In a 43‑year‑old woman on postoperative day 9 after a vaginal hysterectomy, with a kidney (and likely pancreas) transplant on anticoagulation, presenting with acute right‑upper‑quadrant to mid‑abdominal pain and guarding, what does a white‑blood‑cell count of 10.8 × 10⁹/L with an absolute neutrophil count of 8.33 × 10⁹/L indicate and what is the appropriate next diagnostic and therapeutic step?

Acute Surgical Abdomen with Neutrophilia in a Post-Hysterectomy Transplant Patient

In this 43-year-old woman with a transplanted kidney (and likely pancreas) presenting on postoperative day 9 with acute right-upper-quadrant to mid-abdominal pain, guarding, and a WBC of 10.8 with neutrophils of 8.33 (77% neutrophils), the laboratory values indicate a significant neutrophil-predominant response that—despite a "normal" total WBC—strongly suggests acute bacterial infection requiring immediate diagnostic imaging and likely urgent surgical intervention. 1

Critical Context: Why "Normal" WBC is Misleading in Transplant Patients

Transplant recipients on immunosuppression frequently fail to mount typical leukocytosis even with serious bacterial infections. 1 The guideline evidence demonstrates that:

• Transplanted patients with acute appendicitis had median WBC counts of only 7.5 × 10⁹/L versus 12.5 in non-transplanted patients (p=0.002), yet 50% had perforated appendicitis. 1
• Only 25-43% of transplant patients with acute appendicitis showed leukocytosis, though all had elevated CRP. 1
• The absolute neutrophil count of 8.33 × 10⁹/L represents marked neutrophilia in this immunosuppressed context, even though it would be considered only mildly elevated in immunocompetent patients. 2

Interpretation of These Specific Laboratory Values

The Neutrophil Predominance is the Key Finding

• A neutrophil percentage of 77% (calculated from 8.33/10.8) approaches the threshold of 84% that carries moderate likelihood of bacterial infection, and the absolute neutrophil count exceeds normal ranges. 2
• The most diagnostically powerful marker—absolute band count—is not provided, but the elevated absolute neutrophil count in an immunosuppressed patient is highly concerning. 2
• In transplant patients, even modest neutrophilia warrants aggressive investigation for intra-abdominal sepsis, particularly spontaneous bacterial peritonitis in those with ascites or post-surgical complications. 2

Why This Pattern Demands Urgent Action

The combination of:

• Postoperative day 9 timing (peak risk for anastomotic leak, abscess formation)
• Right-upper-quadrant to mid-abdominal pain with guarding (peritoneal signs)
• Neutrophil-predominant response in an immunosuppressed patient
• Anticoagulation (increasing bleeding/hematoma risk)

...creates a surgical emergency requiring immediate cross-sectional imaging. 1

Immediate Diagnostic Algorithm

Step 1: Obtain CT Abdomen/Pelvis with IV Contrast (Stat)

The priority is to identify:

• Intra-abdominal abscess or fluid collection 1
• Bowel perforation or anastomotic dehiscence 1
• Acute cholecystitis (acalculous cholecystitis occurs in 41.9% of transplant patients) 1
• Appendicitis (though less common, 50% are perforated when diagnosed in transplant patients) 1
• Pancreatic complications if pancreas transplant present 1

Step 2: Obtain Blood Cultures and Inflammatory Markers Before Antibiotics

• Blood cultures × 2 sets from separate sites 2
• C-reactive protein (CRP)—this is more reliable than WBC in transplant patients 1
• Lactate level (marker of tissue hypoperfusion/sepsis) 2
• Procalcitonin if available (bacterial infection marker) 2

Step 3: Empiric Broad-Spectrum Antibiotics

Do not delay antibiotics while awaiting imaging if the patient shows any signs of sepsis (hypotension, tachycardia, altered mental status). 2 Coverage should include:

• Gram-negative organisms (including E. coli, Klebsiella)
• Anaerobes (for intra-abdominal source)
• Consider antifungal coverage given immunosuppression and post-surgical status 1

Specific High-Risk Conditions to Rule Out

Acute Cholecystitis in Transplant Patients

• Among 1,595 renal transplant patients undergoing cholecystectomy, 48.4% had severe cholecystitis (empyema, phlegmon, or gangrene) and 41.9% had acalculous cholecystitis. 1
• Conversion rate to open surgery was 32.3%, with overall morbidity of 19.4%. 1
• Right-upper-quadrant pain in a transplant patient mandates ultrasound or CT to evaluate the gallbladder. 1

Acute Appendicitis in Transplant Patients

• Transplanted patients with appendicitis should undergo appendectomy within 24 hours of diagnosis. 1
• 50% of kidney transplant patients had perforated appendicitis at surgery, and all patients operated after 72 hours had perforation. 1
• Laparoscopic approach is preferred when feasible. 1

Spontaneous Bacterial Peritonitis (if Ascites Present)

• Any neutrophilia in a patient with cirrhosis and ascites requires diagnostic paracentesis; SBP is diagnosed when ascitic fluid neutrophil count >250 cells/µL. 2
• While this patient's transplant history doesn't specify cirrhosis, post-surgical ascites can occur. 2

Common Pitfalls to Avoid

Pitfall 1: Waiting for "Significant" Leukocytosis

Do not dismiss this presentation because the total WBC is 10.8. 1 In transplant patients:

• Immunosuppression blunts the WBC response 1
• The neutrophil predominance (77%) is the critical finding 2
• CRP is more reliable than WBC count in this population 1

Pitfall 2: Delaying Surgery for "Medical Management"

Transplant patients with acute appendicitis or cholecystitis have worse outcomes with delayed surgery. 1 The guideline states:

• No data supports conservative treatment of acute appendicitis in transplant patients 1
• Operative management is safer given high rates of complicated disease 1
• All perforated appendicitis cases occurred in patients operated >72 hours after symptom onset 1

Pitfall 3: Overlooking Acalculous Cholecystitis

41.9% of cholecystitis in transplant patients is acalculous, which can be missed if only looking for gallstones. 1 CT or ultrasound showing gallbladder wall thickening, pericholecystic fluid, or distension requires surgical consultation. 1

Pitfall 4: Inadequate Antibiotic Coverage

Empiric antibiotics must cover nosocomial pathogens given the postoperative day 9 timing and transplant immunosuppression. 2 Narrow-spectrum agents are insufficient. 2

Anticoagulation Management

The patient's anticoagulation status requires urgent coordination with transplant surgery:

• If emergent surgery is needed, anticoagulation must be reversed 1
• If diagnostic paracentesis is performed, coagulation parameters should be checked first 2
• The risk of thrombosis must be balanced against surgical bleeding risk—this decision requires transplant team input 1

Expected Timeline

• CT imaging: Within 1-2 hours 1
• Surgical consultation: Immediately upon imaging results 1
• Antibiotics: Within 1 hour if sepsis suspected, otherwise after cultures obtained 2
• Surgery if indicated: Within 24 hours of diagnosis for appendicitis; emergently for perforation/peritonitis 1

Monitoring During Workup

While awaiting imaging and surgical evaluation:

• Serial vital signs every 1-2 hours (watch for sepsis progression) 2
• Strict intake/output (assess for acute kidney injury in transplanted kidney) 1
• Serial abdominal exams (worsening peritoneal signs mandate expedited surgery) 1
• Nothing by mouth (prepare for potential surgery) 1

The neutrophil count of 8.33 in this clinical context is not reassuring—it represents a significant inflammatory response in an immunosuppressed patient with acute abdominal findings that requires immediate imaging and likely surgical intervention. 1, 2