A 58-year-old man is evaluated in the emergency department for a 4-day history of progress… — USMLE Step 2 CK

A $58$ -year-old man is evaluated in the emergency department for a $4$ -day history of progressively worsening left lower quadrant abdominal pain, subjective fevers, and chills. His temperature is $38.6^\circ\text{C}$ ( $101.5^\circ\text{F}$ ), pulse is $96/\text{min}$ , and blood pressure is $128/80\text{ mm Hg}$ . Physical examination reveals marked tenderness in the left lower quadrant with a palpable, tender mass. There is voluntary guarding but no diffuse rigidity or rebound tenderness. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$ . A CT scan of the abdomen and pelvis with intravenous contrast demonstrates severe sigmoid diverticulitis with an adjacent $5.5\text{-cm}$ well-defined, rim-enhancing fluid collection containing gas bubbles.

Arrange the following management steps in the most appropriate chronological sequence for this patient:

1Initiation of intravenous broad-spectrum antibiotics and bowel rest
2Image-guided percutaneous drainage of the fluid collection
3Removal of the percutaneous drainage catheter after output is minimal
4Elective interval sigmoid colectomy after resolution of acute inflammation

Cevap

The correct chronological sequence is: Initiation of intravenous antibiotics -> Image-guided percutaneous drainage -> Removal of drainage catheter when output is minimal -> Elective interval sigmoid colectomy.

The correct sequence for managing Hinchey II diverticulitis (localized abscess) begins with immediate medical stabilization (IV antibiotics and bowel rest). Because the abscess is large (> 3-4 cm), it will likely fail antibiotic therapy alone, making image-guided percutaneous drainage the next necessary step for source control. The drain is left in place until the cavity collapses and output is minimal. Finally, once the acute inflammation has resolved over several weeks, the patient undergoes an elective interval sigmoid colectomy, which permits a primary anastomosis.

Adım Adım Çözüm

Analyze the clinical and radiographic findings to determine the severity of the patient's diverticulitis.

The patient has Hinchey II diverticulitis (localized pelvic or intra-abdominal abscess greater than 3 cm) without generalized peritonitis.

The patient is hemodynamically stable without diffuse abdominal rigidity, and the CT scan confirms a 5.5-cm abscess.

Determine the initial management step for a stable patient with complicated diverticulitis.

Initiate intravenous broad-spectrum antibiotics and bowel rest.

Medical stabilization is the universal first step to control the systemic infection and prevent further spread before any invasive procedures are performed.

Identify the appropriate intervention for a diverticular abscess of this size.

Perform image-guided percutaneous drainage of the fluid collection.

While abscesses smaller than 3 cm can often be treated with antibiotics alone, abscesses greater than 3-4 cm typically require source control via percutaneous drainage to prevent failure of non-operative management.

Determine the criteria for concluding the percutaneous drainage therapy.

Remove the percutaneous drainage catheter after daily output becomes minimal.

The drain provides a continuous egress for infected fluid, allowing the cavity walls to appose and heal. Premature removal leads to abscess re-accumulation.

Determine the long-term definitive management strategy to prevent recurrence.

Perform an elective interval sigmoid colectomy after resolution of acute inflammation.

Interval surgery (typically 6-8 weeks later) removes the diseased colon segment in a clean, controlled setting. Operating on an uninflamed colon significantly increases the likelihood of a successful primary anastomosis without needing a temporary stoma.

Anahtar Kavram

Sequential management of complicated (Hinchey II) diverticulitis requires immediate medical stabilization, source control via percutaneous drainage for abscesses > 3-4 cm, and delayed elective resection to allow for primary anastomosis.

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