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Difficulty: MediumSurgical and Procedural Interventions

A 62-year-old man is hospitalized for the management of acute diverticulitis. He has been receiving intravenous ceftriaxone and metronidazole for 4848 hours, but his clinical condition has deteriorated. He continues to have a fever of 39.0∘C39.0^\circ\text{C} (102.2∘F102.2^\circ\text{F}) and complains of worsening severe left lower quadrant abdominal pain. Physical examination reveals focal rebound tenderness in the left lower quadrant without diffuse abdominal rigidity. His leukocyte count has increased from 14,000/mm314,000/\text{mm}^3 to 18,500/mm318,500/\text{mm}^3. A repeat computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast demonstrates a new 5.5-cm5.5\text{-cm} rim-enhancing fluid collection adjacent to the sigmoid colon.

Which of the following are appropriate procedural and management steps at this time? (Select all that apply)

  1. Image-guided percutaneous catheter drainage of the fluid collectionAnswer
  2. Continuation of broad-spectrum intravenous antibiotic therapyAnswer
  3. C
    Immediate exploratory laparotomy with a planned Hartmann procedure
  4. D
    Urgent diagnostic colonoscopy to rule out underlying colonic malignancy
  5. E
    Lower gastrointestinal series with barium contrast to assess for fistulous tracts

Answer

The correct interventions are image-guided percutaneous catheter drainage of the fluid collection and continuation of broad-spectrum intravenous antibiotic therapy.
The patient has developed a complicated diverticulitis characterized by a 5.5-cm5.5\text{-cm} macroscopic abscess. For hemodynamically stable patients with a localized diverticular abscess larger than 3 cm3\text{ cm}, the standard of care is image-guided (CT or ultrasound) percutaneous catheter drainage combined with ongoing intravenous antibiotic therapy. This approach effectively provides source control while avoiding the significant morbidity and mortality associated with an emergency laparotomy, which often results in a temporary colostomy.

Step-by-Step Solution

1
Evaluate the clinical deterioration in the setting of acute diverticulitis.
The patient has persistent fever, worsening pain, and leukocytosis despite 4848 hours of appropriate intravenous antibiotics.
Identifying treatment failure is crucial to prompt further investigation for complications such as abscess formation or perforation.
2
Analyze the repeat imaging findings.
The CT scan shows a new 5.5-cm5.5\text{-cm} rim-enhancing fluid collection, which indicates a macroscopic diverticular abscess.
The size of the abscess determines the appropriate procedural intervention. Abscesses larger than 3 cm3\text{ cm} generally require drainage.
3
Determine the optimal procedural and management sequence.
Image-guided percutaneous drainage is indicated for abscesses >3 cm>3\text{ cm} in hemodynamically stable patients, alongside continued antibiotics.
Percutaneous drainage provides effective source control with lower morbidity compared to surgery, while continued antibiotics treat the systemic infectious component.

Key Concept

In a hemodynamically stable patient, a diverticular abscess larger than 3 cm3\text{ cm} should be managed with image-guided percutaneous catheter drainage and continuation of intravenous antibiotics.
Estimated Time:1m 30s
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Topics

Surgical and Procedural Interventions

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