A 58-year-old man is admitted to the hospital with a 4-day history of progressively worsen… — USMLE Step 3

A $58$ -year-old man is admitted to the hospital with a $4$ -day history of progressively worsening left lower quadrant abdominal pain, subjective fever, and reduced appetite. His past medical history is significant for hypertension and hyperlipidemia. His temperature is $38.6^\circ\text{C}$ ( $101.5^\circ\text{F}$ ), blood pressure is $118/74\text{ mmHg}$ , pulse is $106/\text{min}$ , and respirations are $18/\text{min}$ . Physical examination reveals a non-distended abdomen with marked tenderness and guarding in the left lower quadrant. There is no diffuse rebound tenderness or rigidity. Bowel sounds are hypoactive. Laboratory evaluation shows a leukocyte count of $16,500/\text{mm}^3$ with $82\%$ neutrophils. Intravenous fluid resuscitation and broad-spectrum antibiotics are initiated. Cross-sectional imaging of the abdomen and pelvis with intravenous contrast reveals severe wall thickening of the sigmoid colon with surrounding fat stranding, as well as an adjacent, well-circumscribed $6.5\text{-cm}$ fluid collection with rim enhancement. There is no evidence of free air in the peritoneal cavity.

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

Image-guided percutaneous drainageAnswer
B
Diagnostic colonoscopy
C
Immediate laparoscopic sigmoid resection with primary anastomosis
D
Discharge home with a $14$ -day course of oral antibiotics
E
Fluoroscopic water-soluble contrast enema

Answer

Image-guided percutaneous drainage is the most appropriate next step.

The patient's clinical presentation and imaging findings are diagnostic of acute diverticulitis complicated by a macroscopic abscess. For diverticular abscesses larger than

3

4\text{ cm}

in a hemodynamically stable patient without generalized peritonitis, the standard of care is intravenous antibiotics combined with image-guided percutaneous drainage (usually via CT or ultrasound). This minimally invasive procedural intervention achieves adequate source control, allows the acute localized inflammation to subside, and frequently bridges the patient to an elective, single-stage sigmoid resection at a later date, thereby avoiding an emergent operation with a temporary colostomy (Hartmann procedure).

Step-by-Step Solution

Diagnose the patient's acute condition based on clinical presentation and imaging.

The patient has acute diverticulitis complicated by a large (

6.5\text{ cm}

) abscess.

Identifying the specific complication (abscess) determines whether medical management alone is sufficient or procedural intervention is required.

Determine the indications for percutaneous drainage versus surgical intervention.

Abscesses larger than

3

4\text{ cm}

require percutaneous drainage, while surgery is reserved for diffuse peritonitis or failed drainage.

Percutaneous drainage provides necessary source control while avoiding the high morbidity of emergent bowel resection in an acutely inflamed field.

Key Concept

Management of complicated diverticulitis (large abscess)

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