Acute Diverticulitis · Conservative vs Surgery

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] Hinchey grade / complexity
   Hinchey grade / abscess or perforation? (Elective sigmoid colectomy: individualize for complicated/recurrent disease (not rigidly by number of episodes).)
   • Uncomplicated (Hinchey 0/Ia, no abscess or perforation) → Uncomplicated → supportive/selective antibiotics
   • Abscess (Hinchey Ib/II) → Abscess · by size
   • Diffuse peritonitis (Hinchey III purulent / IV feculent)/free perforation/sepsis → Peritonitis/perforation → emergency surgery
2. [End] Uncomplicated → supportive/selective antibiotics
   Uncomplicated diverticulitis → outpatient/inpatient supportive care, bowel rest; mild disease in the immunocompetent may have selective no-antibiotics (observation); high-risk/progressing/immunosuppressed get antibiotics.
3. [Decision] Abscess · by size
   Abscess size?
   • Abscess <4 cm → Abscess <4 cm → antibiotics
   • Abscess ≥4 cm → Abscess ≥4 cm → percutaneous drainage
4. [End] Abscess <4 cm → antibiotics
   Abscess <3–4 cm → IV antibiotics + support, usually resorbs; monitor closely, drain/operate if progressing.
5. [End] Abscess ≥4 cm → percutaneous drainage
   Abscess ≥4 cm → percutaneous drainage + IV antibiotics; failed drainage/progression to peritonitis → surgery.
6. [End] Peritonitis/perforation → emergency surgery
   Diffuse peritonitis (Hinchey III/IV)/free perforation/sepsis → emergency surgery (Hartmann's resection + stoma or resection + primary anastomosis ± diversion); resuscitation + broad-spectrum antibiotics.

Source guidelines & references

• Acute diverticulitis management (ASCRS 2020; WSES; 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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