Review of current classifications for diverticular disease and a translation into clinical practice
Bastiaan R. Klarenbeek
Niels de Korte
Donald L. van der Peet
Miguel A. Cuesta
Introduction Diverticular disease of the sigmoid colon prevails in Western society. Its presentation may vary greatly per individual patient, from symptomatic diverticulosis to perforated diverticulitis. Since publication of the original Hinchey classification, several modifications and new grading systems have been developed. Yet, new insights in the natural history of the disease, the emergence of the computed tomography scan, and new treatment modalities plead for evolving classifications. Methods This article reviews all current classifications for diverticular disease. Result A three-stage model is advanced for a renewed and comprehensive classification system for diverticular disease, incorporating up-to-date imaging and treatment modalities.
Diverticular disease of the sigmoid colon is a common
condition in Western society. Its presentation among
patients may vary from symptomatic diverticulosis to
perforated diverticulitis. The incidence for diverticulosis is
3366%. Of these patients, 1025% will develop an acute
episode of diverticulitis . Although diverticular disease is
more common among elderly patients, a dramatic rise of its
incidence is seen in the younger age groups .
Furthermore, depending on the severity of the disease, the
treatments for the various presentations of the disease will
differ. Accordingly, diagnostic tools, indications for surgery
as well as treatment modalities have been evolving,
resulting in more options in the therapy for diverticular
Since Hincheys traditional classification for perforated
diverticulitis in 1978, several modifications and new
grading systems have been presented to display a more
contemporary overview of the disease . Unfortunately,
these different classifications of diverticular disease have
led to conflicting terminology in current literature.
Moreover, none of the classifications seem to sufficiently
embrace the entire spectrum of the disease. This calls for
a thorough review and a new parameter.
The current classifications of diverticular disease are
based on clinical, radiological, or operative findings, yet
most lack a translation into daily clinical practice. Given a
useful classification system ought to guide clinical
decision making and management, this review serves
to combine the available classifications with current
knowledge of practice into a more useful practice parameter for
treating diverticular disease.
An extensive literature analysis was performed using the
PubMed database. The following MeSH terms were used
during the first PubMed search: diverticulitis, classification,
and colonic diverticulosis. Only a few classifications for
diverticular disease were revealed. In most publications, the
results of a clinical study on imaging or treatment modalities
are described, and rarely the proposal of a new classification
system. A second analysis using manual cross reference
search of the bibliographies of relevant articles located
studies not found in the first search. The third strategy
used the related article function in PubMed to select
articles not found in above searches. All articles in
English, German, and Dutch have been included. A
total of nine classifications and modified classifications
for diverticular disease were collected.
A proper classification system can improve mutual
communication between doctors of different specialties and
support clinical decision making. This seems indispensible
for the management of the wide spectrum of manifestations
and many treatment modalities embraced by the term
diverticular disease. Uniform classification in clear
subgroups of diverticular disease could help the clinician
in predicting outcomes and prognosis more accurately.
In 1978, Hinchey et al. published their classification for
acute diverticulitis . The Hinchey classification has
traditionally been used in international literature to
distinguish four stages of perforated disease (see Table 1). This
most widely used classification was actually based on an
earlier clinical division of acute diverticulitis published by
Hughes et al. (see Fig. 1) . Since the introduction of the
computed tomography (CT scan) in the 1980s, this imaging
modality has established itself as the primary diagnostic
tool in the assessment of diverticular disease (see Fig. 2).
The much more detailed information provided by CT scans
led earlier to modifications of the original Hinchey
classification. Subcategories could be defined by taking the
radiological findings into account. Hence, in 1997, Sher et al.
introduced the first modification for distinguishing between a
pericolic abscesses (stage I), distant abscesses amendable for
percutaneous drainage (stage IIa), and complex abscesses
Hinchey classification 
Modified Hinchey classification
by Sher et al. 
associated with a possible fistula (stage IIb) . This
modification also implied the use of new treatment strategies,
such as CT-guided percutaneous drainage of abscesses.
Fig. 2 CT scan images resembling the four Hughes stages. I Pericolic
phlegmon with small associated abscess. II Large intraabdominal
abscess. III Small amounts of free air and fluid. IV Massive
pneumoperitoneum and free fluid
In 1999, Wasvary et al. published another modification,
which since then has been widely adopted (see Table 2) .
This modification broadened the original Hinchey
classification by not only addressing perforated disease, but also
including mild clinical disease (stage 0). Additionally, a
difference was made between confined pericolic
inflammation or phlegmon (stage Ia) and a confined pericolic abscess
Also in 1999, Khler et al. published a consensus
statement drawn up by the European Association of
Endoscopic Surgeons entailing a clinical classification that
differentiated symptomatic uncomplicated disease,
recurrent symptomatic disease, and complicated disease (see
Table 3) .
In German literature since 1998, the Hansen/Stock
classification has been mainly used. This is also a clinical
classification accounting for asymptomatic diverticulosis as
well as complicated diverticulitis in different stages,
depending on the severity of the complications (see Table 4)
. These aspects make it probably the most useful
classification in clinical practice; however, it has rarely
been adopted in international literature. Another German
classification published in 1995 by Siewert et al. followed a
similar delineation for complicated disease .
Each classification accentuates different aspects of
diverticular disease, creating its own strength and
limitation. Moreover, some of these classifications appear to be
used at random in todays literature, thereby hampering
adequate interpretation and comparison. Despite this variety
of classifications, still a few clinical manifestations comprised
by diverticular disease seem to be lacking; for example
recurrent diverticular bleeding and post-inflammatory stenosis.
Table 2 Modified Hinchey classification by Wasvary et al. and CT
findings by Kaiser et al.
Modified Hinchey classification
by Wasvary et al. 
Mild clinical diverticulitis
CT findings by Kaiser et al. 
Purulent and fecal peritonitis
Small bowel obstruction due
to post-inflammatory adhesions
Table 3 Classification by Khler et al.
Classification by Khler et al. 
As stated above, Khler et al. presented a classification for
diverticular disease based on the clinical severity and
presentation of the disease. Although subjective complaints
are obviously difficult to grade, Khler et al. considered
crampy pain in the left lower quadrant, fever, and changes
in relief pattern to be symptomatic. One must consider that
a large number of patients with complaints of pain in the
left lower quadrant, fever, and soiling are probably out of
clinical sight, consulting only their general practitioner.
Such complaints are considered to be self-limiting,
sometimes assisted by antibiotic therapy. Published data on
clinical episodes of diverticulitis do not account for these
subjective complaints, leading to an underestimation of the
real scale of these mild manifestations of diverticular
disease. Furthermore, limitations of the clinical diagnosis
of diverticulitis have to be regarded .
Clinical episodes are characterized by focus on more
objective signs, like raised infectious parameters in laboratory
tests and typical findings on CT scan or colonoscopy . Yet,
this does not discount the initial subjective complaints. It is
the combination of specific symptoms that still form the
basis for a differential diagnosis and the indication for
additional examinations. For instance, impaired passage of a
stool is suggestive for a stenosis, in which a colonoscopy can
Table 4 Hansen/Stock and Siewert classification
Hansen/Stock classification 
Siewert et al. 
differentiate between post-diverticulitis stenosis or cancer;
diverticular bleeding is the most common cause of recurrent
rectal blood loss, but again cancer should be ruled out by a
colonoscopy; and pneumaturia is pathognomic for a
colovesical fistula, usually a CT scan will reveal its pathway.
Furthermore, a generalized peritonitis is only diagnosed by
physical examination. The combination of the following
symptoms should be suspected: an ill patient with fever,
absence of peristalsis, very tender abdomen on palpation,
relief pain, and dfnce musculair. A CT scan is often
mandatory in uncovering its cause and confirming the
absolute indication for surgery.
When elective surgery for diverticular disease is considered,
indications are mainly determined by the impact of symptoms
on patients lives. Complications such as stenosis, fistula, or
recurrent diverticular bleeding are clear indications for an
elective sigmoid resection, but also the prevention of perforated
diverticulitis by performing an elective sigmoid resection has
been standard policy for several decades. Recently, these
recommendations have been challenged because new data on
the natural history of diverticulitis has shown that most
perforations do not occur after recurrences, but at the first
attack of acute diverticulitis . Furthermore, conservative
management of recurrent non-perforated diverticulitis is
associated with low rates of morbidity and mortality. These
new insights resulted in a more individualized and
conservative approach to mild diverticular disease, making the extent
of subjective complaints even more important [2, 12].
The original Hinchey classification was based on both clinical
and surgical findings. Since then diagnostic tools have widely
been improved and new modalities have been developed. The
usual tests performed at the acute phase of diverticular disease
are the following: water-soluble contrast enema, CT scan, and
ultrasound (US). Although US has been proven as a
noninvasive, readily available, and well-performing tool for
the diagnosis of acute diverticulitis, its drawbacks are the
dependency on the level of the examiners competence and the
fact that images are unreadable for other physicians .
In todays clinical practice regarding diverticular disease,
CT scans enhanced with intravenous and intrarectal contrast
have, because of their superior sensitivity and specificity up
to 100%, replaced contrast enemas as the most important
imaging modality [14, 15]. Especially when an associated
abscess is suspected, a CT scan can be very helpful to
demonstrate its presence. Also, the possibility of direct
percutaneous drainage makes it a valuable attribute in the
treatment of complicated diverticular disease . In the
case of diverticular bleeding, a CT scan enhanced with
intravenous contrast (CT angio) may demonstrate a contrast
blush, a limitation is that blood loss has to be at least 2 ml/min.
Furthermore, it has to be considered that 80% of all
diverticular bleeding is self-limiting. The role of interventional
radiology is yet to be determined, occasional successes of
highly selective arterial embolization are described .
A colonoscopy is indicated when there is doubt about
cancer, persisting or recurrent complaints in the left lower
quadrant, and suspicion of a stenosis or recurrent blood loss.
Colonoscopy enables biopsies for histological diagnosis, and
cessation of diverticular bleeding may be attempted by
endoscopic measures, such as clipping, coagulation, or
adrenaline injections . Follow-up colonoscopy for ruling
out malignancy is usually performed 6 weeks after an
episode of acute diverticulitis. Routine colonoscopy divulges
the majority finds of asymptomatic diverticular disease.
In recent years, magnetic resonance imaging (MRI) has
gained popularity, because it lacks the ionizing radiation of a CT
scan, yet matches its sensitivity and specificity . Additional
advantages of MRI over CT scan are its better visualization of
fistulae and the possibility of virtual colonoscopy, thereby
making invasive colonoscopy unnecessary. To current date, the
availability of the MRI and experienced radiologists are often
limited and therefore not suitable for routine use.
The wide use of CT scans initiated modifications to the
Hinchey classification, but also several new radiological
classifications for diverticular disease were developed. Kaiser
et al. have published specific CT findings per modified
Hinchey stage (see Table 2), resulting in a guideline for
objective observation and reporting of CT scans . The
publications on the role of CT scans in diverticular disease
by Ambrosetti et al. allocate diverticulitis into severe or
moderate disease (see Table 5). In this approach, the CT scan
provides the physician guidance in the treatment of acute
complications, as well as a prognostic factor in the
development of chronic complications after a first
conservatively treated episode .
The wide spectrum of diverticular disease warrants a
differentiated approach to the different manifestations. Treatment
Table 5 CT findings by Ambrosetti et al.
CT findings by Ambrosetti et al. 
options for mild disease, associated abscesses, perforations,
bleeding, and post-inflammatory complications are discussed
separately. Also, the role of elective or preventive sigmoid
resection will be addressed.
Moderate cases of diverticular disease, such as phlegmon or
small abscesses, can be treated conservatively. Initial
prescriptions are often antibiotics and an easily digestible diet, although
no clear evidence exists for both their beneficial actions.
Preventive measures are thought to be more successful by
several authors, high-fiber diet, and prevention of obesity and
treatment of comorbidities are the usual ingredients .
Newer insights into the pathophysiology of diverticular
disease, comparable to inflammatory bowel disease, have
led to research on the potentials of 5-aminosalicylic acid
(Mesalazine) and probiotics as adjunctive treatments for
diverticular disease. Tursi et al. have described promising
results, but these medications are still only administered in
experimental settings [25, 26].
Large abscesses, if amendable and usually larger than 5 cm,
should be good candidates for CT-guided percutaneous
drainage . This procedure may relieve symptoms or
function as a bridge to (elective) surgery. A purulent or fecal
peritonitis results from a perforation and is associated with
high morbidity and mortality (1035%) . In these severe
circumstances, acute surgical intervention is warranted.
Hartmanns procedure used to be the treatment of choice
for decades, but in recent literature, a few interesting
alternatives have emerged. Several authors consider a
primary anastomosis a safe option in purulent peritonitis,
with or without defunctioning stoma. Even in fecal
peritonitis, successful series of primary anastomosis have been
published . In 2008, Myers et al. introduced the concept
of laparoscopic lavage for purulent peritonitis. This minimal
invasive method provided resolution in 87% of patients and
a reduction in mortality of up to 25% described for
Hartmanns procedure to 3% for laparoscopic lavage. Since
then, several series have been published, but evidence from a
randomized controlled trial is still to be awaited .
In order to prevent complicated disease after two episodes
of acute diverticulitis, it has been considered good practice
for years to perform elective sigmoid resection after two
episodes of symptomatic diverticulitis and even doing so
after one episode in the younger patients . These
recommendations drawn up by the American Society of
Colorectal Surgeons in 2000 have recently been challenged.
It is now thought that after a conservatively treated episode,
diverticular disease usually follows a rather benign course
and that complications occur mostly at first presentation [10,
32, 33]. Therefore, elective sigmoid resections should be
restricted for use in treating complicated disease, such as
symptomatic stenosis, fistulas to a hollow organ, or recurrent
diverticular bleeding. Furthermore, recent publications on the
natural course of diverticular disease suggest applying early
elective sigmoid resection in high-risk patients, such as the
use of immune suppression therapy, having chronic renal
failure, or collagenvascular diseases. The management of
diverticular disease in young patients remains controversial.
A more hazardous course has been suggested. In contrast,
opponents account the longer lifespan responsible for more
recurrences and complications and thereby a higher
cumulative risk of emergency surgery. An individual approach,
weighing symptoms and peri-operative risks on a case by
case basis, seems the most appropriate policy [34, 35].
Since the mid-1990s, laparoscopic sigmoid resections for
diverticular disease have gained popularity. Several
retrospective series after laparoscopic sigmoid resections suggested
improvements in minor complication rates, earlier resumption
of food, and shorter hospital stay . In January 2009,
these beneficial effects were confirmed by a randomized
controlled trial; the short-term results showed that a
laparoscopic approach delivered a significant 15.4%
reduction in major morbidity, less pain, shorter hospitalization, and
improved quality of life at the cost of a longer operating time
. After 6 months follow-up, the reduction in major
morbidity accumulated to 27% . Therefore, laparoscopic
sigmoid resection may well be the procedure of choice for
patients requiring elective resection for diverticular disease.
Discussion and a proposal of a new classification
This review of the current classification systems for a
condition as complex as diverticular disease raises the
question: Is there a need for another classification? We
acknowledge that the introduction of still another
classification could be even more confusing. Consequently, the aim of
this review is not to add another modification or new
classification, but to combine the existing classifications and
make a comprehensive translation of the findings for use in
daily clinical practice. By doing so, new imaging and
treatment modalities are to be incorporated. The clinical
applicability of this three-stage model has yet to be addressed
by means of prospective data and expert panel validation.
We propose three stages of differentiating diverticular
disease: Auncomplicated, Bchronic complicated, and
Cacute complicated (see Table 6). We thereby address
clinical findings (Clinical presentation), radiological
findings (Imaging), and treatment modalities (Treatment) in
different paragraphs. This stepwise approach resembles
clinical decision making and forms the basis for a practice
parameter on diverticular disease (see Table 6).
The three stages A, B, and C is in accordance with the
clinical classification as devised by Khler et al. and the
German Hansen/Stock classification. An important difference
is that since indications for elective resection no longer depend
on the number of episodes, there is no further need to distinguish
CT scan or US
Treatment acute episode
Table 6 Proposed classification
between symptomatic uncomplicated disease and recurrent
symptomatic disease. Furthermore, the category of
complicated disease found in both Khler and Hansen/Stock
classifications embraces all possible complications of
diverticular disease, both moderate and severe, and so may be
confusing. In this classification, complications are certified by
severity and therapeutic options.
The original Hinchey classification for perforated
diverticulitis and its modifications are mainly represented in
stage C. Large abscesses (C1) and perforated disease (C4)
are severe complications, but also massive diverticular (C3)
bleeding and total bowel obstruction (C2) are entitled to
acute interventions. In large abscesses, if amendable and
usually larger than 5 cm, CT- or US-guided percutaneous
drainage should be attempted as final treatment or bridge to
surgery. Massive diverticular bleeding might be approached
endoscopically (clipping, coagulation, or adrenaline injections)
or even endovascular (coiling), but in most centers, a
(laparoscopic) sigmoid resection is probably the final
resolution. When a general peritonitis is suspected on physical
examination, confirmed by CT scan, surgical intervention is
warranted. According to current literature, a safe strategy
might be to primarily perform a diagnostic laparoscopy. In the
case of a purulent peritonitis, either (laparoscopic) sigmoid
resection with primary anastomosis (with or without
defunctioning stoma) or even laparoscopic lavage may be considered
in selected cases. When fecal contamination is discovered,
Hartmanns procedure is still considered the safest option, but
in select cases, a primary anastomosis (with or without
defunctioning stoma) might be a safe alternative.
In most classifications, post-inflammatory changes like
stenosis or fistulas are not included. Patients may have serious
complaints, but interventions can usually be postponed to an
elective setting. Stage B includes non-acute complications of
diverticular disease, such as symptomatic stenosis, fistulas to
hollow organ, recurrent (self-limiting) diverticular bleeding,
and incapacitating complaints. This last group of patients
covers mainly those young patients who are incapacitated by
recurrent attacks and hospital admissions, which prevent them
from having normal working careers and social life. In
addition, high-risk patients, such as those immune
compromised, using of NSAIDs and other immune suppressants or
experiencing chronic renal failure, might be good candidates
for early elective sigmoid resection. The planning of an
elective operation makes it possible to do a proper
preoperative work-up to prevent unwelcome surprises during surgery.
In cases of stenosis or recurrent rectal blood loss, it is
advisable to perform a colonoscopy to rule out cancer.
CT scan is of superior diagnostic value in case of
stenosis or fistula. During preoperative planning of
complex fistula, MRI might have some benefit over
CT scan. Stage B disease forms indications for elective
sigmoid resections, preferably laparoscopically.
Stage A contains symptomatic uncomplicated disease.
Patients with subclinical complaints or recurrent hospital
admission should not be considered differently because
both groups will fully recover with conservative measures.
Acute episodes of stage A diverticulitis can mostly be
resolved with antibiotics and a low residue diet.
Recurrent episodes usually follow a benign course and
risks of complications are low. At presentation, a CT
scan or US (provided an experienced radiologist is
available) has to be performed to rule out complicated
disease. Moreover, these baseline findings are crucial if
the patient deteriorates during conservative treatment.
Small amounts of mucus or blood loss are generic signs
of inflammation, whereby colonoscopy has to rule out
other inflammatory bowel diseases or colon cancer.
After a first attack, preventive measures have to be
taken into account, such as high-fiber diet, weight loss,
and treatment of comorbid conditions. In the near
future, the prescription of Mesalazine might be added
to this preventive strategy.
In conclusion, this manuscript provides an overview
of current classification systems for diverticular disease.
The proposed three-stage model provides a renewed and
comprehensive classification system for diverticular
disease, incorporating up-to-date imaging and (future)
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