What is the best management approach for a patient with a known history of Ulcerative Colitis (UC) presenting with frequent diarrhea, tenderness in the right iliac fossa (RIF), and imaging showing a large collection and swollen bowel?

Management of Large Intra-Abdominal Collection in UC Patient

This patient requires percutaneous drainage of the collection combined with broad-spectrum antibiotics as the initial management approach (Option C), NOT high-dose IV corticosteroids alone. 1

Critical Clinical Context

This presentation is highly atypical for ulcerative colitis and raises serious concern for:

• Superimposed infection/abscess formation - The 16 x 18 cm collection with RIF tenderness and non-visualized appendix suggests either a perforated appendicitis or, less commonly, a Crohn's disease complication misdiagnosed as UC 1
• Diagnostic uncertainty - True UC does not typically cause large RIF collections; this presentation is more consistent with Crohn's disease with penetrating complications or concurrent appendiceal pathology 1

Immediate Management Algorithm

Step 1: Source Control (Priority)

• Percutaneous drainage is mandatory for collections >3 cm with concurrent broad-spectrum antibiotics covering gram-negative aerobes, facultative bacilli, gram-positive streptococci, and obligate anaerobes 1
• Clinical improvement should occur within 3-5 days with decreased drainage output 1
• If no improvement occurs, repeat imaging and consider drain repositioning or surgical intervention 1

Step 2: Multidisciplinary Evaluation

• Immediate involvement of both gastroenterology and acute care surgery is essential for all IBD patients presenting with acute abdominal complications 1
• Reassess the diagnosis - this clinical picture may represent Crohn's disease rather than UC, or concurrent appendiceal pathology 1

Step 3: Medical Therapy Considerations

• High-dose IV corticosteroids (Option D) are contraindicated as monotherapy in the presence of an intra-abdominal abscess 1
• Antibiotics should be administered promptly but are NOT routine in UC - they are specifically indicated for superinfection and abscesses 1
• The patient's current low-dose prednisone and methotrexate increase risk for intra-abdominal sepsis and should be held during acute infection management 1

Step 4: Surgical Decision-Making

• Diagnostic laparoscopy (Option A) or exploratory laparotomy (Option B) are NOT first-line unless the patient is hemodynamically unstable, has signs of perforation with peritonitis, or fails percutaneous drainage 1
• Surgery becomes mandatory if: clinical deterioration despite drainage, persistent sepsis after 3-5 days, or development of shock/peritonitis 1
• Preoperative percutaneous drainage, when feasible, decreases the extent of intestinal resection, reduces postoperative septic complications, and potentially reduces stoma rates 1

Critical Pitfalls to Avoid

• Do not start high-dose IV steroids in the presence of an undrained abscess - this dramatically increases mortality and septic complications 1
• Do not delay source control - percutaneous drainage must occur within hours, not days 1
• Do not assume this is typical UC - the RIF location, large collection, and non-visualized appendix are atypical and warrant diagnostic reconsideration 1
• Do not continue immunosuppression - methotrexate and steroids combined with anti-TNF agents are risk factors for intra-abdominal sepsis in patients requiring emergency surgery 1

Monitoring and Reassessment

• Assess clinical response by day 3-5 with serial inflammatory markers (CRP, WBC) and drainage output 1
• Repeat imaging if no improvement to confirm adequate drainage 1
• Plan definitive therapy only after sepsis control - if Crohn's disease is confirmed, infliximab can be considered after adequate abscess resolution 1
• Patients with concomitant stenosis, enterocutaneous fistula, or refractory disease will likely require surgery, but delayed surgery after adequate drainage improves outcomes 1

Hemodynamic Status Determines Urgency

• If hemodynamically stable: Percutaneous drainage + antibiotics + close monitoring 1
• If hemodynamically unstable or signs of perforation/peritonitis: Immediate surgical exploration is mandatory 1, 2