What is the next step in managing a patient with multiple paracolic abscesses on computed tomography (CT) scan without free air?

Management of Multiple Paracolic Abscesses Without Free Air

Patients with multiple paracolic abscesses on CT without free air should be referred to general surgery or acute care surgery for combined management with interventional radiology, with treatment consisting of percutaneous drainage for large abscesses (>4 cm) plus broad-spectrum intravenous antibiotics covering gram-negative bacteria and anaerobes. 1

Immediate Management Steps

Antibiotic Therapy

• Initiate broad-spectrum IV antibiotics immediately covering gram-negative bacteria (particularly E. coli) and anaerobes (particularly Bacteroides fragilis) 1
• The colonic source of these abscesses mandates coverage for typical bowel flora 1
• Continue antibiotics until resolution of physiological abnormalities (fever, leukocytosis, tachycardia) 1

Percutaneous Drainage Indications

• Large abscesses (>4 cm diameter) should undergo percutaneous drainage in addition to antibiotics 1
• Smaller abscesses may be treated with antibiotics alone, though careful clinical monitoring is mandatory 1
• The 2017 WSES guidelines specifically state that patients with large-diameter abscesses should be treated by percutaneous drainage and IV antibiotics (Recommendation 1C) 1

When Percutaneous Drainage Is Not Feasible

• If interventional radiology is unavailable or drainage is technically not feasible, antibiotic therapy alone can be attempted 1
• However, this requires very careful clinical monitoring for signs of treatment failure 1
• Failure of conservative management necessitates surgical intervention 1

Referral and Consultation

Primary Referral

• Refer to general surgery or acute care surgery immediately 1
• Early surgical involvement is required even if initial management is non-operative 1
• Surgery should coordinate with interventional radiology for drainage procedures 1

Interventional Radiology

• Coordinate percutaneous drainage for abscesses >4 cm 1
• Send cultures from drainage fluid to guide antibiotic therapy 1
• Multiple abscesses may require multiple drainage catheters 2

Clinical Monitoring Requirements

Watch for Treatment Failure

• Monitor for persistent fever or leukocytosis beyond 3 days of treatment 2
• Development of peritoneal signs mandates surgical exploration 1
• Grossly feculent drainage suggests fistulous communication requiring early surgery and possible fecal diversion 2

Red Flags Requiring Surgery

• Development of diffuse peritonitis 1
• Hemodynamic instability despite resuscitation 1
• Failure of percutaneous drainage (persistent sepsis, inability to drain adequately) 1, 2
• Fecal fistula with inadequate infection control 2

Important Caveats

Consider Underlying Pathology

• Multiple paracolic abscesses raise concern for perforated diverticulitis, perforated colon cancer, or inflammatory bowel disease 1, 3
• Colonoscopy should be planned after resolution of acute inflammation to exclude malignancy 1, 3
• The absence of free air does NOT exclude perforation—contained perforations commonly present as abscesses 1

Duration of Drainage

• Percutaneous catheters typically remain in place for 7-34 days depending on abscess resolution 2, 4
• Routine sinography through the catheter can identify fistulous communications to bowel 2
• Approximately 47% of diverticular abscesses have fistulous communications to colon 2

Surgical Planning

• If source control is achieved with drainage, approximately 74% of patients can undergo single-stage sigmoid colectomy with primary anastomosis without requiring colostomy 2
• Patients with fecal fistulas typically require early surgery with fecal diversion 2
• The presence of multiple abscesses may indicate more extensive disease requiring broader resection 3