A 64-year-old man presents to the emergency department with a 4-day history of worsening left lower quadrant abdominal pain, fever, and chills. His temperature is 38.6°C (101.5°F), blood pressure is 128/82 mmHg, and pulse is 98/min. Physical examination demonstrates a tender, palpable mass in the left lower quadrant. There is no diffuse rigidity or rebound tenderness. Laboratory tests show a leukocyte count of . Arrange the following management steps in the most appropriate chronological sequence for this patient's condition.
- 1Computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast
- 2Image-guided percutaneous drainage
- 3Diagnostic colonoscopy
- 4Elective sigmoid colectomy
Answer
The most appropriate chronological sequence is: 1) CT scan of the abdomen and pelvis, 2) Image-guided percutaneous drainage, 3) Diagnostic colonoscopy, and 4) Elective sigmoid colectomy.
The correct chronological management of a hemodynamically stable patient presenting with complicated diverticulitis (localized abscess) begins with a CT scan for diagnosis. This is followed by acute source control via percutaneous drainage. Once the acute inflammation subsides (6 to 8 weeks), a colonoscopy is performed to rule out malignancy. Finally, an elective definitive resection is planned to prevent recurrence.
Step-by-Step Solution
Key Concept
The management of stable, complicated acute diverticulitis (Hinchey II) follows a step-up approach: initial diagnosis via CT, acute source control via percutaneous drainage, delayed endoscopic evaluation, and subsequent elective surgical resection.