What imaging modalities are recommended for an adult female patient with dehisced internal surgical incisions, possibly following a procedure related to an itchy ear condition?

Imaging for Dehisced Internal Surgical Incisions

Primary Recommendation

CT with intravenous contrast is the first-line imaging modality for suspected internal surgical incision dehiscence, with 91% sensitivity and 100% specificity for detecting anastomotic leaks and associated complications. 1

Clinical Context and Imaging Strategy

When to Image

• Image immediately when clinical suspicion exists based on fever, tachycardia, abdominal pain, peritoneal signs, or unexplained leukocytosis following any internal surgical procedure 1
• Do not wait for definitive clinical deterioration, as early detection significantly impacts morbidity and mortality 1

First-Line Imaging: CT with Contrast

CT scan with intravenous contrast is the definitive initial study for evaluating suspected internal surgical dehiscence 1:

• Provides comprehensive assessment of anastomotic integrity, fluid collections, abscesses, and free air 2, 1
• Identifies extraluminal complications including pelvic sepsis (9.5% incidence post-IPAA) 1
• Guides potential percutaneous drainage procedures 2

Important caveat: A negative CT does not definitively exclude postoperative gastrointestinal leaks, particularly in the early postoperative period 2. Combine CT findings with laboratory values and clinical assessment for optimal diagnostic accuracy 2.

Complementary Imaging Modalities

MRI should be used instead of CT in pregnant patients to avoid radiation exposure while maintaining diagnostic capability for soft tissue complications 1

Endoscopic evaluation should follow CT imaging in stable patients to directly visualize mucosal integrity and obtain tissue if needed 1

Contrast studies (loopography/pouchography) are indicated:

• Prior to ostomy reversal to assess anastomotic healing 1
• For characterizing fistulae, sinuses, and strictures when CT findings are equivocal 2
• Correlation of CT, MRI, and contrast studies increases diagnostic accuracy to 100% for pouch-related complications 2

Site-Specific Considerations

For pelvic/anastomotic complications (IPAA, colorectal surgery):

• CT or MRI with contrast detects abscesses, fistulae, and sinus tracts with high sensitivity 2
• Transanal or transperineal ultrasound can detect anastomotic dehiscence but requires CT/MRI to define full extent 2

For temporal bone/ear surgery complications (if relevant to "itchy ear" context):

• CT temporal bone without contrast is the primary modality for bony dehiscence evaluation 2
• MRI with diffusion-weighted imaging differentiates infection/cholesteatoma from postoperative changes 3

Diagnostic Algorithm

1. Clinical suspicion of dehiscence → Immediate CT abdomen/pelvis with IV contrast 1
2. Positive CT findings → Multidisciplinary discussion for drainage vs. reoperation 2
3. Negative CT with persistent suspicion → Endoscopy or contrast study 2, 1
4. Pregnant patients → MRI without contrast as first-line 1
5. Pre-reversal assessment → CT loopogram or contrast pouchography 1

Critical Pitfalls to Avoid

• Do not rely on plain radiographs for internal dehiscence—they lack sensitivity for early complications 2
• Do not delay imaging waiting for "classic" signs—early detection prevents progression to sepsis 1
• Do not assume negative CT excludes leak—clinical correlation is mandatory 2
• Do not order ultrasound as primary modality for intra-abdominal dehiscence—it cannot adequately assess deep pelvic or retroperitoneal complications 2