Surgical management in acute diverticulitis and its association with multi-detector CT, modified Hinchey classification, and clinical parameters

Abstract

Purpose: To assess whether CT findings, clinical parameters, and modified Hinchey classification are predictive of management outcomes of patients with acute diverticulitis.

Materials and methods: Data were accrued between January 2014 and December 2015. A total of 301 adult subjects were identified from radiology reports, of which six who did not met the inclusion criteria were excluded, thus yielding 295 subjects. Subjects were 43.1% (n = 127) male and 56.9% female (n = 168), with mean age 51.9 years (range 18-90). Two independent abdominal radiologists reviewed all scans; imaging features and a modified Hinchey classification were scored. Descriptive statistics compared the relationships between imaging findings, clinical parameters obtained from medical record review, and modified Hinchey classification with management outcomes.

Results: CT findings associated with surgical management include the presence of a pericolonic fluid collection (36.8% vs. 8.2%, P = 0.0001), colonic fistula (13.2% vs. 0.4%, P = 0.0002), extraluminal air (26.4% vs. 9.3%, P = 0.0052), bowel obstruction (5.2% vs. 0.0%, P = 0.0162), and a modified Hinchey score of Ib or higher (55.3% vs. 11.7%, P = 0.0001). Slightly lower systolic blood pressure was also associated with operative management (137.2 mmHg vs. 128.2 mmHg, P = 0.0220).

Conclusion: Specific CT imaging features and modified Hinchey classification are associated with subsequent surgical management in patients with acute diverticulitis.

Keywords: Abscess; Colon; Computed tomography; Diverticulitis; Hinchey; Management.

Fig. 1.

A Hinchey Ia diverticulitis is characterized by a pericolonic phlegmon and associated inflammation is present, without an organized fluid collection. B Hinchey Ib diverticulitis is characterized by the additional finding of a pericolonic abscess less than 4 cm in size, adjacent to the area of diverticulitis. C Hinchey II diverticulitis is characterized by the presence of a pelvic or inter-loop abscess, or by the presence of an abscess that is larger than 4 cm. D Hinchey III and E Hinchey IV diverticulitis are characterized by the presence of purulent peritonitis and feculent peritonitis, respectively.

Fig. 2.

Representative images demonstrating common types of colonic fistulae seen as complications of diverticulitis. Included are sagittal images of a colocolonic fistula (A, arrows), colovesicular fistula (B, arrow), and colovaginal fistula (C, arrow).

Fig. 3.

A 75-year-old woman with a history of diverticulitis who presented with lower abdominal pain. Contrast-enhanced axial(A) and coronal (C) CT images of the abdomen and pelvis demonstrated acute diverticulitis with pericolonic fat stranding, engorgement of vasa recta, and mesenteric lymphadenopathy. She also had that near-circumferential intramural abscess of the sigmoid colon (A and B, arrows).