the patient's recent surgery for a gastrinoma increases the risk of recurrence or metastasis. The abdominal pain and elevated inflammatory markers could be indicative of tumor recurrence.
  • Adrenal insufficiency: The patient's recent surgery and potential manipulation of the adrenal glands increase the risk of adrenal insufficiency. The patient's symptoms of abdominal pain, fever, and hypotension (if present) could be indicative of adrenal insufficiency.

Management Plan

The management plan should include:

1. Imaging studies: CT scan or ultrasound to evaluate for intra-abdominal infection, abscess, or bile duct injury.
2. Blood cultures: To evaluate for bacteremia or sepsis.
3. Antibiotics: Broad-spectrum antibiotics should be started empirically to cover for potential intra-abdominal infection.
4. Supportive care: Fluid resuscitation, pain management, and monitoring of vital signs.
5. Surgical consultation: A surgical consultation should be obtained to evaluate the need for re-exploration or intervention.
6. Endoscopic evaluation: An endoscopic evaluation may be necessary to evaluate for bile duct injury or stricture.