Acute Diverticulitis — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] CT grade
   CT grade — complicated or uncomplicated (modified Hinchey)? (Acute left-colonic diverticulitis, 75% uncomplicated. Contrast CT is the first-line diagnostic + grading test (clinical accuracy is low; it also excludes colon cancer, etc.). Modified Hinchey: 0 uncomplicated; Ia confined phlegmon; Ib pericolic/mesenteric abscess; II pelvic/abdominal abscess; III diffuse purulent peritonitis; IV diffuse feculent peritonitis.)
   • Diffuse peritonitis (III/IV) / medical failure → Diffuse peritonitis → emergency surgery
   • Abscess (Ib/II) → Abscess · antibiotics ± drainage
   • Uncomplicated (Hinchey 0), stable → Uncomplicated · outpatient
2. [End] Uncomplicated · outpatient
   Uncomplicated (Hinchey 0), stable: outpatient, bowel rest, diet as tolerated; selective no-antibiotics for mild disease in the immunocompetent (ESCP/WSES), use antibiotics if imaging shows complicated features; should improve in 2–3 days — repeat CT if no improvement/worsening.
3. [End] Abscess · antibiotics ± drainage
   Abscess (Hinchey Ib/II): IV antibiotics; abscess >3–4 cm and accessible → image-guided percutaneous drainage, small abscesses may have antibiotics alone; monitor closely, escalate to surgery if worsening/not resolving. Later, assess for elective sigmoid colectomy.
4. [End] Diffuse peritonitis → emergency surgery
   Diffuse peritonitis (Hinchey III/IV) or medical failure: emergency surgery — Hartmann's procedure (sigmoid resection + end colostomy) or primary anastomosis ± defunctioning stoma, laparoscopic lavage for selected purulent peritonitis; fluid resuscitation + broad-spectrum antibiotics, anti-shock.

Source guidelines & references

• Acute diverticulitis (WSES 2020; ESCP; modified Hinchey classification)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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