A 58-year-old man presents with acute left lower abdominal pain, fever (38.5°C), and elevated inflammatory markers. CECT abdomen/pelvis shows sigmoid wall thickening with diverticula, pericolic fat stranding, and a rim-enhancing fluid collection measuring 5.2 cm adjacent to the sigmoid colon, marked as **B** in the diagram. Which of the following is the most appropriate management for this patient?

Question

Accepted Answer

C. CT-guided percutaneous drainage of the abscess followed by IV antibiotics and interval colonoscopy at 6–8 weeks. ## Why CT-guided percutaneous drainage is correct The structure marked **B** is a rim-enhancing pericolic abscess measuring 5.2 cm (>4 cm) in the setting of acute diverticulitis. According to the Hinchey Classification (modified), this represents Stage Ib–II complicated diverticulitis. The Sabiston Textbook of Surgery and ASCRS guidelines mandate CT-guided percutaneous drainage for abscesses >4 cm, with a success rate of 75–90%. This approach allows source control, avoids immediate surgery, and permits interval colonoscopy at 6–8 weeks to exclude malignancy before elective sigmoidectomy. IV antibiotics covering gram-negatives and anaerobes are essential adjuncts. ## Why each distractor is wrong - **Immediate open sigmoidectomy with Hartmann's procedure**: This is reserved for Hinchey Stage III–IV (perforated diverticulitis with purulent or feculent peritonitis). The patient has a localized abscess without signs of generalized peritonitis, making percutaneous drainage the standard of care. - **Outpatient management with oral antibiotics alone**: Outpatient oral antibiotic therapy is appropriate only for uncomplicated diverticulitis (Hinchey 0–Ia) or small abscesses <4 cm. An abscess of 5.2 cm requires percutaneous drainage to prevent sepsis and treatment failure. - **Laparoscopic lavage and primary repair**: Laparoscopic lavage is controversial and not first-line even for Hinchey III peritonitis (SCANDIV, LADIES trials). It is not indicated for localized abscess management and carries higher morbidity than percutaneous drainage. **High-Yield:** Pericolic abscess >4 cm in diverticulitis = percutaneous drainage + IV antibiotics + interval colonoscopy; <4 cm may respond to antibiotics alone. [cite: Sabiston Textbook of Surgery 21e; ASCRS Diverticulitis Guidelines 2020; Hinchey Classification]

Answer

A. Immediate open sigmoidectomy with Hartmann's procedure

Answer

B. Laparoscopic lavage and primary repair of the perforation

Answer

D. Outpatient management with oral antibiotics (ciprofloxacin + metronidazole) and bowel rest alone

Explanation

Why CT-guided percutaneous drainage is correct

Why each distractor is wrong

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