Examkin

Question

Difficulty: MediumSurgical and Procedural Interventions

An emergency physician evaluates a 62-year-old man who reports three days of progressively worsening left lower abdominal pain accompanied by fever and chills. His medical history is significant for hypertension and hyperlipidemia, both well-controlled with medications. His temperature is 38.7°C (101.7°F), blood pressure is 134/82 mm Hg, pulse is 105/min, and respiratory rate is 16/min. Physical examination demonstrates marked tenderness and guarding over the left lower quadrant, but the abdomen is otherwise soft without diffuse rigidity or generalized rebound tenderness. Laboratory studies show a leukocyte count of 16,500/mm³ with 82% neutrophils. A contrast-enhanced computed tomography scan of the abdomen and pelvis reveals inflammatory changes adjacent to the sigmoid colon, complicated by a well-defined, 5.2-cm unilocular pericolic fluid collection with an enhancing rim. There is no evidence of free intraperitoneal air. Which of the following is the most appropriate next step in the management of this patient?

  1. Image-guided percutaneous drainageAnswer
  2. B
    Exploratory laparotomy with sigmoid resection and end colostomy
  3. C
    Intravenous antibiotics and observation
  4. D
    Colonoscopy with evaluation of the sigmoid colon
  5. E
    Magnetic resonance imaging of the abdomen and pelvis

Answer

Image-guided percutaneous drainage
The correct intervention is image-guided percutaneous drainage because the patient has acute complicated diverticulitis with a large, localized abscess. In hemodynamically stable patients lacking signs of generalized peritonitis, percutaneous drainage (typically CT-guided) combined with intravenous antibiotics is the standard of care. This approach achieves immediate source control while avoiding the significant morbidity of an emergent bowel resection. Once the acute episode resolves, an elective single-stage colon resection can safely be performed.

Step-by-Step Solution

1
Analyze the clinical presentation and imaging results.
The patient has acute sigmoid diverticulitis complicated by a 5.2-cm pericolic abscess, but remains hemodynamically stable without generalized peritonitis.
Establishing the exact stage and severity of complicated diverticulitis is necessary to select the correct intervention.
2
Determine the indication for intervention based on abscess size.
Fluid collections greater than 3 to 4 cm require active source control, typically via drainage.
Antibiotics alone have a high failure rate for larger abscesses, risking progressive sepsis or rupture.
3
Select the optimal procedural approach for source control.
Percutaneous drainage is preferred over surgical resection in a stable patient with a well-defined, accessible abscess.
Percutaneous drainage allows the acute inflammation to subside, converting a high-risk emergent operation (often requiring a colostomy) into a lower-risk elective single-stage resection weeks later.

Key Concept

The standard of care for acute diverticulitis complicated by a localized abscess larger than 3 cm in a stable patient is image-guided percutaneous drainage combined with intravenous antibiotics.
Rate this question

Topics

Surgical and Procedural Interventions

More questions from this topic