Examkin

Question

Difficulty: MediumGastrointestinal and Abdominal Surgery

A 62-year-old male patient is evaluated in the emergency department for three days of progressively worsening left lower quadrant abdominal pain accompanied by chills. His vital signs show a temperature of 38.6°C (101.5°F), blood pressure of 128/78 mmHg, and heart rate of 92/min. On physical examination, there is focal tenderness and voluntary guarding in the left lower quadrant, but the abdomen is not rigid and there is no diffuse rebound tenderness. Laboratory evaluation reveals a leukocyte count of 16,500/mm³. A contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis confirms severe sigmoid diverticulitis complicated by a 5.5-cm, well-defined peri-colonic fluid collection.

Arrange the following management steps in the most appropriate chronological sequence for this patient, from immediate acute care to definitive long-term management.

  1. 1Initiate broad-spectrum intravenous antibiotics
  2. 2Perform CT-guided percutaneous drainage of the fluid collection
  3. 3Perform a colonoscopy to rule out underlying colorectal malignancy
  4. 4Proceed with an elective sigmoid colectomy

Answer

The correct chronological sequence is: 1) Initiate broad-spectrum intravenous antibiotics, 2) Perform CT-guided percutaneous drainage of the fluid collection, 3) Perform a colonoscopy to rule out underlying colorectal malignancy, and 4) Proceed with an elective sigmoid colectomy.
The standard sequence of care for a hemodynamically stable patient with a diverticular abscess greater than 3 centimeters begins with inpatient admission for intravenous antibiotics, followed closely by CT-guided percutaneous drainage to evacuate the infected fluid. Once the patient is discharged and recovers for 6 to 8 weeks, the risk of bowel perforation decreases, making it safe to perform an interval colonoscopy to ensure there is no underlying colonic neoplasm. After malignancy is definitively ruled out, the final step is an elective sigmoid colectomy to prevent future episodes of complicated diverticulitis.

Step-by-Step Solution

1
Identify the diagnosis and determine the acute treatment pathway.
The patient has Hinchey II complicated diverticulitis (a 5.5-cm abscess) and is hemodynamically stable, allowing for a non-operative initial approach.
Stable patients with localized abscesses should be managed medically and radiologically to avoid the morbidity of an emergent laparotomy and colostomy (Hartmann procedure).
2
Select the immediate acute interventions.
Intravenous antibiotics are started immediately, followed by CT-guided percutaneous drainage.
While antibiotics treat the infection systemically, abscesses larger than 3-4 cm require physical drainage for adequate source control and clinical improvement.
3
Determine the necessary interval diagnostic workup.
A colonoscopy is scheduled for 6 to 8 weeks after the acute episode resolves.
Colorectal cancer can present with localized perforation mimicking an abscess. Colonoscopy is contraindicated acutely due to perforation risk but is mandatory once the bowel heals.
4
Determine the definitive long-term surgical plan.
An elective sigmoid colectomy is planned.
Patients who survive an episode of complicated diverticulitis are at high risk for severe recurrent attacks; elective resection with primary anastomosis removes the diseased segment safely.

Key Concept

The management of complicated diverticulitis with a localized abscess (Hinchey II) involves acute source control with intravenous antibiotics and percutaneous drainage, followed by an interval colonoscopy to rule out malignancy, and finally consideration of an elective colon resection.
Rate this question

Topics

Gastrointestinal and Abdominal Surgery

More questions from this topic