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Diverticular abscess — ESEGH MCQ

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HardLuminal GIDiverticular abscessESEGH

A 72-year-old man is admitted with CT-confirmed acute sigmoid diverticulitis and a 4.5 cm pericolic abscess. After 48 hours of appropriate intravenous antibiotics, he remains febrile with persistent left iliac fossa pain and rising inflammatory markers. He is haemodynamically stable with a normal lactate, and CT shows no free perforation or generalised peritonitis. Interventional radiology confirms that the abscess has a safe percutaneous access route. What is the most appropriate next management step?

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Correct answer: C — Continue intravenous antibiotics and perform image-guided percutaneous drainage

The correct answer is C. This is complicated acute diverticulitis with a 4.5 cm abscess that has not improved after intravenous antibiotics. NICE recommends intravenous antibiotics for diverticular abscesses and consideration of percutaneous drainage for collections greater than 3 cm when anatomically feasible. His stability, absence of generalised peritonitis and confirmed safe access route favour drainage rather than emergency resection. Antibiotics alone are less appropriate given persistent sepsis despite treatment. Switching to oral therapy and discharge would be unsafe. Emergency resection is generally reserved for deterioration, generalised peritonitis, failed source control or an abscess unsuitable for drainage. Colonoscopy should not be performed during acute diverticulitis because inflamed bowel carries an increased perforation risk.

Reference: National Institute for Health and Care Excellence. Diverticular disease: diagnosis and management (NG147), recommendations 1.3.15–1.3.25 and rationale on management of abscesses, 2019. https://www.nice.org.uk/guidance/NG147/chapter/rationale-and-impact