Febrile obstructed right colon: stent, surgery, or divert?
A 68-year-old woman presents with 3 days of colicky right-sided abdominal pain, vomiting, and distension. She has hypertension, type 2 diabetes (HbA1c 8.9%), and a BMI of 34. Temperature 38.4 °C, BP 96/58 mmHg, HR 118/min, RR 24. Abdomen is distended and tender in the right lower quadrant with guarding. WCC 19.8 ×10^9/L, lactate 3.1 mmol/L, creatinine 168 µmol/L (baseline 90). CT shows a 5 cm mass at the hepatic flexure with proximal colonic dilatation to 9 cm, a closed ileocaecal valve, and no free gas. There is a single 1.5 cm hypodense liver lesion in segment 6. She is on a medical ward with a 1:6 nurse ratio; ICU has no bed tonight.
1. What is your immediate management priority, and how do you decide between emergency resection, decompression, and damage-control measures?
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Assessment
- This is an obstructing right colon cancer with a competent ileocaecal valve - a closed-loop obstruction with impending perforation (caecum 9 cm) and early sepsis (lactate 3.1, tachycardia, hypotension). She is not stable for a prolonged elective workup.
- The single liver lesion is indeterminate; do not let staging delay source control.
Immediate priorities
- Resuscitation: IV fluids, broad-spectrum antibiotics (e.g., piperacillin-tazobactam), urinary catheter, NG tube for decompression, correction of electrolytes and glucose.
- Senior surgical review and anaesthetic review. Mark the patient for theatre; consent including stoma.
Decision
- Emergency surgery is indicated because of peritonitis/sepsis and closed-loop obstruction with a 9 cm caecum - a stent is contraindicated in a perforation-risk/peritonitic patient and is generally avoided for right-sided lesions where resection is straightforward.
- Preferred operation: right hemicolectomy with primary ileocolic anastomosis if the patient is stable and the bowel is viable; this is a single-stage oncological resection.
- If she is physiologically unstable or the bowel is grossly contaminated/ischaemic, consider damage control: resection without anastomosis (end ileostomy + mucous fistula) and planned relook.
- Avoid a defunctioning stoma alone without resection - it leaves the cancer and the closed loop.
Staging
- The liver lesion should be characterised post-operatively (MRI liver with hepatobiliary contrast, MDT). It does not change the emergency indication.
Perioperative
- Correct glucose, give VTE prophylaxis once bleeding risk allows, and plan HDU/ICU post-op. If no ICU bed, discuss with anaesthesia for a high-dependency area with continuous monitoring.
2. Post-operatively she develops atrial fibrillation at 130/min and a falling urine output. How do you approach this, and what does it tell you about her volume and operative risk?
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Interpretation
- New post-operative AF in a patient with sepsis, diabetes, and a major abdominal operation is usually driven by hypovolaemia, sepsis, electrolyte disturbance, or pain rather than primary cardiac disease. Treat the cause first.
- Falling urine output (<0.5 mL/kg/h) with AF suggests inadequate preload and/or ongoing sepsis.
Approach
- Assess volume status: check JVP, capillary refill, lactate trend, and consider bedside echo or passive leg raise. Give a 250–500 mL crystalloid bolus and reassess - do not blindly flood a patient who may have capillary leak.
- Correct electrolytes: magnesium and potassium to high-normal; check calcium.
- Rate control: IV amiodarone is preferred in the septic/post-operative patient with hypotension; avoid beta-blockers if BP is low. Target rate <110/min.
- Anticoagulation: calculate CHA2DS2-VASc. If AF is new and likely transient, most guidelines support short-term LMWH after bleeding risk is acceptable; discuss with cardiology. Do not start a DOAC immediately after major surgery.
- Search for sepsis source: wound, anastomotic leak (CT with contrast if stable), urine, chest, line. Re-look at lactate and WCC.
- Escalate: if she remains oliguric despite fluid and is on pressors, this is critical care - advocate for ICU transfer or a high-dependency bed with invasive monitoring.
What it teaches
- Post-operative AF is a marker of physiological stress and predicts worse outcomes; it should prompt a search for leak/sepsis rather than being treated as an isolated rhythm problem.
- Her diabetes and obesity increase the risk of anastomotic leak and SSI; maintain glucose 6–10 mmol/L and review the anastomosis if she deteriorates.