A 62-year-old woman is admitted to the hospital with a 3-day history of severe left lower … — USMLE Step 2 CK

A 62-year-old woman is admitted to the hospital with a 3-day history of severe left lower quadrant abdominal pain, fever, and nausea. Her temperature is $38.7^{\circ}\text{C}$ ( $101.7^{\circ}\text{F}$ ), blood pressure is $118/76\text{ mmHg}$ , and heart rate is $92/\text{min}$ . Physical examination reveals marked tenderness in the left lower quadrant without diffuse rebound tenderness or guarding. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$ . A computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast reveals acute sigmoid diverticulitis complicated by a $5.5\text{ cm}$ peridiverticular abscess. Arrange the following management steps in the most appropriate chronological sequence for this patient.

1Initiation of bowel rest and intravenous broad-spectrum antibiotics
2Percutaneous CT-guided drainage of the peridiverticular abscess
3Removal of the percutaneous drain after output significantly decreases
4Elective sigmoid colectomy with primary anastomosis after 6 to 8 weeks

Answer

The correct chronological sequence is: Initiation of antibiotics -> Percutaneous drainage -> Drain removal -> Elective colectomy.

The standard sequence for managing a stable patient with complicated diverticulitis involving an abscess >3 cm begins with resuscitation and IV antibiotics. This is rapidly followed by percutaneous image-guided drainage for source control. The drain remains until clinical resolution and minimal output indicate cavity closure. Finally, because complicated diverticulitis has a high recurrence rate, definitive management with an elective sigmoid resection and primary anastomosis is performed 6-8 weeks later, after acute inflammation has subsided.

Step-by-Step Solution

Identify the clinical condition and the patient's stability.

The patient has complicated acute diverticulitis with a 5.5 cm abscess, but she is hemodynamically stable and lacks signs of generalized peritonitis.

Patient stability dictates whether management can be minimally invasive (drainage) versus surgical (emergent laparotomy).

Determine the immediate medical management.

Initiate bowel rest and intravenous broad-spectrum antibiotics.

Systemic infection control and reducing bowel workload are the foundational first steps for acute complicated diverticulitis.

Select the appropriate intervention for the large abscess.

Perform percutaneous CT-guided drainage.

Abscesses larger than 3 cm generally do not resolve with antibiotics alone and require source control. Percutaneous drainage avoids the morbidity of emergency surgery.

Determine the criteria for step-down care.

Remove the percutaneous drain once output significantly decreases and acute inflammation resolves.

The drain must remain in place until the source of infection is entirely cleared and the cavity closes.

Plan definitive long-term surgical management.

Schedule an elective sigmoid colectomy with primary anastomosis after 6 to 8 weeks.

Patients with a history of complicated diverticulitis (e.g., abscess) are at high risk for future severe episodes. Operating electively on a non-inflamed colon allows for a single-stage procedure (primary anastomosis) instead of a Hartmann procedure.

Key Concept

The management sequence for acute diverticulitis complicated by a large abscess (>3 cm) in a stable patient is intravenous antibiotics, percutaneous drainage, clinical recovery, and delayed elective resection.

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