Acute Diverticulitis with Pericolic Abscess (Hinchey II)
medium
scissors Surgery
A 62-year-old woman presents with 5 days of progressive left lower quadrant pain, fever (38.7°C), and a palpable tender mass. Laboratory studies show WBC 17,500 with left shift and CRP 218 mg/L. Contrast-enhanced CT of the abdomen and pelvis reveals sigmoid diverticulitis with segmental wall thickening, pericolic fat stranding, and a 5.2 cm rim-enhancing fluid collection (marked **B** in the diagram). There is no free intraperitoneal air. Which of the following is the most appropriate immediate management for the structure marked **B**?
A. Immediate colonoscopy to exclude malignancy before any other intervention
B. Emergent surgical intervention with Hartmann procedure
C. Conservative management with intravenous antibiotics alone without drainage
D. CT-guided percutaneous drainage of the abscess followed by broad-spectrum antibiotics and bowel rest
Explanation
Why CT-guided percutaneous drainage of the abscess followed by broad-spectrum antibiotics and bowel rest is right
The structure marked B is a rim-enhancing pericolic abscess measuring 5.2 cm, which defines Hinchey Stage II acute diverticulitis. According to Sabiston Textbook of Surgery, the presence of a pericolic or pelvic abscess greater than 4 cm is the key distinguishing feature of Hinchey II and mandates CT-guided percutaneous drainage as part of non-operative management. The patient has localized inflammation without diffuse peritonitis, making her an ideal candidate for percutaneous drainage combined with broad-spectrum antibiotics (covering gram-negatives and anaerobes) and bowel rest. This approach allows resolution of the acute infection while avoiding emergent surgery.
Why each distractor is wrong
Emergent surgical intervention with Hartmann procedure: Hartmann procedure is reserved for Hinchey III (purulent peritonitis) and Hinchey IV (feculent peritonitis), or for failure of non-operative management. This patient has no signs of diffuse peritonitis and is hemodynamically stable, making her suitable for percutaneous drainage rather than emergency surgery.
Conservative management with intravenous antibiotics alone without drainage: An abscess greater than 4 cm cannot be reliably treated with antibiotics alone. Percutaneous drainage is mandatory for abscesses of this size to prevent progression to diffuse peritonitis and to improve clinical outcomes.
Immediate colonoscopy to exclude malignancy before any other intervention: While colonoscopy is recommended 6–8 weeks after resolution to exclude malignancy (since imaging can mimic perforated colon cancer), it is contraindicated in the acute phase of diverticulitis and should never precede abscess drainage and antibiotic therapy.
High-YieldNEET PG
Hinchey II diverticulitis with abscess >4 cm = percutaneous drainage + antibiotics + bowel rest; Hinchey III/IV = emergent surgery.
Sabiston Textbook of Surgery, 21st Edition, Chapter 52: Colon, Rectum, and Anus — Diverticular Disease
Practice similar questions
Sign up free to access AI-powered MCQ practice with detailed explanations and adaptive learning.
