The approach to the treatment of diverticulitis can be broadly classified into either uncomplicated disease or complicated disease.
Acute uncomplicated diverticulitis is successfully treated in 70-100% of patients with conservative management.
- 15-25% of patients presenting with a first episode of acute diverticulitis have complicated disease that requires surgery.
- 15-30% of patients admitted for management of diverticulitis will need surgery during their admission, with an 18% surgical mortality rate.
Several staging schemes have been proposed based on clinical findings, extent on imaging studies, and the presence of complications.
Clinical staging by Hinchey's classification is geared toward choosing the proper surgical procedure when diverticulitis is complicated, as follows:
- Stage I disease - Small or confined pericolic or mesenteric abscess
- Stage II disease - Large abscess, often confined to the pelvis
- Stage III disease - Perforated diverticulitis causing generalized purulent peritonitis
- Stage IV disease - Rupture of diverticula into the peritoneal cavity with fecal contamination causing generalized fecal peritonitis.
Indications for surgery include some features characteristic of Hinchey stage III or IV disease and are as follows:
- Free-air perforation with fecal peritonitis
- Suppurative peritonitis secondary to a ruptured abscess
- Uncontrolled sepsis
- Abdominal or pelvic abscess
- Fistula formation
- Inability to rule out carcinoma
- Intestinal obstruction
- Failing medical therapy
- Immunocompromised status
- Extremes of age