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Difficulty: MediumGastrointestinal and Abdominal Surgery

A 62-year-old woman presents to the emergency department with a 4-day history of progressively worsening left lower quadrant abdominal pain, fever, and chills. Her temperature is 38.9°C (102.0°F), blood pressure is 105/65 mm Hg, and pulse is 112/min. Physical examination reveals focal tenderness, erythema, and localized guarding in the left lower quadrant, but no diffuse abdominal rigidity. Bowel sounds are hypoactive. Laboratory studies show a leukocyte count of 17,500/mm³. Arrange the following management steps in the most appropriate chronological order for this patient.

  1. 1Initiate intravenous crystalloid fluid resuscitation and empiric broad-spectrum antibiotics.
  2. 2Obtain a contrast-enhanced CT scan of the abdomen and pelvis.
  3. 3Perform percutaneous image-guided drainage of the identified pericolic abscess.
  4. 4Perform a colonoscopy 6 to 8 weeks after the resolution of acute symptoms.

Answer

The correct chronological sequence is: 1) Initiate intravenous fluids and antibiotics, 2) Obtain a contrast-enhanced CT scan, 3) Perform percutaneous image-guided drainage, 4) Perform a colonoscopy in 6 to 8 weeks.
The standard sequence for a patient presenting with sepsis secondary to complicated diverticulitis involves immediate resuscitation, followed by diagnostic imaging to stage the disease. Once a localized abscess is identified, percutaneous drainage is utilized for source control. Finally, after acute inflammation has completely resolved, an interval colonoscopy is required to rule out underlying malignancy.

Step-by-Step Solution

1
Stabilize the patient hemodynamically and treat suspected infection.
Intravenous crystalloid fluids and broad-spectrum antibiotics are administered immediately.
The patient exhibits signs of sepsis (fever, tachycardia). Early sepsis management is critical and must be initiated prior to transporting the patient for imaging.
2
Confirm the diagnosis and evaluate disease severity.
A contrast-enhanced CT scan of the abdomen and pelvis is obtained.
CT imaging is highly sensitive and specific for diagnosing acute diverticulitis and is essential for detecting complications such as a pericolic abscess (Hinchey II) that alter the management plan.
3
Achieve source control of the localized complication.
Percutaneous image-guided drainage is performed on the identified abscess.
The inclusion of this step in the options implies the CT scan revealed a drainable fluid collection. Percutaneous drainage is the standard of care for a stable patient with a large diverticular abscess, precluding the need for an emergent bowel resection.
4
Rule out underlying neoplastic pathology.
A colonoscopy is scheduled 6 to 8 weeks later.
Acute inflammation can mask neoplastic changes on a CT scan. A follow-up colonoscopy ensures a perforated colon cancer was not misdiagnosed as diverticulitis, and must be delayed to allow inflammation to subside, significantly reducing the risk of iatrogenic perforation.

Key Concept

Sequential management of complicated acute diverticulitis
Estimated Time:1m 30s
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Topics

Gastrointestinal and Abdominal Surgery

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