A 58-year-old woman is evaluated in the emergency department for a 3-day history of progre… — USMLE Step 2 CK

A 58-year-old woman is evaluated in the emergency department for a 3-day history of progressively worsening left lower quadrant abdominal pain, accompanied by fever and chills. She has a history of chronic constipation but has had no previous similar episodes of abdominal pain. Her temperature is $38.6^\circ\text{C}$ ( $101.5^\circ\text{F}$ ), blood pressure is $132/82\text{ mm Hg}$ , pulse is $98/\text{min}$ , and respirations are $16/\text{min}$ . Physical examination reveals focal tenderness in the left lower quadrant with voluntary guarding. There is no rebound tenderness or abdominal rigidity. Bowel sounds are hypoactive. Laboratory evaluation shows a leukocyte count of $16,500/\text{mm}^3$ with $85\%$ neutrophils. An abdominal CT scan with oral and intravenous contrast demonstrates mural thickening of the sigmoid colon with prominent diverticula, pericolic fat stranding, and a $4.5\text{-cm}$ adjacent rim-enhancing fluid collection.

Which of the following is the most appropriate next step in management?

A
Emergent exploratory laparotomy
B
Intravenous ciprofloxacin and metronidazole alone
CT-guided percutaneous drainageAnswer
D
Intravenous meropenem and vancomycin
E
Colonoscopy with decompression

Answer

CT-guided percutaneous drainage

This patient has complicated acute diverticulitis with a

4.5\text{-cm}

abscess. The standard of care for a diverticular abscess measuring

3\text{ cm}

or larger is CT-guided percutaneous drainage combined with intravenous antibiotics. This provides definitive source control while avoiding the significant morbidity associated with emergent surgery.

Step-by-Step Solution

Identify the primary diagnosis from the clinical and radiographic presentation.

The patient has acute complicated diverticulitis, characterized by a 4.5-cm pericolic abscess.

Fever, left lower quadrant pain, leukocytosis, and specific CT findings confirm the diagnosis and its complicated nature.

Evaluate the stability of the patient and indications for surgical versus minimally invasive intervention.

The patient is hemodynamically stable without generalized peritonitis, making emergent laparotomy unnecessary.

Minimally invasive approaches are preferred for stable patients with contained infections.

Determine the optimal management for a diverticular abscess based on its size.

Abscesses measuring

\geq 3\text{ cm}

require percutaneous drainage in addition to intravenous antibiotics, whereas those

< 3\text{ cm}

can often be managed with antibiotics alone.

Larger abscesses have a high failure rate with pharmacotherapy alone and require physical source control.

Key Concept

The management of complicated acute diverticulitis with a localized abscess depends on its size; abscesses measuring

\geq 3\text{ cm}

should be treated with CT-guided percutaneous drainage and intravenous antibiotics.

Question

Answer

Step-by-Step Solution

Key Concept

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