ICU · Gastroenterology
Acute diverticulitis in ICU: complicated presentations
Also known as Diverticulitis · Complicated diverticulitis · Diverticular perforation · Diverticular abscess · Hinchey classification
Diverticular disease: diverticula (mucosal herniations through colonic wall) ± inflammation. Acute diverticulitis: inflammation of diverticula. ICU-relevant complicated diverticulitis (Hinchey III-IV): peritonitis, perforation, abscess, fistula, obstruction. Hinchey classification: I — pericolic abscess, II — distant abscess, III — purulent peritonitis, IV — faeculent peritonitis. Management: Hinchey I-II (abscess) — antibiotics + percutaneous drainage. Hinchey III (purulent peritonitis) — laparoscopic lavage + drainage (controversial) or Hartmann's. Hinchey IV (faeculent peritonitis) — Hartmann's procedure (sigmoid colectomy + end colostomy).
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Red flags
- Faeculent peritonitis (Hinchey IV) — free perforation with faeces in peritoneum, mortality 20-30%, emergency Hartmann's
- Purulent peritonitis (Hinchey III) — perforation with pus, surgical emergency (laparoscopic lavage NOT recommended after LOLA/SCANDIV/DILALA — Hartmann's or primary anastomosis)
- Large abscess (>4-5 cm) — percutaneous drainage + antibiotics; surgery if fails or clinical deterioration
- Free gas on imaging — indicates perforation, urgent surgical review
- Septic shock from diverticular source — early antibiotics + source control within 6h (Surviving Sepsis)
- Immunosuppressed/transplant patient — atypical presentation (often afebrile), higher perforation rate, worse outcomes, lower threshold for imaging and surgery
- Rectal bleeding with peritonitis — suspect concurrent diverticular haemorrhage AND perforation (rare but catastrophic)
- Recurrent sepsis after drainage — suspect undrained collection, fistula, or tertiary peritonitis with resistant organisms
Meet the patient
A 72-year-old man arrives confused and septic after three days of left lower quadrant pain, now with a rigid abdomen and free gas on the plain film. His lactate is 5.2 and his MAP is 60 despite two litres of crystalloid. This is Hinchey IV faeculent peritonitis — the catastrophic end of diverticular disease — and the question that decides whether he survives the night is whether the operating table can be readied before his lactate clears the screen.[9]
Hold that image and the topic falls into line. Diverticulitis is the same disease at every stage — a pseudo-diverticulum obstructed, inflamed, and perforated — and the Hinchey grade simply tells you how far the perforation has travelled and whether the answer is a drain or a knife.[9]
References12ShowHide
- [1]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
- [2]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
- [3]Chabok A, Påhlman L, Hjern F, et al. Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis Br J Surg, 2012.PMID 22290281
- [4]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
- [5]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
- [6]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
- [7]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
- [8]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
- [9]Hawkins AT, Wise PE, Chan T, et al. Diverticulitis: An Update From the Age Old Paradigm Curr Probl Surg, 2020.PMID 33077029
- [10]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
- [11]Ambrosetti P, Grossholz M, Becker C, et al. Computed tomography in acute left colonic diverticulitis Br J Surg, 1997.PMID 9112910
- [12]Hulnick DH, Megibow AJ, Balthazar EJ, et al. Computed tomography in the evaluation of diverticulitis Radiology, 1984.PMID 6739821