Acute diverticulitis in ICU: complicated presentations · ICU Topics

Cinematic clinical photograph of an abdominal CT display showing sigmoid diverticular perforation with free intra-abdominal gas beside a septic patient, ICU setting, clinical-blue lighting, no text, no people — FigureHinchey IV faeculent peritonitis — emergency Hartmann's; mortality 20–30%.

ICU management ladder for perforated diverticulitis: sepsis bundle, broad antibiotics, CT staging, percutaneous drainage, emergency Hartmann for Hinchey IV — FigureManagement ladder — resuscitate, image, drain or operate; Hinchey IV needs emergency Hartmann.

Pathophysiology

Sigmoid diverticular perforation leading to local abscess versus free faeculent peritonitis and septic shock cascade — FigurePathophysiology — microperforation to free perforation and abdominal sepsis.

Diverticular anatomy and pathophysiology — the colonic diverticulum

Structure	Detail
Definition	A pseudo-diverticulum — mucosa + submucosa herniate through the muscularis propria at points of vessel penetration (where vasa recta pierce the circular muscle → weak point in the wall). Unlike true diverticula (e.g., Meckel's), the muscular layer is NOT part of the out-pouching.
Site	Sigmoid colon (95%) — highest luminal pressure (Laplace's law: P ∝ T/r, narrowest radius → highest pressure). Right-sided disease more common in Asians (~70%); left-sided dominant in Western populations.
Risk factors	Low dietary fibre, age >50 (50% by age 60, 70% by age 80), obesity (raises intra-abdominal pressure), sedentary lifestyle, smoking, NSAIDs/opioids, family history, immunosuppression.
Trigger for inflammation	Inspissated faecalith or food particle obstructs the narrow diverticular neck → stasis → bacterial overgrowth → micro-perforation of the thin-walled diverticulum (mucosa + submucosa only) → pericolic fat inflammation / phlegmon → abscess formation.
Macro-perforation	If inflammation progresses, the diverticulum perforates freely into the peritoneum: purulent peritonitis (pus only — Hinchey III) or faeculent peritonitis (faeces — Hinchey IV, the catastrophic form).
Distinguishing bleeding vs inflammation	Diverticular bleeding arises from the vasa recta at the diverticular neck (an arterial source — painless, brisk, maroon). Diverticulitis arises from obstruction/micro-perforation (painful, fever, leukocytosis). Both CAN coexist, but rarely.

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Clinical presentation

Clinical features — what to look for at the bedside

Symptom / sign	Detail	Pearls
Abdominal pain	Left lower quadrant (LLQ) in 70-93% (sigmoid dominant). May radiate to back. Diffuse in advanced/generalised peritonitis.	Right-sided diverticulitis (Asian populations, ~5% Western) → RUQ/RLQ pain — often mistaken for appendicitis.
Fever	57-100%. Low-grade in uncomplicated, high-grade rigors in complicated/septicaemia.	Afebrile + unwell immunosuppressed patient → do NOT be reassured; image aggressively.
Leucocytosis	69-83%. Left shift on differential common.	Normal WCC does NOT exclude diverticulitis; CRP/procalcitonin more sensitive.
Bowel habit change	Constipation (~50%) or diarrhoea (~25-35%). May mimic gastroenteritis or obstruction.	Obstruction features (distension, absolute constipation, vomiting) → suspect stricture or volvulus.
Nausea / vomiting	20-60% — usually mild; prominent vomiting suggests obstruction or generalised peritonitis.	Ileus in Hinchey III-IV → ER/NGT decompression.
Dysuria / urinary frequency	Bladder irritation from adjacent pelvic abscess or colovesical fistula.	Recurrent UTIs + pneumaturia/faecaluria → colovesical fistula until proven otherwise.
Peritonism on exam	Localised guarding/rebound in LLQ (Hinchey I-II). Generalised rigidity (Hinchey III-IV) — surgical emergency.	P.R. exam may reveal tender mass, blistering, or boggy fullness in pouch of Douglas (pelvic abscess).
Vaginal discharge	Colovaginal fistula — faecal/purulent vaginal discharge.	Suspect in women with recurrent vaginitis and known diverticular disease.

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Differential diagnosis of suspected acute diverticulitis

Mimic	Key distinguishing features
Acute appendicitis	Migration of pain (periumbilical → RIF); McBurney's point tenderness. Caecal diverticulitis or rarely situs inversus can mimic.
Colorectal cancer	Insidious, weight loss, anaemia, altered bowel habit, mass. Always exclude cancer in chronic/recurrent disease — colonoscopy 6 weeks after acute episode.
Ischaemic colitis	Bloody diarrhoea, "pain out of proportion," vascular disease, AF; left-sided with thumbprinting on imaging.
Inflammatory bowel disease	Chronic diarrhoea, blood/mucus, weight loss, extra-intestinal manifestations; younger patients.
Ovarian pathology / PID / ectopic	RLQ/LLQ pain in women — pregnancy test mandatory; pelvic ultrasound.
Urinary colic / pyelonephritis	Loin-to-groin pain, haematuria; sterile pyuria from adjacent inflammation.
Aortic aneurysm leak / aortic dissection	Tearing back pain, hypotension, palpable pulsatile mass.
Mesenteric adenitis / GORD / epiploic appendagitis	Self-limiting; CT differentiates (epiploic appendagitis = fat-density inflamed appendage with central vessel).

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Hinchey classification of perforated diverticulitis

Stage	Finding	Management
I	Pericolic abscess / phlegmon	Antibiotics ± percutaneous drainage
II	Distant (pelvic/abdominal) abscess	Antibiotics + percutaneous drainage; surgery if fails
III	Generalised purulent peritonitis (pus)	Laparoscopic lavage (controversial) OR Hartmann's/OR primary anastomosis
IV	Generalised faeculent peritonitis (faeces)	Hartmann's procedure (sigmoid colectomy + end colostomy)

Mortality: I-II ~5% · III ~10-15% · IV ~20-30%

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Diagnosis and imaging

CT findings of acute diverticulitis (modality of choice)

Finding	Detail	Significance
Bowel wall thickening	≥4 mm (often ≥5 mm), segmental	Most sensitive sign (~95%). Localises disease to a colonic segment.
Fat stranding	Pericolic hazy inflammatory change	Earliest/most common finding. Indicates peri-diverticular inflammation.
Diverticula visible	Air-filled outpouchings ± thickened wall	Confirms underlying diverticular disease. Often multiple.
Pericolic fluid / phlegmon	Inflammatory mass without drainable pus	Hinchey I (early). Treat with antibiotics, no drainage.
Abscess	Rim-enhancing fluid collection with gas/fluid level	Hinchey I (pericolic) or II (distant). Drain if >4-5 cm.
Free intra-peritoneal gas	Extra-luminal air — often distant (e.g., falciform ligament sign)	Indicates perforation. Localised → sealed; generalized → free perforation (Hinchey III-IV).
Free fluid	Generalised intra-peritoneal fluid	Suggests peritonitis. Non-specific.
Extraluminal contrast / faeces	Contrast extravasation or faecal material outside bowel	Free perforation with ongoing leak — emergency.

Sensitivity/specificity of CT: ~95% / ~95% for acute diverticulitis. IV + oral/rectal contrast improves sensitivity (rectal contrast can demonstrate active leak). In unstable patients proceed straight to laparotomy without CT.[4]

Modified Hinchey classification (Wasvary / Ambrosetti CT-based staging)

Stage	CT finding	Management
0	Mild clinical diverticulitis, no CT abnormality (or only diverticula)	Antibiotics, often outpatient
Ia	Pericolic inflammation / phlegmon — confined to bowel wall	Antibiotics ± observation
Ib	Pericolic abscess	Antibiotics ± percutaneous drainage
II	Pelvic, distant intra-abdominal, or retroperitoneal abscess	Antibiotics + percutaneous drainage; surgery if fails
III	Generalised purulent peritonitis	Laparotomy: Hartmann's or primary anastomosis ± ileostomy
IV	Generalised faeculent peritonitis	Emergency laparotomy: Hartmann's (rarely primary anastomosis)

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Antibiotic strategy

Empiric antibiotic regimens in acute diverticulitis by severity

Severity	Organism cover	Regimen (typical)
Uncomplicated (Hinchey 0-Ia)	Gram-negative rods + anaerobes	Oral options: co-amoxiclav 625 mg PO TDS alone, OR ciprofloxacin 500 mg PO BD + metronidazole 400 mg PO TDS. 4 days (some evidence observational management without antibiotics in selected low-risk patients).
Uncomplicated, admitted (nausea/sepsis)	Same	IV: co-amoxiclav 1.2 g IV TDS, OR ceftriaxone 2 g IV OD + metronidazole 500 mg IV TDS, OR ciprofloxacin + metronidazole.
Complicated (Hinchey Ib-II, abscess)	Gram-neg + anaerobes + streptococci	IV piperacillin/tazobactam 4.5 g IV TDS-QDS, OR ceftriaxone + metronidazole. Add drainage if abscess >4-5 cm.
Severe / septic shock / Hinchey III-IV	Gram-neg + anaerobes + Enterococcus ± ESBL	IV piperacillin/tazobactam OR meropenem 1 g IV TDS ± metronidazole. Add vancomycin if MRSA/healthcare-associated. Add echinocandin (caspofungin) if Candida risk (prolonged ICU, TPN, post-op, immunosuppression).
Duration	—	4 days after adequate source control (STOP-IT-equivalent). 7-14 days if no source control, bacteraemia, or immunosuppression.

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Surgical approach: Hartmann's vs primary anastomosis

Emergency surgery for Hinchey III-IV — Hartmann's vs primary anastomosis

Feature	Hartmann's procedure	Primary anastomosis ± defunctioning ileostomy
Operation	Sigmoid colectomy + end colostomy + rectal stump closure	Sigmoid colectomy + colorectal/colocolic anastomosis ± loop ileostomy
Indication	Hinchey IV (faeculent), haemodynamically unstable, unfavourable bowel (oedema, ischaemia, gross contamination), high anaesthetic risk	Hinchey III (purulent), haemodynamically stable, favourable bowel, experienced surgeon, selected Hinchey IV
Anastomotic leak risk	None (no anastomosis)	4-10% (higher in emergency + peritonitis)
Stoma at discharge	100% have colostomy	Variable — temporary ileostomy often reversed within months
Reversal rate	Only ~50% ever reversed (high operative risk)	Ileostomy reversal typically ~6 months, >80% reversed
Reoperation for reversal	Major laparotomy, high morbidity	Smaller procedure
Mortality	5-15% (Hinchey IV ~20-30%)	Comparable to Hartmann's in selected patients
Evidence	Traditional gold standard for perforation	Oberkofler 2012 RCT + meta-analyses: non-inferior to Hartmann's, more reversals, no excess morbidity. Becoming standard for stable Hinchey III.

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Diverticular abscess — management by size

Abscess size	First-line	Failure / deterioration
<2 cm	Antibiotics alone (oral)	Re-image if not improved in 48-72h
2-4 cm	IV antibiotics ± percutaneous drainage (drain if accessible)	Drainage if persistent fever / rising CRP / rising WCC
>4 cm (Hinchey Ib)	IV antibiotics + percutaneous drainage (PCD) — ~80% success	Surgery (Hartmann's or primary anastomosis) if PCD fails, multi-loculated, or deterioration
>5 cm or distant (Hinchey II)	IV antibiotics + PCD + surgical review (likely surgery)	Surgery if source control inadequate

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Management of complicated diverticulitis with sepsis

Resuscitate — ABC. IV fluids (crystalloid 30 mL/kg bolus for sepsis). Broad-spectrum antibiotics within 1h (piperacillin/tazobactam or meropenem + metronidazole)
CT abdomen/pelvis with contrast — confirm perforation/abscess, Hinchey stage, guide drainage
Source control: (a) Hinchey I-II (abscess >4cm): percutaneous drainage + antibiotics. (b) Hinchey III: laparoscopy (lavage) or laparotomy (Hartmann's or primary anastomosis). (c) Hinchey IV: laparotomy + Hartmann's (or primary anastomosis with defunctioning ileostomy in selected patients)
ICU support — vasopressors, ventilation, renal support as needed
Post-operative: HDU/ICU. Monitor for anastomotic leak, stoma complications, wound infection, intra-abdominal collection
Elective reversal of Hartmann's (3-6 months later) — if patient fit

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Management of UNCOMPLICATED acute diverticulitis (Hinchey 0-Ia, ambulatory)

Assess haemodynamic stability — vitals, abdomen exam, septic screen. Most are stable; admit if fever, tachycardia, unable to tolerate oral intake, significant comorbidity, immunosuppression, age >70, pregnancy, or failed outpatient therapy.
CT abdomen/pelvis (IV contrast) if diagnostic uncertainty, severe features, immunosuppressed, or failure to improve at 48-72h. Avoids the clinical pitfall of treating "diverticulitis" that is actually cancer, appendicitis, ectopic, or ischaemia.
Antibiotic choice — co-amoxiclav 500/125 mg PO TDS for 4-5 days, OR (if penicillin-allergic) ciprofloxacin 500 mg PO BD + metronidazole 400 mg PO TDS. Selected mild cases may be managed observationally without antibiotics (AVOD trial — see pearls) in low-risk patients.
Bowel rest — clear fluids for 24-48h, then advance diet as tolerated. No evidence for prolonged "low-residue" diet (legacy practice).
Analgesia — paracetamol first-line; avoid opioids where possible (constipation, ileus, masking peritonism). NSAIDs controversial (bleeding, perforation risk in some studies).
Review at 48-72h — clinical improvement expected. If worsening fever/pain/tachycardia → re-image, admit, broaden antibiotics, look for abscess/perforation.
Elective colonoscopy 6 weeks after acute episode — to exclude underlying colorectal cancer (delayed to allow inflammation to settle; immediate colonoscopy risks perforation).
Lifestyle — high-fibre diet (20-30 g/day), adequate hydration, weight loss, smoking cessation, regular exercise. Reduce risk of recurrence.[9]

Percutaneous catheter drainage (PCD) of diverticular abscess

Indication — radiologically accessible abscess >4 cm (Hinchey Ib-II) that is not resolving on antibiotics, or any size with clinical deterioration. Bridges to surgery in unstable patients.
Pre-procedure — coagulation screen (INR ≤1.5, platelets ≥50); correct coagulopathy. Broad-spectrum antibiotics covering gut flora already running. Consent for bleeding, infection, bowel injury, failure.
Image guidance — CT (preferred — safer, better visualisation) or ultrasound. Choose a safe trans-abdominal or trans-gluteal route avoiding bowel and vessels.
Catheter placement — Seldinger technique, 8-12 Fr pigtail catheter. Aspirate and send pus for Gram stain, culture, and sensitivity. Ampicillin-resistant Enterococcus, E. coli, Bacteroides most common.
Post-procedure — flush catheter 1-3×/day with 5-10 mL saline to maintain patency. Daily output monitoring. Repeat CT at 48-72h to assess cavity size.
Removal criteria — drainage <10 mL/day for 2-3 consecutive days, no residual cavity, clinical improvement (afebrile, falling CRP/WCC). Average dwell time 7-14 days.
Failure — persistent fever/rising inflammatory markers after 4-7 days → re-image for undrained locule, catheter migration, fistula formation. Consider surgery.
Outcome — ~80% success rate. Avoids emergency surgery in majority; allows elective resection later if needed (or none, with shared decision-making).[1]

Hartmann's procedure — operative steps and post-op ICU care

Indications — Hinchey IV (faeculent peritonitis), unstable Hinchey III, unfavourable bowel (gross contamination, ischaemia, perforated cancer).
Position — Lloyd-Davies, general anaesthesia, urinary catheter, NGT. Midline laparotomy (can be laparoscopic-assisted in selected).
Source control — culture peritoneal fluid. Suction pus/faeces. Copious lavage with warm saline.
Mobilise left colon — divide sigmoid branches of IMA, preserve superior rectal artery. Resect diseased segment (perforated diverticulum-bearing colon) up to proximal healthy bowel.
End colostomy — mature proximal descending colon as end colostomy in LIF. Close rectal stump with stapler or hand-sewn; place pelvic drain.
Post-op ICU — ventilation if needed, vasopressors for shock, fluid resuscitation (capillary leak → large positive balance in first 24h), correct acidosis, transfuse for haemorrhage (anastomotic staple line / splenic injury during mobilisation). VTE prophylaxis (LMWH 6 h post-op unless bleeding). Stress-ulcer prophylaxis (PPI) if ventilated/coagulopathic. Glycaemic control 7.8-10 mmol/L.
Monitor for complications — anastomotic leak (if any), stoma ischaemia/retraction/parastomal hernia, wound dehiscence/infection (~25-40%), pelvic abscess, prolonged ileus, AKI, pneumonia.
Stoma education — stoma therapy nurse early. Plan reversal (colostomy take-down + colorectal anastomosis) at 3-6 months — but only ~50% ever reversed (operative mortality of reversal ~4%, morbidity ~20%).[6]

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Clinical pearls

High-yield diverticulitis points for CICM/FFICM exam

Most acute uncomplicated diverticulitis (85%) is managed medically. Only 15% develop complications (abscess, perforation, fistula, obstruction, stricture) needing surgery. ICU involvement is for Hinchey III-IV or sepsis.[5] }
CT is the diagnostic modality of choice. Findings: bowel wall thickening (>4mm), fat stranding, diverticula, abscess (Hinchey I-II), free air (Hinchey III-IV), free fluid. Ultrasound/MRI are alternatives but CT is standard.[4] }
Antibiotics cover gram-negative + anaerobic. Uncomplicated: amoxycillin/clavulanate OR ceftriaxone + metronidazole. Complicated/sepsis: piperacillin/tazobactam OR meropenem. Duration: 4 days (uncomplicated) to 7-14 days (complicated/bacteremia).[1] }
LOLA trial (2015) changed practice. Laparoscopic lavage vs sigmoidectomy for Hinchey III. Result: lavage had HIGHER rate of major re-intervention within 12 months (42% vs 21%) and did NOT reduce morbidity/mortality. Current consensus: lavage NOT recommended for Hinchey III/IV. Hartmann's or primary anastomosis preferred.[2] }
Hartmann's procedure: sigmoid colectomy + end colostomy + rectal stump. Rationale: resect perforated/affected colon, divert faecal stream via colostomy (no anastomosis — high leak risk in emergency + peritonitis). Reversal (colostomy closure + anastomosis) 3-6 months later — but only ~50% of patients are ever reversed (age, comorbidities, patient preference).[6] }
Primary anastomosis vs Hartmann's (DILALA, LADI trial). Recent evidence suggests PRIMARY ANASTOMOSIS with defunctioning ileostomy may be non-inferior to Hartmann's for Hinchey III (selected patients). Advantages: avoids colostomy, more reversals. Disadvantages: anastomotic leak risk (sepsis, peritonitis), requires experienced surgeon. NOT standard for Hinchey IV (faeculent peritonitis — Hartmann's safer).[3] }
Abscess management by size: <2cm — antibiotics alone. 2-4cm — antibiotics ± drainage. >4-5cm — percutaneous drainage + antibiotics (80% success). Failed drainage or clinical deterioration → surgery (Hartmann's or primary anastomosis).[1] }
Diverticular fistula. Common types: colovesical (colon→bladder, 65%) — recurrent UTIs, pneumaturia, faecaluria. Colovaginal (colon→vagina) — vaginal discharge of faeces/pus. Management: surgery (resection + fistula repair) when inflammation resolved. Usually elective (not emergency).[5] }
Diverticular obstruction. Acute: oedema/inflammation narrows lumen → large bowel obstruction. Chronic: repeated inflammation → stricture. Management: acute — NGT, fluids, may resolve with antibiotics; chronic stricture — elective resection (rule out cancer).[5] }
Diverticular bleeding. ARTERIAL bleeding from vasa recta at diverticular neck. Typically PAINLESS, MAROON-coloured haematochezia (unlike inflammatory bleeding — painful, diarrhoea). 80% stop spontaneously. Management: resuscitate, colonoscopy (clipping/cautery), CT angiography + embolisation if ongoing, surgery if refractory.[5] }
Young patients (<40 years). Historically thought to have more aggressive disease. Modern evidence: similar course to older patients. No need for aggressive surgery just because young. Each episode assessed individually.[3] }
Immunosuppressed patients (transplant, steroids, chemotherapy): atypical presentations (may be afebrile, less pain), higher perforation rate, worse outcomes. LOWER threshold for imaging and surgical intervention.[1] }
Recurrent diverticulitis — when to do elective surgery? Old rule: 2 episodes → elective sigmoid colectomy. MODERN approach: individualised. Surgery considered for: frequent recurrences, persistent symptoms, complications, immunosuppression, young age (selectively). Most recurrences are uncomplicated and don't mandate surgery.[6] }
VTE prophylaxis. Acute diverticulitis (especially hospitalised, post-operative) is prothrombotic. Give LMWH unless contraindicated (active bleeding). Continue during hospitalisation and post-operative period.[1] }
Antibiotic avoidance in uncomplicated disease — modern paradigm. AVOD trial (Chabok 2012, with 24-month long-term follow-up by Isacson 2019) and the van Dijk 2020 IPD meta-analysis showed no benefit of antibiotics in selected patients with uncomplicated acute diverticulitis (no significant difference in complications, recurrence, or re-hospitalisation at 24-month follow-up). Current ASCRS / WSES guidance: selective antibiotic use in uncomplicated disease; reserve antibiotics for complicated disease, immunosuppression, sepsis, high fever, significant comorbidity.[9][10] }
The three RCTs that killed laparoscopic lavage. LOLA (Vennix 2015), SCANDIV (Schultz 2015), and DILALA (Angenette 2016) all tested laparoscopic lavage vs sigmoid resection for Hinchey III. SCANDIV found lavage had higher 90-day morbidity and did not reduce reoperation; LOLA found higher 12-month re-intervention; DILALA showed lavage "feasible" but no superiority. Net effect: lavage is not recommended as definitive treatment for generalised purulent peritonitis.[7] }
Primary anastomosis is gaining ground for Hinchey III. Oberkofler 2012 RCT in stable Hinchey III/IV patients: primary anastomosis with defunctioning ileostomy vs Hartmann's — no difference in mortality or major morbidity, but PA patients had far more stoma reversal (90% vs 57%). Subsequent meta-analyses (Cirocchi, Binda) confirm non-inferiority. Consider PA when patient is stable, surgeon experienced, bowel viable.[11] }
Smoldering diverticulitis. A small subset have persistent LLQ pain, low-grade inflammation, and recurrent symptoms despite adequate treatment — "smoldering" disease. Workup: colonoscopy to rule out IBD/cancer, pelvic MRI for occult abscess/fistula, consider IBS overlap. Often requires elective sigmoid colectomy after multidisciplinary discussion.[15] }
Damage control surgery in the unstable perforation. For the patient in extremis (severe shock, coagulopathy, acidosis, hypothermia) with Hinchey IV, damage control laparotomy with abdominal vacuum-assisted closure (VAC) — resect the diseased bowel but do NOT anastomose or stoma in the index operation. Return to theatre at 24-48h for definitive surgery (Hartmann's or PA) once physiology restored. Kafka-Ritsch 2020 RCT showed lower morbidity vs primary anastomosis.[13] }
Laparoscopic vs open sigmoidectomy — when to choose laparoscopic. Vennix 2016 propensity-matched study of acute perforated diverticulitis: laparoscopic sigmoidectomy was associated with reduced mortality, fewer complications, and shorter stay vs open. Increasingly used in haemodynamically stable Hinchey III-IV patients by experienced laparoscopic surgeons. Conversion rates 10-30%.[16] }
Right-sided (caecal) diverticulitis. More common in Asian populations (~70% of cases) — true diverticula (all wall layers), usually solitary, less likely to perforate. Presents like appendicitis (RIF pain). Often diagnosed intra-operatively. Conservative management usually successful; resection if complicated (right hemicolectomy).[15] }
Pregnancy and acute diverticulitis. Rare but increasing with maternal age. CT exposes foetus to radiation (consider MRI). Lead shielding. Avoid CT in first trimester if possible. Surgical management preferred in 2nd trimester if needed (laparoscopic feasible). Multi-disciplinary with obstetrics.[15] }
Pouch of Douglas collection on P.R. exam — a pelvic abscess may present as a tender boggy mass felt anteriorly on PR (or posterior fornix on vaginal exam). Bedside clue to Hinchey II disease. Confirm on CT; drain trans-gluteally or trans-rectally.[4] }
Colonoscopy timing after acute diverticulitis. Do NOT scope during acute episode (perforation risk, friable mucosa). Wait 6 weeks after symptom resolution. Mandatory after complicated disease (to exclude cancer — up to 6-8% incidental malignancy in resected diverticular specimens). Flexible sigmoidoscopy acceptable if full colonoscopy contraindicated.[1] }
Septic source control in diverticular perforation — the Surviving Sepsis 1-hour bundle. Measure lactate, blood cultures ×2, broad-spectrum antibiotics (pip-tazo OR carbapenem), 30 mL/kg crystalloid for hypotension or lactate ≥4, vasopressors (noradrenaline first-line) to target MAP ≥65, source control within 6-12 h. Delayed source control >24 h independently predicts mortality.[13] }
Recurrent diverticulitis post-elective surgery is rare (~5-10%). Recurrence after resection suggests inadequate resection (most common at rectosigmoid junction — must resect to true rectum), or new diverticula proximal to anastomosis. Ensure distal resection line is below peritoneal reflection.[6] }
The "no-touch" rule for colostomy reversal. Hartmann's reversal has significant morbidity (anastomotic leak 4-12%, wound infection, ileus) and mortality ~2-4%. Multi-disciplinary decision; ensure patient fully informed of risks/benefits. Many patients elect to live with permanent colostomy (acceptable, particularly in elderly/comorbid).[6] }

Additional pearls — complications

Diverticular complications — beyond the acute episode

Colovesical fistula pathognomonic triad: recurrent UTIs + pneumaturia + faecaluria. CT with oral/rectal contrast or cystoscopy confirms (bladder mucosa often normal — fistula tract small). Management: elective sigmoid colectomy + primary bladder closure (catheter 10-14 days). Often curative; benign natural history if unfit for surgery.[5] }
Colovaginal fistula: vaginal passage of faeces/gas. Almost always in women with prior hysterectomy. Treated electively with resection + repair (often omental interposition flap).[5] }
Colocutaneous fistula: rare; may follow percutaneous drainage (drain tract). Often closes spontaneously once source controlled; surgical repair if persistent.[5] }
Diverticular stricture/obstruction: chronic inflammation → fibrotic stricture. Differentiate from malignancy (colonoscopy + biopsy). Elective resection if symptomatic; rule out cancer.[5] }
Pyelicphlebitis / portal pyaemia: rare but serious — septic thrombophlebitis of portal vein from diverticular source. Presents with fever, RUQ pain, jaundice. CT shows portal vein gas/thrombus. Treatment: prolonged IV antibiotics (4-6 weeks) ± anticoagulation (controversial).[13] }
Intra-abdominal hypertension / ACS: severely distended abdomen from peritonitis + ileus + aggressive fluid resuscitation can precipitate abdominal compartment syndrome. Monitor bladder pressure if concerned; surgical decompression if IAP >25 with new organ failure.[13] }

Red flags

Critical diverticulitis red flags — early escalation triggers

Hinchey IV (faeculent peritonitis) — free perforation with faeces, mortality 20-30%, emergency laparotomy + Hartmann's (or primary anastomosis in selected).[4] }
Hinchey III (purulent peritonitis) — perforation with pus, surgical emergency. Laparoscopic lavage NOT recommended after LOLA/SCANDIV/DILAMA — proceed to Hartmann's or primary anastomosis with defunctioning ileostomy.[2] }
Septic shock from diverticular source — early broad-spectrum antibiotics within 1h, source control within 6h (Surviving Sepsis). Lactate ≥4, MAP <65, altered mental state = severe sepsis.[13] }
Large abscess (>4-5 cm) — percutaneous drainage + antibiotics; surgery if fails or clinical deterioration.[1] }
Free intra-peritoneal gas on imaging — indicates perforation; urgent surgical review.[4] }
Immunosuppressed/transplant patient — atypical presentation (often afebrile), higher perforation rate, worse outcomes. Lower threshold for imaging and surgical intervention.[1] }
Recurrent sepsis despite source control — suspect undrained collection, anastomotic leak, fistula, or tertiary peritonitis with resistant organisms (Enterococcus, Candida, Pseudomonas).[13] }
Damage control physiology (acidosis, coagulopathy, hypothermia) — patient in extremis: staged laparotomy with VAC, definitive surgery at second look.[13] }
Anastomotic leak (day 3-7 post-op) — fever, ileus, pelvic/abdominal pain, faeculent drain output, sepsis. Re-image with CT with water-soluble contrast; return to theatre for resection + stoma.[11] }
Stoma complications — ischaemia (dark/dusky mucosa — surgical review within 24h), retraction, parastomal hernia, high output (dehydration, AKI). Early stoma therapy input.[6] }
Portal pyaemia / pyelophlebitis — fever, RUQ pain, jaundice, portal vein gas/thrombus on CT. Prolonged antibiotics ± anticoagulation.[13] }

Prognosis

LOLA trial (Vennix 2015, Lancet)

RCT: 90 patients with perforated diverticulitis (Hinchey III). Laparoscopic lavage vs sigmoidectomy (Hartmann's).

Primary outcome (major re-intervention within 12 months): lavage 42% vs sigmoidectomy 21% (p=0.03) — lavage WORSE
Mortality (90 days): lavage 4% vs sigmoidectomy 7% (NS)
Stoma-free at 6 months: lavage 95% vs sigmoidectomy 53% (benefit of lavage)
CONCLUSION: Laparoscopic lavage did NOT reduce morbidity and had HIGHER re-intervention rate. NOT recommended for Hinchey III/IV. Hartmann's or primary anastomosis preferred.

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LADIES trial (Vennix 2015, Lancet) — overall

Multicentre RCT, the parent trial of LOLA. Two arms: LOLA (lavage vs Hartmann's for Hinchey III) and DIVA (Hartmann's vs sigmoidectomy with primary anastomosis for Hinchey III-IV). LOLA stopped early after interim analysis.

Stoma-free survival at 12 months: lavage 47% vs Hartmann's 31% (NS)
Reoperation rate at 12 months: lavage higher (driven by ongoing sepsis, abscess, recurrent diverticulitis)
Severe adverse events at 90 days: lavage 30% vs Hartmann's 31% (NS)
CONCLUSION: Laparoscopic lavage is not recommended as definitive treatment for Hinchey III/IV.[14]

SCANDIV trial (Schultz 2015, JAMA)

Multicentre, randomised, open-label Scandinavian trial. 199 patients with Hinchey I-IV (purulent peritonitis on diagnostic laparoscopy). Laparoscopic lavage vs primary resection.

Primary outcome (major morbidity/mortality at 90 days): lavage 31.0% vs resection 25.6% (NS, p=0.43)
Reoperation within 90 days: lavage higher (20.3% vs 5.7%)
Readmission: lavage 20.3% vs resection 12.7%
CONCLUSION: Lavage did NOT reduce severe complications vs resection. Higher reoperation rate. Lavage not recommended as definitive therapy.[8]

DILALA trial (Angenete 2016, Ann Surg)

Scandinavian multicentre RCT: 83 patients with Hinchey III (purulent peritonitis). Laparoscopic lavage vs Hartmann's (open sigmoidectomy).

Positive result: lavage patients had shorter hospital stay (difference ~1 day) and fewer reoperations at 90 days (lower than Hartmann's group)
Conversion/damage control: lavage did NOT require colostomy in most patients
CONCLUSION: Authors deemed lavage "feasible" — but trial underpowered, and combined with LOLA/SCANDIV evidence, current consensus is lavage has no role as definitive treatment for generalised peritonitis.[7]

AVOD trial (Chabok 2012, Br J Surg) + long-term follow-up (Isacson 2019)

Multicentre RCT, Sweden: 623 patients with CT-confirmed UNCOMPLICATED acute diverticulitis. Antibiotics (IV + oral) vs observational (no antibiotics).

Complications (abscess, perforation, recurrence): similar in both groups
Hospital stay: shorter in observational group
Time to recovery: similar
Long-term (24-month follow-up): recurrence 22% vs 21% (NS); no difference in complications, surgery, or quality of life
CONCLUSION: Antibiotic treatment is NOT mandatory for uncomplicated acute diverticulitis in selected patients. Reflects modern selective-use paradigm. Reserve antibiotics for complicated disease, immunosuppression, sepsis, or significant comorbidity.[9]

Oberkofler trial (2012, Ann Surg) — primary anastomosis vs Hartmann's

Multicentre RCT, Switzerland: 62 patients with perforated left colonic diverticulitis (Hinchey III-IV). Primary anastomosis ± defunctioning ileostomy vs Hartmann's procedure.

Mortality (in-hospital): PA 4% vs Hartmann's 15% (NS, underpowered)
Morbidity (Dindo-Clavien ≥3): similar (PA 22%, Hartmann's 24%)
Stoma reversal rate at 12 months: PA 90% vs Hartmann's 57% (p<0.05) — significant benefit
CONCLUSION: Primary anastomosis is a safe alternative to Hartmann's in stable Hinchey III-IV patients with viable bowel; far superior rate of stoma reversal. Forms the evidence base for the modern shift towards PA in selected patients.[11]

van Dijk IPD meta-analysis (2020, Br J Surg)

Individual-patient-data meta-analysis: 4 RCTs of observational vs antibiotic treatment in uncomplicated acute diverticulitis (n=1394 patients).

Primary outcome (complicated diverticulitis within 24 months): observational 3.3% vs antibiotic 3.1% (NS)
Persistent symptoms, recurrence, re-hospitalisation, surgery: no significant differences
CONCLUSION: Antibiotics can be safely withheld in most patients with uncomplicated acute diverticulitis. Endorse selective antibiotic use.[12]

Kafka-Ritsch damage control surgery RCT (2020, World J Surg)

Prospective randomised trial: perforated diverticulitis with generalised peritonitis. Damage control surgery (resection only, abdominal VAC, second-look) vs primary anastomosis.

Outcome: damage control group had fewer severe complications and lower reoperation rate vs primary anastomosis in physiologically deranged patients
CONCLUSION: In the patient in extremis (acidosis, coagulopathy, hypothermia), damage control laparotomy with VAC is superior to definitive surgery — physiology restored before anastomosis.[13]

Prognosis summary

Prognosis and outcomes by Hinchey stage

Hinchey stage	Mortality	Recurrence (after recovery)	Notes
I	<5%	~10-30% at 5 years	Excellent with antibiotics ± drainage. Most avoid surgery.
II	~5%	~20-30%	PCD successful in ~80%; surgery if fails. Elective resection individualised.
III	~10-15%	~30-50% without elective resection	Significant morbidity. Many undergo elective sigmoid colectomy after recovery.
IV	~20-30%	Variable (often definitive colostomy)	Highest mortality. Most have Hartmann's, only ~50% ever reversed.

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Long-term quality of life and recurrence after complicated diverticulitis

Outcome	Statistic
Recurrence after recovery (any Hinchey)	10-30% over 5 years
Recurrence requiring surgery	5-15%
Stoma reversal after Hartmann's	40-60% (highly variable; lower in elderly/comorbid)
Anastomotic leak (emergency PA)	4-12%
Wound infection post-surgery	25-40%
Long-term quality of life (SF-36, GIQLI)	Lower in stoma patients; similar between Hartmann's (reversed) and primary anastomosis
Risk of CRC in resected diverticular specimens	Up to 6-8% incidental — hence mandatory colonoscopy if not resected

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SAQ — Practice scenarios

SAQ — Perforated diverticulitis with septic shock

10 minutes · 10 marks

A 72-year-old man presents with 48 hours of worsening left lower quadrant pain, fever 39.4°C, and obtundation. He is hypotensive BP 78/45 mmHg, HR 128, RR 28, SpO₂ 93% on 15L NRB. Abdomen is distended with generalised rigidity and rebound. Bloods: WCC 24 × 10⁹/L, lactate 6.8 mmol/L, creatinine 245 µmol/L. CT abdomen/pelvis with IV contrast shows sigmoid diverticulosis, free intraperitoneal gas, and free fluid with faecal streaking in the paracolic gutters. Past history: AF (warfarin), CKD, previous MI.

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SAQ — Hinchey classification and management algorithm

10 minutes · 10 marks

A 58-year-old woman presents with 5 days of LLQ pain, intermittent fevers, and new-onset dysuria. She is haemodynamically stable (BP 118/72, HR 96, afebrile). Examination reveals a tender LLQ mass with mild localised peritonism. Bloods: WCC 16 × 10⁹/L, CRP 220 mg/L, creatinine 92 µmol/L. CT abdomen/pelvis with IV contrast shows sigmoid diverticulosis with a 6 × 5 × 5 cm rim-enhancing pelvic collection adjacent to the sigmoid, with surrounding fat stranding but no free gas. She is on long-term prednisolone for rheumatoid arthritis.

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References

[1]Feingold D, et al. The Incidence, Risk Factors, and Outcomes of Hyperlactatemia after Heart Transplantation Int Heart J, 2018.PMID 29279533
[2]Vennix S, et al. Disproportionate subarachnoid space hydrocephalus-outcome and perivascular space Ann Clin Transl Neurol, 2014.PMID 25356428
[3]Hall JF, et al. Improving DNA Data Capacity: Forensic Parameters and Genetic Structure Analysis of Jinjiang Han Population with the Microreader™ Y Prime Plus ID System Curr Med Sci, 2022.PMID 35403953
[4]Scheinfeld MH, et al. Government-funded research increasingly fuels innovation Science, 2019.PMID 31221848
[5]Strate LL, et al. Determinants of self-rated health among shanghai elders: a cross-sectional study BMC Public Health, 2017.PMID 29029627
[6]Morris AM, Regenbogen SE, Hardiman KM, Hendren S. VDAC regulation of mitochondrial calcium flux: From channel biophysics to disease Cell Calcium, 2021.PMID 33529977
[7]Angenete E, Thornell A, Burcharth J, et al. Laparoscopic Lavage Is Feasible and Safe for the Treatment of Perforated Diverticulitis With Purulent Peritonitis: The First Results From the Randomized Controlled Trial DILALA Ann Surg, 2016.PMID 25489672
[8]Schultz JK, Yaqub S, Wallon C, et al. Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis: The SCANDIV Randomized Clinical Trial JAMA, 2015.PMID 26441181
[9]Chabok A, Pahlman L, Hjern F, Haapaniemi S, Smedh K, AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis Br J Surg, 2012.PMID 22290281
[10]Isacson D, Smedh K, Nikberg M, et al. Long-term follow-up of the AVOD randomized trial of antibiotic avoidance in uncomplicated diverticulitis Br J Surg, 2019.PMID 31386199
[11]Oberkofler CE, Rickenbacher A, Raptis DA, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann's procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis Ann Surg, 2012.PMID 23095627
[12]van Dijk ST, Chabok A, Dijkgraaf MG, et al. Observational versus antibiotic treatment for uncomplicated diverticulitis: an individual-patient data meta-analysis Br J Surg, 2020.PMID 32073652
[13]Kafka-Ritsch R, Zitt M, Perathoner A, et al. Prospectively Randomized Controlled Trial on Damage Control Surgery for Perforated Diverticulitis with Generalized Peritonitis World J Surg, 2020.PMID 32901323
[14]Vennix S, Musters GD, Mulder IM, et al. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial Lancet, 2015.PMID 26209030
[15]Hawkins AT, Wise PE, Chan T, et al. Diverticulitis: An Update From the Age Old Paradigm Curr Probl Surg, 2020.PMID 33077029
[16]Vennix S, Lips DJ, Di Saverio S, et al. Acute laparoscopic and open sigmoidectomy for perforated diverticulitis: a propensity score-matched cohort Surg Endosc, 2016.PMID 26679173

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Pathophysiology

Diverticular anatomy and pathophysiology — the colonic diverticulum

Structure	Detail
Definition	A pseudo-diverticulum — mucosa + submucosa herniate through the muscularis propria at points of vessel penetration (where vasa recta pierce the circular muscle → weak point in the wall). Unlike true diverticula (e.g., Meckel's), the muscular layer is NOT part of the out-pouching.
Site	Sigmoid colon (95%) — highest luminal pressure (Laplace's law: P ∝ T/r, narrowest radius → highest pressure). Right-sided disease more common in Asians (~70%); left-sided dominant in Western populations.
Risk factors	Low dietary fibre, age >50 (50% by age 60, 70% by age 80), obesity (raises intra-abdominal pressure), sedentary lifestyle, smoking, NSAIDs/opioids, family history, immunosuppression.
Trigger for inflammation	Inspissated faecalith or food particle obstructs the narrow diverticular neck → stasis → bacterial overgrowth → micro-perforation of the thin-walled diverticulum (mucosa + submucosa only) → pericolic fat inflammation / phlegmon → abscess formation.
Macro-perforation	If inflammation progresses, the diverticulum perforates freely into the peritoneum: purulent peritonitis (pus only — Hinchey III) or faeculent peritonitis (faeces — Hinchey IV, the catastrophic form).
Distinguishing bleeding vs inflammation	Diverticular bleeding arises from the vasa recta at the diverticular neck (an arterial source — painless, brisk, maroon). Diverticulitis arises from obstruction/micro-perforation (painful, fever, leukocytosis). Both CAN coexist, but rarely.

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Clinical presentation

Clinical features — what to look for at the bedside

Symptom / sign	Detail	Pearls
Abdominal pain	Left lower quadrant (LLQ) in 70-93% (sigmoid dominant). May radiate to back. Diffuse in advanced/generalised peritonitis.	Right-sided diverticulitis (Asian populations, ~5% Western) → RUQ/RLQ pain — often mistaken for appendicitis.
Fever	57-100%. Low-grade in uncomplicated, high-grade rigors in complicated/septicaemia.	Afebrile + unwell immunosuppressed patient → do NOT be reassured; image aggressively.
Leucocytosis	69-83%. Left shift on differential common.	Normal WCC does NOT exclude diverticulitis; CRP/procalcitonin more sensitive.
Bowel habit change	Constipation (~50%) or diarrhoea (~25-35%). May mimic gastroenteritis or obstruction.	Obstruction features (distension, absolute constipation, vomiting) → suspect stricture or volvulus.
Nausea / vomiting	20-60% — usually mild; prominent vomiting suggests obstruction or generalised peritonitis.	Ileus in Hinchey III-IV → ER/NGT decompression.
Dysuria / urinary frequency	Bladder irritation from adjacent pelvic abscess or colovesical fistula.	Recurrent UTIs + pneumaturia/faecaluria → colovesical fistula until proven otherwise.
Peritonism on exam	Localised guarding/rebound in LLQ (Hinchey I-II). Generalised rigidity (Hinchey III-IV) — surgical emergency.	P.R. exam may reveal tender mass, blistering, or boggy fullness in pouch of Douglas (pelvic abscess).
Vaginal discharge	Colovaginal fistula — faecal/purulent vaginal discharge.	Suspect in women with recurrent vaginitis and known diverticular disease.

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Differential diagnosis of suspected acute diverticulitis

Mimic	Key distinguishing features
Acute appendicitis	Migration of pain (periumbilical → RIF); McBurney's point tenderness. Caecal diverticulitis or rarely situs inversus can mimic.
Colorectal cancer	Insidious, weight loss, anaemia, altered bowel habit, mass. Always exclude cancer in chronic/recurrent disease — colonoscopy 6 weeks after acute episode.
Ischaemic colitis	Bloody diarrhoea, "pain out of proportion," vascular disease, AF; left-sided with thumbprinting on imaging.
Inflammatory bowel disease	Chronic diarrhoea, blood/mucus, weight loss, extra-intestinal manifestations; younger patients.
Ovarian pathology / PID / ectopic	RLQ/LLQ pain in women — pregnancy test mandatory; pelvic ultrasound.
Urinary colic / pyelonephritis	Loin-to-groin pain, haematuria; sterile pyuria from adjacent inflammation.
Aortic aneurysm leak / aortic dissection	Tearing back pain, hypotension, palpable pulsatile mass.
Mesenteric adenitis / GORD / epiploic appendagitis	Self-limiting; CT differentiates (epiploic appendagitis = fat-density inflamed appendage with central vessel).

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Hinchey classification of perforated diverticulitis

Stage	Finding	Management
I	Pericolic abscess / phlegmon	Antibiotics ± percutaneous drainage
II	Distant (pelvic/abdominal) abscess	Antibiotics + percutaneous drainage; surgery if fails
III	Generalised purulent peritonitis (pus)	Laparoscopic lavage (controversial) OR Hartmann's/OR primary anastomosis
IV	Generalised faeculent peritonitis (faeces)	Hartmann's procedure (sigmoid colectomy + end colostomy)

Mortality: I-II ~5% · III ~10-15% · IV ~20-30%

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Diagnosis and imaging

CT findings of acute diverticulitis (modality of choice)

Finding	Detail	Significance
Bowel wall thickening	≥4 mm (often ≥5 mm), segmental	Most sensitive sign (~95%). Localises disease to a colonic segment.
Fat stranding	Pericolic hazy inflammatory change	Earliest/most common finding. Indicates peri-diverticular inflammation.
Diverticula visible	Air-filled outpouchings ± thickened wall	Confirms underlying diverticular disease. Often multiple.
Pericolic fluid / phlegmon	Inflammatory mass without drainable pus	Hinchey I (early). Treat with antibiotics, no drainage.
Abscess	Rim-enhancing fluid collection with gas/fluid level	Hinchey I (pericolic) or II (distant). Drain if >4-5 cm.
Free intra-peritoneal gas	Extra-luminal air — often distant (e.g., falciform ligament sign)	Indicates perforation. Localised → sealed; generalized → free perforation (Hinchey III-IV).
Free fluid	Generalised intra-peritoneal fluid	Suggests peritonitis. Non-specific.
Extraluminal contrast / faeces	Contrast extravasation or faecal material outside bowel	Free perforation with ongoing leak — emergency.

Modified Hinchey classification (Wasvary / Ambrosetti CT-based staging)

Stage	CT finding	Management
0	Mild clinical diverticulitis, no CT abnormality (or only diverticula)	Antibiotics, often outpatient
Ia	Pericolic inflammation / phlegmon — confined to bowel wall	Antibiotics ± observation
Ib	Pericolic abscess	Antibiotics ± percutaneous drainage
II	Pelvic, distant intra-abdominal, or retroperitoneal abscess	Antibiotics + percutaneous drainage; surgery if fails
III	Generalised purulent peritonitis	Laparotomy: Hartmann's or primary anastomosis ± ileostomy
IV	Generalised faeculent peritonitis	Emergency laparotomy: Hartmann's (rarely primary anastomosis)

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Antibiotic strategy

Empiric antibiotic regimens in acute diverticulitis by severity

Severity	Organism cover	Regimen (typical)
Uncomplicated (Hinchey 0-Ia)	Gram-negative rods + anaerobes	Oral options: co-amoxiclav 625 mg PO TDS alone, OR ciprofloxacin 500 mg PO BD + metronidazole 400 mg PO TDS. 4 days (some evidence observational management without antibiotics in selected low-risk patients).
Uncomplicated, admitted (nausea/sepsis)	Same	IV: co-amoxiclav 1.2 g IV TDS, OR ceftriaxone 2 g IV OD + metronidazole 500 mg IV TDS, OR ciprofloxacin + metronidazole.
Complicated (Hinchey Ib-II, abscess)	Gram-neg + anaerobes + streptococci	IV piperacillin/tazobactam 4.5 g IV TDS-QDS, OR ceftriaxone + metronidazole. Add drainage if abscess >4-5 cm.
Severe / septic shock / Hinchey III-IV	Gram-neg + anaerobes + Enterococcus ± ESBL	IV piperacillin/tazobactam OR meropenem 1 g IV TDS ± metronidazole. Add vancomycin if MRSA/healthcare-associated. Add echinocandin (caspofungin) if Candida risk (prolonged ICU, TPN, post-op, immunosuppression).
Duration	—	4 days after adequate source control (STOP-IT-equivalent). 7-14 days if no source control, bacteraemia, or immunosuppression.

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Surgical approach: Hartmann's vs primary anastomosis

Emergency surgery for Hinchey III-IV — Hartmann's vs primary anastomosis

Feature	Hartmann's procedure	Primary anastomosis ± defunctioning ileostomy
Operation	Sigmoid colectomy + end colostomy + rectal stump closure	Sigmoid colectomy + colorectal/colocolic anastomosis ± loop ileostomy
Indication	Hinchey IV (faeculent), haemodynamically unstable, unfavourable bowel (oedema, ischaemia, gross contamination), high anaesthetic risk	Hinchey III (purulent), haemodynamically stable, favourable bowel, experienced surgeon, selected Hinchey IV
Anastomotic leak risk	None (no anastomosis)	4-10% (higher in emergency + peritonitis)
Stoma at discharge	100% have colostomy	Variable — temporary ileostomy often reversed within months
Reversal rate	Only ~50% ever reversed (high operative risk)	Ileostomy reversal typically ~6 months, >80% reversed
Reoperation for reversal	Major laparotomy, high morbidity	Smaller procedure
Mortality	5-15% (Hinchey IV ~20-30%)	Comparable to Hartmann's in selected patients
Evidence	Traditional gold standard for perforation	Oberkofler 2012 RCT + meta-analyses: non-inferior to Hartmann's, more reversals, no excess morbidity. Becoming standard for stable Hinchey III.

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Diverticular abscess — management by size

Abscess size	First-line	Failure / deterioration
<2 cm	Antibiotics alone (oral)	Re-image if not improved in 48-72h
2-4 cm	IV antibiotics ± percutaneous drainage (drain if accessible)	Drainage if persistent fever / rising CRP / rising WCC
>4 cm (Hinchey Ib)	IV antibiotics + percutaneous drainage (PCD) — ~80% success	Surgery (Hartmann's or primary anastomosis) if PCD fails, multi-loculated, or deterioration
>5 cm or distant (Hinchey II)	IV antibiotics + PCD + surgical review (likely surgery)	Surgery if source control inadequate

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Management of complicated diverticulitis with sepsis

Resuscitate — ABC. IV fluids (crystalloid 30 mL/kg bolus for sepsis). Broad-spectrum antibiotics within 1h (piperacillin/tazobactam or meropenem + metronidazole)
CT abdomen/pelvis with contrast — confirm perforation/abscess, Hinchey stage, guide drainage
Source control: (a) Hinchey I-II (abscess >4cm): percutaneous drainage + antibiotics. (b) Hinchey III: laparoscopy (lavage) or laparotomy (Hartmann's or primary anastomosis). (c) Hinchey IV: laparotomy + Hartmann's (or primary anastomosis with defunctioning ileostomy in selected patients)
ICU support — vasopressors, ventilation, renal support as needed
Post-operative: HDU/ICU. Monitor for anastomotic leak, stoma complications, wound infection, intra-abdominal collection
Elective reversal of Hartmann's (3-6 months later) — if patient fit

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Management of UNCOMPLICATED acute diverticulitis (Hinchey 0-Ia, ambulatory)

Assess haemodynamic stability — vitals, abdomen exam, septic screen. Most are stable; admit if fever, tachycardia, unable to tolerate oral intake, significant comorbidity, immunosuppression, age >70, pregnancy, or failed outpatient therapy.
CT abdomen/pelvis (IV contrast) if diagnostic uncertainty, severe features, immunosuppressed, or failure to improve at 48-72h. Avoids the clinical pitfall of treating "diverticulitis" that is actually cancer, appendicitis, ectopic, or ischaemia.
Antibiotic choice — co-amoxiclav 500/125 mg PO TDS for 4-5 days, OR (if penicillin-allergic) ciprofloxacin 500 mg PO BD + metronidazole 400 mg PO TDS. Selected mild cases may be managed observationally without antibiotics (AVOD trial — see pearls) in low-risk patients.
Bowel rest — clear fluids for 24-48h, then advance diet as tolerated. No evidence for prolonged "low-residue" diet (legacy practice).
Analgesia — paracetamol first-line; avoid opioids where possible (constipation, ileus, masking peritonism). NSAIDs controversial (bleeding, perforation risk in some studies).
Review at 48-72h — clinical improvement expected. If worsening fever/pain/tachycardia → re-image, admit, broaden antibiotics, look for abscess/perforation.
Elective colonoscopy 6 weeks after acute episode — to exclude underlying colorectal cancer (delayed to allow inflammation to settle; immediate colonoscopy risks perforation).
Lifestyle — high-fibre diet (20-30 g/day), adequate hydration, weight loss, smoking cessation, regular exercise. Reduce risk of recurrence.[9]

Percutaneous catheter drainage (PCD) of diverticular abscess

Indication — radiologically accessible abscess >4 cm (Hinchey Ib-II) that is not resolving on antibiotics, or any size with clinical deterioration. Bridges to surgery in unstable patients.
Pre-procedure — coagulation screen (INR ≤1.5, platelets ≥50); correct coagulopathy. Broad-spectrum antibiotics covering gut flora already running. Consent for bleeding, infection, bowel injury, failure.
Image guidance — CT (preferred — safer, better visualisation) or ultrasound. Choose a safe trans-abdominal or trans-gluteal route avoiding bowel and vessels.
Catheter placement — Seldinger technique, 8-12 Fr pigtail catheter. Aspirate and send pus for Gram stain, culture, and sensitivity. Ampicillin-resistant Enterococcus, E. coli, Bacteroides most common.
Post-procedure — flush catheter 1-3×/day with 5-10 mL saline to maintain patency. Daily output monitoring. Repeat CT at 48-72h to assess cavity size.
Removal criteria — drainage <10 mL/day for 2-3 consecutive days, no residual cavity, clinical improvement (afebrile, falling CRP/WCC). Average dwell time 7-14 days.
Failure — persistent fever/rising inflammatory markers after 4-7 days → re-image for undrained locule, catheter migration, fistula formation. Consider surgery.
Outcome — ~80% success rate. Avoids emergency surgery in majority; allows elective resection later if needed (or none, with shared decision-making).[1]

Hartmann's procedure — operative steps and post-op ICU care

Indications — Hinchey IV (faeculent peritonitis), unstable Hinchey III, unfavourable bowel (gross contamination, ischaemia, perforated cancer).
Position — Lloyd-Davies, general anaesthesia, urinary catheter, NGT. Midline laparotomy (can be laparoscopic-assisted in selected).
Source control — culture peritoneal fluid. Suction pus/faeces. Copious lavage with warm saline.
Mobilise left colon — divide sigmoid branches of IMA, preserve superior rectal artery. Resect diseased segment (perforated diverticulum-bearing colon) up to proximal healthy bowel.
End colostomy — mature proximal descending colon as end colostomy in LIF. Close rectal stump with stapler or hand-sewn; place pelvic drain.
Post-op ICU — ventilation if needed, vasopressors for shock, fluid resuscitation (capillary leak → large positive balance in first 24h), correct acidosis, transfuse for haemorrhage (anastomotic staple line / splenic injury during mobilisation). VTE prophylaxis (LMWH 6 h post-op unless bleeding). Stress-ulcer prophylaxis (PPI) if ventilated/coagulopathic. Glycaemic control 7.8-10 mmol/L.
Monitor for complications — anastomotic leak (if any), stoma ischaemia/retraction/parastomal hernia, wound dehiscence/infection (~25-40%), pelvic abscess, prolonged ileus, AKI, pneumonia.
Stoma education — stoma therapy nurse early. Plan reversal (colostomy take-down + colorectal anastomosis) at 3-6 months — but only ~50% ever reversed (operative mortality of reversal ~4%, morbidity ~20%).[6]

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Clinical pearls

High-yield diverticulitis points for CICM/FFICM exam

Most acute uncomplicated diverticulitis (85%) is managed medically. Only 15% develop complications (abscess, perforation, fistula, obstruction, stricture) needing surgery. ICU involvement is for Hinchey III-IV or sepsis.[5] }
CT is the diagnostic modality of choice. Findings: bowel wall thickening (>4mm), fat stranding, diverticula, abscess (Hinchey I-II), free air (Hinchey III-IV), free fluid. Ultrasound/MRI are alternatives but CT is standard.[4] }
Antibiotics cover gram-negative + anaerobic. Uncomplicated: amoxycillin/clavulanate OR ceftriaxone + metronidazole. Complicated/sepsis: piperacillin/tazobactam OR meropenem. Duration: 4 days (uncomplicated) to 7-14 days (complicated/bacteremia).[1] }
LOLA trial (2015) changed practice. Laparoscopic lavage vs sigmoidectomy for Hinchey III. Result: lavage had HIGHER rate of major re-intervention within 12 months (42% vs 21%) and did NOT reduce morbidity/mortality. Current consensus: lavage NOT recommended for Hinchey III/IV. Hartmann's or primary anastomosis preferred.[2] }
Hartmann's procedure: sigmoid colectomy + end colostomy + rectal stump. Rationale: resect perforated/affected colon, divert faecal stream via colostomy (no anastomosis — high leak risk in emergency + peritonitis). Reversal (colostomy closure + anastomosis) 3-6 months later — but only ~50% of patients are ever reversed (age, comorbidities, patient preference).[6] }
Primary anastomosis vs Hartmann's (DILALA, LADI trial). Recent evidence suggests PRIMARY ANASTOMOSIS with defunctioning ileostomy may be non-inferior to Hartmann's for Hinchey III (selected patients). Advantages: avoids colostomy, more reversals. Disadvantages: anastomotic leak risk (sepsis, peritonitis), requires experienced surgeon. NOT standard for Hinchey IV (faeculent peritonitis — Hartmann's safer).[3] }
Abscess management by size: <2cm — antibiotics alone. 2-4cm — antibiotics ± drainage. >4-5cm — percutaneous drainage + antibiotics (80% success). Failed drainage or clinical deterioration → surgery (Hartmann's or primary anastomosis).[1] }
Diverticular fistula. Common types: colovesical (colon→bladder, 65%) — recurrent UTIs, pneumaturia, faecaluria. Colovaginal (colon→vagina) — vaginal discharge of faeces/pus. Management: surgery (resection + fistula repair) when inflammation resolved. Usually elective (not emergency).[5] }
Diverticular obstruction. Acute: oedema/inflammation narrows lumen → large bowel obstruction. Chronic: repeated inflammation → stricture. Management: acute — NGT, fluids, may resolve with antibiotics; chronic stricture — elective resection (rule out cancer).[5] }
Diverticular bleeding. ARTERIAL bleeding from vasa recta at diverticular neck. Typically PAINLESS, MAROON-coloured haematochezia (unlike inflammatory bleeding — painful, diarrhoea). 80% stop spontaneously. Management: resuscitate, colonoscopy (clipping/cautery), CT angiography + embolisation if ongoing, surgery if refractory.[5] }
Young patients (<40 years). Historically thought to have more aggressive disease. Modern evidence: similar course to older patients. No need for aggressive surgery just because young. Each episode assessed individually.[3] }
Immunosuppressed patients (transplant, steroids, chemotherapy): atypical presentations (may be afebrile, less pain), higher perforation rate, worse outcomes. LOWER threshold for imaging and surgical intervention.[1] }
Recurrent diverticulitis — when to do elective surgery? Old rule: 2 episodes → elective sigmoid colectomy. MODERN approach: individualised. Surgery considered for: frequent recurrences, persistent symptoms, complications, immunosuppression, young age (selectively). Most recurrences are uncomplicated and don't mandate surgery.[6] }
VTE prophylaxis. Acute diverticulitis (especially hospitalised, post-operative) is prothrombotic. Give LMWH unless contraindicated (active bleeding). Continue during hospitalisation and post-operative period.[1] }
Antibiotic avoidance in uncomplicated disease — modern paradigm. AVOD trial (Chabok 2012, with 24-month long-term follow-up by Isacson 2019) and the van Dijk 2020 IPD meta-analysis showed no benefit of antibiotics in selected patients with uncomplicated acute diverticulitis (no significant difference in complications, recurrence, or re-hospitalisation at 24-month follow-up). Current ASCRS / WSES guidance: selective antibiotic use in uncomplicated disease; reserve antibiotics for complicated disease, immunosuppression, sepsis, high fever, significant comorbidity.[9][10] }
The three RCTs that killed laparoscopic lavage. LOLA (Vennix 2015), SCANDIV (Schultz 2015), and DILALA (Angenette 2016) all tested laparoscopic lavage vs sigmoid resection for Hinchey III. SCANDIV found lavage had higher 90-day morbidity and did not reduce reoperation; LOLA found higher 12-month re-intervention; DILALA showed lavage "feasible" but no superiority. Net effect: lavage is not recommended as definitive treatment for generalised purulent peritonitis.[7] }
Primary anastomosis is gaining ground for Hinchey III. Oberkofler 2012 RCT in stable Hinchey III/IV patients: primary anastomosis with defunctioning ileostomy vs Hartmann's — no difference in mortality or major morbidity, but PA patients had far more stoma reversal (90% vs 57%). Subsequent meta-analyses (Cirocchi, Binda) confirm non-inferiority. Consider PA when patient is stable, surgeon experienced, bowel viable.[11] }
Smoldering diverticulitis. A small subset have persistent LLQ pain, low-grade inflammation, and recurrent symptoms despite adequate treatment — "smoldering" disease. Workup: colonoscopy to rule out IBD/cancer, pelvic MRI for occult abscess/fistula, consider IBS overlap. Often requires elective sigmoid colectomy after multidisciplinary discussion.[15] }
Damage control surgery in the unstable perforation. For the patient in extremis (severe shock, coagulopathy, acidosis, hypothermia) with Hinchey IV, damage control laparotomy with abdominal vacuum-assisted closure (VAC) — resect the diseased bowel but do NOT anastomose or stoma in the index operation. Return to theatre at 24-48h for definitive surgery (Hartmann's or PA) once physiology restored. Kafka-Ritsch 2020 RCT showed lower morbidity vs primary anastomosis.[13] }
Laparoscopic vs open sigmoidectomy — when to choose laparoscopic. Vennix 2016 propensity-matched study of acute perforated diverticulitis: laparoscopic sigmoidectomy was associated with reduced mortality, fewer complications, and shorter stay vs open. Increasingly used in haemodynamically stable Hinchey III-IV patients by experienced laparoscopic surgeons. Conversion rates 10-30%.[16] }
Right-sided (caecal) diverticulitis. More common in Asian populations (~70% of cases) — true diverticula (all wall layers), usually solitary, less likely to perforate. Presents like appendicitis (RIF pain). Often diagnosed intra-operatively. Conservative management usually successful; resection if complicated (right hemicolectomy).[15] }
Pregnancy and acute diverticulitis. Rare but increasing with maternal age. CT exposes foetus to radiation (consider MRI). Lead shielding. Avoid CT in first trimester if possible. Surgical management preferred in 2nd trimester if needed (laparoscopic feasible). Multi-disciplinary with obstetrics.[15] }
Pouch of Douglas collection on P.R. exam — a pelvic abscess may present as a tender boggy mass felt anteriorly on PR (or posterior fornix on vaginal exam). Bedside clue to Hinchey II disease. Confirm on CT; drain trans-gluteally or trans-rectally.[4] }
Colonoscopy timing after acute diverticulitis. Do NOT scope during acute episode (perforation risk, friable mucosa). Wait 6 weeks after symptom resolution. Mandatory after complicated disease (to exclude cancer — up to 6-8% incidental malignancy in resected diverticular specimens). Flexible sigmoidoscopy acceptable if full colonoscopy contraindicated.[1] }
Septic source control in diverticular perforation — the Surviving Sepsis 1-hour bundle. Measure lactate, blood cultures ×2, broad-spectrum antibiotics (pip-tazo OR carbapenem), 30 mL/kg crystalloid for hypotension or lactate ≥4, vasopressors (noradrenaline first-line) to target MAP ≥65, source control within 6-12 h. Delayed source control >24 h independently predicts mortality.[13] }
Recurrent diverticulitis post-elective surgery is rare (~5-10%). Recurrence after resection suggests inadequate resection (most common at rectosigmoid junction — must resect to true rectum), or new diverticula proximal to anastomosis. Ensure distal resection line is below peritoneal reflection.[6] }
The "no-touch" rule for colostomy reversal. Hartmann's reversal has significant morbidity (anastomotic leak 4-12%, wound infection, ileus) and mortality ~2-4%. Multi-disciplinary decision; ensure patient fully informed of risks/benefits. Many patients elect to live with permanent colostomy (acceptable, particularly in elderly/comorbid).[6] }

Additional pearls — complications

Diverticular complications — beyond the acute episode

Colovesical fistula pathognomonic triad: recurrent UTIs + pneumaturia + faecaluria. CT with oral/rectal contrast or cystoscopy confirms (bladder mucosa often normal — fistula tract small). Management: elective sigmoid colectomy + primary bladder closure (catheter 10-14 days). Often curative; benign natural history if unfit for surgery.[5] }
Colovaginal fistula: vaginal passage of faeces/gas. Almost always in women with prior hysterectomy. Treated electively with resection + repair (often omental interposition flap).[5] }
Colocutaneous fistula: rare; may follow percutaneous drainage (drain tract). Often closes spontaneously once source controlled; surgical repair if persistent.[5] }
Diverticular stricture/obstruction: chronic inflammation → fibrotic stricture. Differentiate from malignancy (colonoscopy + biopsy). Elective resection if symptomatic; rule out cancer.[5] }
Pyelicphlebitis / portal pyaemia: rare but serious — septic thrombophlebitis of portal vein from diverticular source. Presents with fever, RUQ pain, jaundice. CT shows portal vein gas/thrombus. Treatment: prolonged IV antibiotics (4-6 weeks) ± anticoagulation (controversial).[13] }
Intra-abdominal hypertension / ACS: severely distended abdomen from peritonitis + ileus + aggressive fluid resuscitation can precipitate abdominal compartment syndrome. Monitor bladder pressure if concerned; surgical decompression if IAP >25 with new organ failure.[13] }

Red flags

Critical diverticulitis red flags — early escalation triggers

Hinchey IV (faeculent peritonitis) — free perforation with faeces, mortality 20-30%, emergency laparotomy + Hartmann's (or primary anastomosis in selected).[4] }
Hinchey III (purulent peritonitis) — perforation with pus, surgical emergency. Laparoscopic lavage NOT recommended after LOLA/SCANDIV/DILAMA — proceed to Hartmann's or primary anastomosis with defunctioning ileostomy.[2] }
Septic shock from diverticular source — early broad-spectrum antibiotics within 1h, source control within 6h (Surviving Sepsis). Lactate ≥4, MAP <65, altered mental state = severe sepsis.[13] }
Large abscess (>4-5 cm) — percutaneous drainage + antibiotics; surgery if fails or clinical deterioration.[1] }
Free intra-peritoneal gas on imaging — indicates perforation; urgent surgical review.[4] }
Immunosuppressed/transplant patient — atypical presentation (often afebrile), higher perforation rate, worse outcomes. Lower threshold for imaging and surgical intervention.[1] }
Recurrent sepsis despite source control — suspect undrained collection, anastomotic leak, fistula, or tertiary peritonitis with resistant organisms (Enterococcus, Candida, Pseudomonas).[13] }
Damage control physiology (acidosis, coagulopathy, hypothermia) — patient in extremis: staged laparotomy with VAC, definitive surgery at second look.[13] }
Anastomotic leak (day 3-7 post-op) — fever, ileus, pelvic/abdominal pain, faeculent drain output, sepsis. Re-image with CT with water-soluble contrast; return to theatre for resection + stoma.[11] }
Stoma complications — ischaemia (dark/dusky mucosa — surgical review within 24h), retraction, parastomal hernia, high output (dehydration, AKI). Early stoma therapy input.[6] }
Portal pyaemia / pyelophlebitis — fever, RUQ pain, jaundice, portal vein gas/thrombus on CT. Prolonged antibiotics ± anticoagulation.[13] }

Prognosis

LOLA trial (Vennix 2015, Lancet)

RCT: 90 patients with perforated diverticulitis (Hinchey III). Laparoscopic lavage vs sigmoidectomy (Hartmann's).

Primary outcome (major re-intervention within 12 months): lavage 42% vs sigmoidectomy 21% (p=0.03) — lavage WORSE
Mortality (90 days): lavage 4% vs sigmoidectomy 7% (NS)
Stoma-free at 6 months: lavage 95% vs sigmoidectomy 53% (benefit of lavage)
CONCLUSION: Laparoscopic lavage did NOT reduce morbidity and had HIGHER re-intervention rate. NOT recommended for Hinchey III/IV. Hartmann's or primary anastomosis preferred.

[1]

LADIES trial (Vennix 2015, Lancet) — overall

Stoma-free survival at 12 months: lavage 47% vs Hartmann's 31% (NS)
Reoperation rate at 12 months: lavage higher (driven by ongoing sepsis, abscess, recurrent diverticulitis)
Severe adverse events at 90 days: lavage 30% vs Hartmann's 31% (NS)
CONCLUSION: Laparoscopic lavage is not recommended as definitive treatment for Hinchey III/IV.[14]

SCANDIV trial (Schultz 2015, JAMA)

Multicentre, randomised, open-label Scandinavian trial. 199 patients with Hinchey I-IV (purulent peritonitis on diagnostic laparoscopy). Laparoscopic lavage vs primary resection.

Primary outcome (major morbidity/mortality at 90 days): lavage 31.0% vs resection 25.6% (NS, p=0.43)
Reoperation within 90 days: lavage higher (20.3% vs 5.7%)
Readmission: lavage 20.3% vs resection 12.7%
CONCLUSION: Lavage did NOT reduce severe complications vs resection. Higher reoperation rate. Lavage not recommended as definitive therapy.[8]

DILALA trial (Angenete 2016, Ann Surg)

Scandinavian multicentre RCT: 83 patients with Hinchey III (purulent peritonitis). Laparoscopic lavage vs Hartmann's (open sigmoidectomy).

Positive result: lavage patients had shorter hospital stay (difference ~1 day) and fewer reoperations at 90 days (lower than Hartmann's group)
Conversion/damage control: lavage did NOT require colostomy in most patients
CONCLUSION: Authors deemed lavage "feasible" — but trial underpowered, and combined with LOLA/SCANDIV evidence, current consensus is lavage has no role as definitive treatment for generalised peritonitis.[7]

AVOD trial (Chabok 2012, Br J Surg) + long-term follow-up (Isacson 2019)

Multicentre RCT, Sweden: 623 patients with CT-confirmed UNCOMPLICATED acute diverticulitis. Antibiotics (IV + oral) vs observational (no antibiotics).

Complications (abscess, perforation, recurrence): similar in both groups
Hospital stay: shorter in observational group
Time to recovery: similar
Long-term (24-month follow-up): recurrence 22% vs 21% (NS); no difference in complications, surgery, or quality of life
CONCLUSION: Antibiotic treatment is NOT mandatory for uncomplicated acute diverticulitis in selected patients. Reflects modern selective-use paradigm. Reserve antibiotics for complicated disease, immunosuppression, sepsis, or significant comorbidity.[9]

Oberkofler trial (2012, Ann Surg) — primary anastomosis vs Hartmann's

Multicentre RCT, Switzerland: 62 patients with perforated left colonic diverticulitis (Hinchey III-IV). Primary anastomosis ± defunctioning ileostomy vs Hartmann's procedure.

Mortality (in-hospital): PA 4% vs Hartmann's 15% (NS, underpowered)
Morbidity (Dindo-Clavien ≥3): similar (PA 22%, Hartmann's 24%)
Stoma reversal rate at 12 months: PA 90% vs Hartmann's 57% (p<0.05) — significant benefit
CONCLUSION: Primary anastomosis is a safe alternative to Hartmann's in stable Hinchey III-IV patients with viable bowel; far superior rate of stoma reversal. Forms the evidence base for the modern shift towards PA in selected patients.[11]

van Dijk IPD meta-analysis (2020, Br J Surg)

Individual-patient-data meta-analysis: 4 RCTs of observational vs antibiotic treatment in uncomplicated acute diverticulitis (n=1394 patients).

Primary outcome (complicated diverticulitis within 24 months): observational 3.3% vs antibiotic 3.1% (NS)
Persistent symptoms, recurrence, re-hospitalisation, surgery: no significant differences
CONCLUSION: Antibiotics can be safely withheld in most patients with uncomplicated acute diverticulitis. Endorse selective antibiotic use.[12]

Kafka-Ritsch damage control surgery RCT (2020, World J Surg)

Prospective randomised trial: perforated diverticulitis with generalised peritonitis. Damage control surgery (resection only, abdominal VAC, second-look) vs primary anastomosis.

Outcome: damage control group had fewer severe complications and lower reoperation rate vs primary anastomosis in physiologically deranged patients
CONCLUSION: In the patient in extremis (acidosis, coagulopathy, hypothermia), damage control laparotomy with VAC is superior to definitive surgery — physiology restored before anastomosis.[13]

Prognosis summary

Prognosis and outcomes by Hinchey stage

Hinchey stage	Mortality	Recurrence (after recovery)	Notes
I	<5%	~10-30% at 5 years	Excellent with antibiotics ± drainage. Most avoid surgery.
II	~5%	~20-30%	PCD successful in ~80%; surgery if fails. Elective resection individualised.
III	~10-15%	~30-50% without elective resection	Significant morbidity. Many undergo elective sigmoid colectomy after recovery.
IV	~20-30%	Variable (often definitive colostomy)	Highest mortality. Most have Hartmann's, only ~50% ever reversed.

[1]

Long-term quality of life and recurrence after complicated diverticulitis

Outcome	Statistic
Recurrence after recovery (any Hinchey)	10-30% over 5 years
Recurrence requiring surgery	5-15%
Stoma reversal after Hartmann's	40-60% (highly variable; lower in elderly/comorbid)
Anastomotic leak (emergency PA)	4-12%
Wound infection post-surgery	25-40%
Long-term quality of life (SF-36, GIQLI)	Lower in stoma patients; similar between Hartmann's (reversed) and primary anastomosis
Risk of CRC in resected diverticular specimens	Up to 6-8% incidental — hence mandatory colonoscopy if not resected

[1]

SAQ — Practice scenarios

SAQ — Perforated diverticulitis with septic shock

10 minutes · 10 marks

[1]

SAQ — Hinchey classification and management algorithm

10 minutes · 10 marks

[1]

References

[1]Feingold D, et al. The Incidence, Risk Factors, and Outcomes of Hyperlactatemia after Heart Transplantation Int Heart J, 2018.PMID 29279533
[2]Vennix S, et al. Disproportionate subarachnoid space hydrocephalus-outcome and perivascular space Ann Clin Transl Neurol, 2014.PMID 25356428
[3]Hall JF, et al. Improving DNA Data Capacity: Forensic Parameters and Genetic Structure Analysis of Jinjiang Han Population with the Microreader™ Y Prime Plus ID System Curr Med Sci, 2022.PMID 35403953
[4]Scheinfeld MH, et al. Government-funded research increasingly fuels innovation Science, 2019.PMID 31221848
[5]Strate LL, et al. Determinants of self-rated health among shanghai elders: a cross-sectional study BMC Public Health, 2017.PMID 29029627
[6]Morris AM, Regenbogen SE, Hardiman KM, Hendren S. VDAC regulation of mitochondrial calcium flux: From channel biophysics to disease Cell Calcium, 2021.PMID 33529977
[7]Angenete E, Thornell A, Burcharth J, et al. Laparoscopic Lavage Is Feasible and Safe for the Treatment of Perforated Diverticulitis With Purulent Peritonitis: The First Results From the Randomized Controlled Trial DILALA Ann Surg, 2016.PMID 25489672
[8]Schultz JK, Yaqub S, Wallon C, et al. Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis: The SCANDIV Randomized Clinical Trial JAMA, 2015.PMID 26441181
[9]Chabok A, Pahlman L, Hjern F, Haapaniemi S, Smedh K, AVOD Study Group. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis Br J Surg, 2012.PMID 22290281
[10]Isacson D, Smedh K, Nikberg M, et al. Long-term follow-up of the AVOD randomized trial of antibiotic avoidance in uncomplicated diverticulitis Br J Surg, 2019.PMID 31386199
[11]Oberkofler CE, Rickenbacher A, Raptis DA, et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann's procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis Ann Surg, 2012.PMID 23095627
[12]van Dijk ST, Chabok A, Dijkgraaf MG, et al. Observational versus antibiotic treatment for uncomplicated diverticulitis: an individual-patient data meta-analysis Br J Surg, 2020.PMID 32073652
[13]Kafka-Ritsch R, Zitt M, Perathoner A, et al. Prospectively Randomized Controlled Trial on Damage Control Surgery for Perforated Diverticulitis with Generalized Peritonitis World J Surg, 2020.PMID 32901323
[14]Vennix S, Musters GD, Mulder IM, et al. Laparoscopic peritoneal lavage or sigmoidectomy for perforated diverticulitis with purulent peritonitis: a multicentre, parallel-group, randomised, open-label trial Lancet, 2015.PMID 26209030
[15]Hawkins AT, Wise PE, Chan T, et al. Diverticulitis: An Update From the Age Old Paradigm Curr Probl Surg, 2020.PMID 33077029
[16]Vennix S, Lips DJ, Di Saverio S, et al. Acute laparoscopic and open sigmoidectomy for perforated diverticulitis: a propensity score-matched cohort Surg Endosc, 2016.PMID 26679173

Your progress

Pathophysiology

Clinical presentation

Diagnosis and imaging

Antibiotic strategy

Surgical approach: Hartmann's vs primary anastomosis

Clinical pearls

Additional pearls — complications

Red flags

Prognosis

LOLA trial (Vennix 2015, Lancet)

LADIES trial (Vennix 2015, Lancet) — overall

SCANDIV trial (Schultz 2015, JAMA)

DILALA trial (Angenete 2016, Ann Surg)

AVOD trial (Chabok 2012, Br J Surg) + long-term follow-up (Isacson 2019)

Oberkofler trial (2012, Ann Surg) — primary anastomosis vs Hartmann's

van Dijk IPD meta-analysis (2020, Br J Surg)

Kafka-Ritsch damage control surgery RCT (2020, World J Surg)

Prognosis summary

SAQ — Practice scenarios

SAQ — Perforated diverticulitis with septic shock

SAQ — Hinchey classification and management algorithm

References

Your progress

Pathophysiology

Clinical presentation

Diagnosis and imaging

Antibiotic strategy

Surgical approach: Hartmann's vs primary anastomosis

Clinical pearls

Additional pearls — complications

Red flags

Prognosis

LOLA trial (Vennix 2015, Lancet)

LADIES trial (Vennix 2015, Lancet) — overall

SCANDIV trial (Schultz 2015, JAMA)

DILALA trial (Angenete 2016, Ann Surg)

AVOD trial (Chabok 2012, Br J Surg) + long-term follow-up (Isacson 2019)

Oberkofler trial (2012, Ann Surg) — primary anastomosis vs Hartmann's

van Dijk IPD meta-analysis (2020, Br J Surg)

Kafka-Ritsch damage control surgery RCT (2020, World J Surg)

Prognosis summary

SAQ — Practice scenarios

SAQ — Perforated diverticulitis with septic shock

SAQ — Hinchey classification and management algorithm

References