Complicated acute diverticulitis with pericolic abscess — MRCEM SBA MCQ

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EasyGastrointestinal and surgical emergenciesComplicated acute diverticulitis with pericolic abscessMRCEM SBA

A 66-year-old woman presents with two days of left iliac fossa pain and fever. She is haemodynamically stable and has localised tenderness without guarding or generalised peritonism. Contrast-enhanced CT shows sigmoid diverticulitis with a 4.5 cm pericolic abscess and no free intraperitoneal gas. The radiologist confirms a safe route for percutaneous drainage. Intravenous antibiotics have been started, and the surgical team has assessed her. Which is the most appropriate next management step?

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Correct answer: D — Arrange image-guided percutaneous drainage.

The CT establishes a diverticular abscess measuring more than 3 cm, and the radiologist has identified a feasible drainage route. She is stable, with localised rather than generalised peritonitis. Alongside intravenous antibiotics and surgical care, image-guided percutaneous drainage is therefore the best next step. NICE advises considering drainage or surgery for an abscess greater than 3 cm when drainage is anatomically feasible. ([nice.org.uk](https://www.nice.org.uk/guidance/ng147/chapter/Recommendations)) A is tempting because antibiotics are essential, but antibiotics alone leave an accessible 4.5 cm collection undrained; this approach is more suitable for a smaller abscess. B is premature: NICE advises switching to oral antibiotics where possible for abscesses *less than* 3 cm, not using that strategy instead of assessing drainage here. C would be reasonable if she failed to improve or deteriorated after treatment, but the existing CT already defines the collection and its access route. E may be needed if drainage is infeasible or treatment fails, and surgery is an option for larger abscesses. In this stable patient with a drainable collection, immediate resection is not the best first step. ([nice.org.uk](https://www.nice.org.uk/guidance/ng147/chapter/Recommendations))

Reference: NICE NG147: Diverticular disease: diagnosis and management — recommendations 1.3.16 and 1.3.20–1.3.25 (27 November 2019) — https://www.nice.org.uk/guidance/ng147/chapter/Recommendations