What are the differential diagnoses for a 56-year-old woman with a 30-year history of smoking, previous hysterectomy and cholecystectomy, stable Relapsing-Remitting Multiple Sclerosis (RRMS) and stable Ulcerative Colitis (UC), 7 days post-abdominoplasty with liposuction?

Differential Diagnoses for Post-Abdominoplasty Patient with Complex Medical History

The most critical differentials to consider immediately are venous thromboembolism (VTE), surgical site infection/abscess, and postoperative ileus, given this patient's multiple risk factors including recent major surgery, prolonged smoking history, and stable ulcerative colitis. 1

High-Priority Surgical Complications (Days 1-14 Post-Op)

Thromboembolic Disease

• Deep vein thrombosis (DVT) and pulmonary embolism (PE) are paramount concerns given:
  • Recent abdominoplasty with liposuction (7 days ago)
  • 30-year smoking history
  • Ulcerative colitis (IBD patients have remarkable thromboembolic tendency with increased risk of both venous and arterial thrombotic complications) 2
  • Prolonged operative time typical of abdominoplasty
  • Age 56 years 1

Infectious Complications

• Surgical site infection (SSI) including:

  • Superficial wound infection
  • Deep space infection/abscess formation
  • Necrotizing soft tissue infection (rare but critical)
  • Smoking significantly increases SSI risk 1

• Intra-abdominal sepsis including:

  • Pelvic abscess (given history of hysterectomy with potential adhesions)
  • Intraperitoneal infection from unrecognized bowel injury during surgery 1

Gastrointestinal Complications

• Postoperative ileus - common after abdominal wall surgery with manipulation 3

• Small bowel obstruction - adhesions from prior hysterectomy and cholecystectomy increase risk 3

• Bowel perforation (delayed presentation) - particularly concerning given:

  • Prior abdominal surgeries creating adhesions
  • Potential unrecognized injury during abdominoplasty 1

Ulcerative Colitis-Related Differentials

Active Disease Flare

• UC exacerbation triggered by:
  • Surgical stress
  • Perioperative medications (NSAIDs, antibiotics, opioids)
  • Postoperative physiologic stress 4
  • Symptoms: increased stool frequency, rectal bleeding, urgency, abdominal cramping 1

Infectious Colitis Superimposed on UC

• Clostridioides difficile infection (CDI) - critical to exclude as:

  • Perioperative antibiotic exposure is likely
  • IBD patients have increased CDI risk with worse outcomes and higher colectomy rates 1
  • Recent surgery is a documented risk factor 1

• Cytomegalovirus (CMV) colitis - consider in UC patients with disease flare 1, 4

Cardiovascular/Cerebrovascular Events

Arterial Thrombosis

• Acute coronary syndrome - smoking history and surgical stress increase risk 2

• Ischemic stroke - IBD patients have increased stroke risk through multiple mechanisms including large artery disease, small vessel disease, and hypercoagulable state 2

• Mesenteric ischemia - rare but critical, particularly in smokers with IBD-associated hypercoagulability 2

Hematologic Complications

• Anemia from:

  • Surgical blood loss
  • Chronic UC-related blood loss
  • Acute GI bleeding 3

• Coagulopathy - assess for bleeding complications versus thrombotic tendency 3

Medication-Related Complications

• Opioid-induced complications:

  • Severe constipation
  • Urinary retention
  • Ileus 3

• NSAID-induced complications (if used postoperatively):

  • UC flare exacerbation
  • Gastric/duodenal ulceration 1

Neurologic Considerations

• MS exacerbation - surgical stress can trigger relapse, though patient described as "stable" 5

• Cerebral venous sinus thrombosis - IBD patients at increased risk, can present with headache, seizures, or focal deficits 2

Metabolic/Electrolyte Disturbances

• Electrolyte abnormalities including:
  • Hypokalemia and hypomagnesemia (risk factors for complications in IBD patients) 3
  • Dehydration from inadequate intake or increased losses 3, 6

Critical Pitfalls to Avoid

• Do not dismiss tachycardia or subtle vital sign changes - may indicate VTE, sepsis, or bleeding even with otherwise normal examination 6

• Do not attribute all abdominal symptoms to postoperative ileus - maintain high suspicion for UC flare, CDI, or surgical complications 1, 4

• Do not delay imaging if severe pain, distension, or fever present - CT can identify perforation, abscess, or bowel ischemia 3, 6

• Do not forget thromboprophylaxis assessment - pharmacologic VTE prophylaxis is critical in this high-risk patient 1

• Always test for C. difficile during any IBD flare, especially with recent antibiotic exposure 1, 4