What surgical intervention is indicated for a 23-year-old female with transverse colon diverticulitis and a small intramural abscess, without signs of peritonitis?

Management of Transverse Colon Diverticulitis with Small Intramural Abscess

For a 23-year-old female with transverse colon diverticulitis with a small intramural abscess without peritonitis, conservative management with broad-spectrum antibiotics is the recommended approach, with no immediate surgical intervention indicated unless clinical deterioration occurs.

Initial Management Approach

The management of diverticulitis with abscess formation depends on several factors:

1. Size of the abscess: Small intramural abscess (<4 cm) can be managed conservatively
2. Patient's clinical status: Absence of peritonitis and hemodynamic stability favor non-surgical approach
3. Location: Transverse colon diverticulitis is less common but follows similar management principles as left-sided diverticulitis

Conservative Management (First-line approach)

• Antibiotic therapy: Broad-spectrum antibiotics covering Gram-negative bacteria and anaerobes 1

  • Options include:
    • Amoxicillin/clavulanic acid or cephalexin with metronidazole (oral if patient can tolerate)
    • IV options: ceftriaxone plus metronidazole or piperacillin-tazobactam 2
  • Duration: 7-10 days, guided by clinical response

• Close monitoring:

  • Vital signs, abdominal examination
  • Laboratory values: WBC, CRP, PCT 1
  • Clinical reassessment every 12-24 hours for signs of deterioration

When to Consider Intervention

Indications for Percutaneous Drainage

• If the abscess is larger than 4 cm (not applicable in this case with small intramural abscess) 1
• If the patient fails to improve with antibiotic therapy alone within 48-72 hours
• If there is clinical deterioration despite appropriate antibiotic therapy

Indications for Surgical Intervention

Surgery is NOT indicated initially for this patient but would be considered if:

1. Development of diffuse peritonitis 1, 3
2. Hemodynamic instability or septic shock 3
3. Failure of conservative management with persistent or worsening symptoms 1
4. Progression of the abscess despite appropriate antibiotic therapy

Surgical Options (If Eventually Required)

If the patient's condition deteriorates and surgery becomes necessary, the following options would be considered:

1. Segmental colectomy with primary anastomosis: Preferred option in a young, otherwise healthy patient without diffuse peritonitis 1, 3

2. Hartmann's procedure (segmental resection with end colostomy): Reserved for critically ill patients or those with diffuse peritonitis 1

Follow-up and Long-term Management

• CT scan before discharge to confirm resolution of the abscess 1
• Colonoscopy 6-8 weeks after resolution of acute episode to rule out malignancy (especially important in this young patient with unusual location of diverticulitis) 1
• No routine elective sigmoid resection is recommended after a single episode of successfully treated diverticulitis 1

Important Considerations

• Young patients (under 50) with diverticulitis may have a more aggressive disease course and higher recurrence rates 4
• Transverse colon diverticulitis is uncommon and may represent a different disease entity than the more typical sigmoid diverticulitis
• The recurrence rate after conservative management of diverticular abscess can be high (up to 60.5%), with many recurrences being more severe than the index episode 4

Pitfalls to Avoid

• Delaying surgical intervention if the patient develops signs of peritonitis or sepsis
• Performing primary anastomosis in hemodynamically unstable patients
• Failing to obtain appropriate imaging (contrast-enhanced CT) for accurate diagnosis and abscess characterization
• Overlooking the need for colonoscopy after resolution to exclude other pathologies, especially given the patient's young age and unusual location of diverticulitis