A 64-year-old woman is admitted to the hospital with a 3-day history of worsening left low… — USMLE Step 3

A 64-year-old woman is admitted to the hospital with a 3-day history of worsening left lower quadrant abdominal pain, subjective fevers, and nausea. She has a history of diet-controlled type 2 diabetes mellitus and essential hypertension. Her temperature is $38.8^\circ\text{C}$ ( $101.8^\circ\text{F}$ ), blood pressure is $118/76\text{ mm Hg}$ , pulse is $108/\text{min}$ , and respirations are $18/\text{min}$ . Physical examination reveals marked tenderness in the left lower quadrant with voluntary guarding. There is no rebound tenderness or abdominal rigidity. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$ . Intravenous fluids and broad-spectrum antibiotics are initiated. A computed tomography scan of the abdomen and pelvis with intravenous contrast reveals inflammation of the sigmoid colon with an adjacent $5.5\text{-cm}$ fluid collection containing gas bubbles and an enhancing rim. Which of the following is the most appropriate next step in management?

A
Colonoscopy with decompression
CT-guided percutaneous drainageAnswer
C
Discharge home with a 14-day course of oral ciprofloxacin and metronidazole
D
Exploratory laparotomy with sigmoid resection and end colostomy
E
Magnetic resonance imaging of the abdomen and pelvis

Answer

CT-guided percutaneous drainage

Acute diverticulitis complicated by a localized intra-abdominal abscess (Hinchey stage II) requires intervention if the fluid collection is large enough to be accessed safely. Generally, abscesses measuring

3\text{ cm}

or larger are treated with CT-guided percutaneous drainage in addition to intravenous antibiotics. This minimally invasive approach effectively provides source control, resolves sepsis, and avoids the significant morbidity associated with emergent surgical resection (which typically necessitates a colostomy). Following successful drainage and resolution of the acute episode, the patient can be evaluated for an elective, single-stage sigmoid resection.

Step-by-Step Solution

Evaluate the patient's clinical presentation and imaging findings.

The patient has acute complicated diverticulitis with a

5.5\text{-cm}

abscess (Hinchey stage II).

Understanding the specific stage and anatomical characteristics of complicated diverticulitis dictates the necessity and type of procedural intervention.

Determine the appropriate intervention based on abscess size and patient stability.

Abscesses

\ge 3\text{ cm}

are typically amenable to percutaneous drainage.

Minimally invasive drainage achieves source control while avoiding the high morbidity of emergent bowel resection and stoma creation.

Key Concept

Complicated acute diverticulitis with a localized abscess

\ge 3\text{ cm}

(Hinchey stage II) should be managed initially with intravenous antibiotics and CT-guided percutaneous drainage to establish source control without the need for emergent surgery.

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Key Concept

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