Acute Colonic Diverticulitis: Experience in Its Treatment and Predictors of Recurrence in a General Surgery Service

Agustina S. Hermida1, Agustín A. Alesandrini2, Juan A. Perriello2, Lisandro M. Alvarez3, Nadia M. Miranda3

Hospital Privado de la Comunidad, Mar del Plata, Provincia de Buenos Aires, Argentina

1General Surgery Resident

2General Surgeon and Colorectal Surgeon

3General Surgeon

ABSTRACT

Background: Diverticular disease is a common condition in Western countries, with an incidence that increases with age. Although most patients remain asymptomatic, a proportion develop acute diverticulitis, which carries a risk of recurrence and complications. While medical treatment is effective in most cases, some patients progress to a complicated disease requiring invasive interventions.

Objective: To describe our institutional experience in the management of acute colonic diverticulitis and to evaluate factors associated with recurrence.

Materials and Methods: A retrospective observational cohort study was conducted including patients admitted for the treatment of acute diverticulitis over an 8-year period (2013–2020) at the General Surgery Service of Hospital Privado de Comunidad.

Results: A total of 329 patients were included, with a mean age of 65 years and a predominance of women. Most patients were overweight or obese and had a low comorbidity index.

Management was predominantly conservative, with invasive interventions reserved for a minority of cases. Percutaneous drainage and laparoscopic lavage with abdominal drainage showed favorable outcomes in selected patients, with a low need for bowel resection. Recurrence occurred in approximately 25% of patients. On multivariable analysis, age >50 years was independently associated with a lower risk of recurrence (OR 0.47; 95% CI 0.24–0.91; p = 0.025).

Conclusions: Most patients with acute diverticulitis were successfully managed conservatively during the initial episode. Minimally invasive strategies, such as percutaneous drainage and laparoscopic lavage with abdominal drainage, were effective in selected patients. Recurrence occurred in approximately one-quarter of cases, and age >50 years was independently associated with a lower risk of recurrence. These findings support a conservative and individualized approach, in which the indication for surgery should not be based solely on recurrence.

Keywords: acute diverticulitis; recurrence; percutaneous drainage; lavage and drainage

INTRODUCTION

Colonic diverticular disease is a common condition in Western countries, with prevalence increasing with age, reaching 60–65% in individuals over 60 years.1,2 Although most patients with diverticulosis remain asymptomatic, a proportion develop acute diverticulitis, the main clinical complication of the disease.

Acute diverticulitis encompasses a wide clinical spectrum, ranging from uncomplicated disease to severe cases with abscesses, perforation, and peritonitis, requiring different management strategies. The Hinchey classification and its modifications remain a fundamental tool for severity stratification, particularly in computed tomography–based assessment.3,6 Although most cases are managed conservatively, recurrence and optimal patient selection for more aggressive interventions remain clinical challenges.7−11

In this context, important questions remain regarding predictors of recurrence and optimal management strategies in real-world practice. There is limited data from local institutional series.

The primary objective of this study was to retrospectively describe the experience in the management of patients hospitalized with acute diverticulitis at the General Surgery Service of Hospital Privado de Comunidad de Mar del Plata. Secondary objectives were to assess the association of age and Charlson Comorbidity Index with disease severity and need for surgery, to identify independent predictors of recurrence, to compare outcomes between medical and surgical treatment in terms of complications and recurrence, and to evaluate the impact of percutaneous drainage on clinical outcomes.

MATERIALS AND METHODS

A retrospective observational cohort study was conducted including patients admitted with acute diverticulitis between 2013 and 2020 at the General Surgery Service of Hospital Privado de Comunidad.

Patients aged ≥18 years with a diagnosis of acute diverticulitis confirmed by computed tomography (CT) were included. Patients managed on an outpatient basis and those who developed diverticulitis during hospitalization for another condition were excluded.

Management was performed according to an institutional protocol based on clinical severity and CT findings, using the modified Hinchey classification for stratification.

Patients classified as Hinchey Ia were managed conservatively with broad-spectrum antibiotics, analgesia, and supportive care, including bowel rest or a liquid diet according to clinical course. In patients with Hinchey Ib and II disease, initial conservative management was indicated in those with abscesses smaller than 2–3 cm and without signs of persistent sepsis. In cases of larger or medically refractory abscesses, CT-guided percutaneous drainage was performed when anatomically feasible and clinically indicated. Patients with Hinchey III diverticulitis, characterized by purulent peritonitis without overt colonic perforation, were treated with abdominal lavage and drainage, with resection reserved for those with clinical deterioration or failure to control sepsis. In Hinchey IV cases, defined as feculent peritonitis due to colonic perforation, emergency resection was performed.

Recurrence was defined as a subsequent hospitalization for acute diverticulitis.

Statistical Analysis

Categorical variables are presented as frequencies and percentages, and continuous variables as means with standard deviations or medians with interquartile ranges, according to data distribution. Multivariable analysis was performed using binary logistic regression to identify independent predictors of recurrence in acute diverticulitis. Variables with a p-value < 0.20 in univariate analysis, as well as those of clinical relevance, were included in the model. Results are expressed as odds ratios (OR) with 95% confidence intervals (95% CI). A p-value < 0.05 was considered statistically significant.

RESULTS

A total of 329 patients were included, with a mean age of 65 years; 57.5% were female. Baseline demographic characteristics, risk factors, and comorbidities among patients with initial and recurrent episodes of acute diverticulitis are shown in Table 1.

Management strategies for the initial episode and recurrence are summarized in Fig. 1. Patients with a first episode of acute diverticulitis were treated according to clinical severity, using the modified Hinchey classification to guide management. The initial episode was managed conservatively in 267 patients (81.1%), including those with Hinchey Ia and selected Hinchey Ib–II disease. Conservative treatment was effective in patients with abscesses smaller than 2–3 cm. Larger collections required percutaneous drainage. During the initial episode, percutaneous drainage was performed in 13 patients, of whom 5 (38.5%) developed recurrence. Considering both initial and recurrent episodes, a total of 21 percutaneous drainages were performed in 20 patients.

Following percutaneous drainage, 15 patients required surgical intervention (11 elective and 4 emergency procedures). In 5 patients, a non-operative strategy was maintained. One patient required emergency surgery during the same admission due to failure of drainage, and another high-risk patient died during follow-up. The remaining emergency procedures occurred during subsequent readmissions.

The initial episode was managed conservatively in 267 patients (81.1%), primarily those with Hinchey Ia and selected Hinchey Ib–II disease. Conservative treatment proved effective for abscesses smaller than 2–3 cm, while larger collections required percutaneous drainage.

Among the 22 patients with purulent peritonitis, initial management consisted of abdominal lavage and drainage; during follow-up, 1 patient (4.5%) required readmission and CT-guided percutaneous drainage, and 4 patients (18.2%) subsequently required elective surgery. No emergency surgery or mortality was observed in this group.

In the 23 patients with feculent peritonitis, emergency resection was performed (17 Hartmann procedures and 6 primary resections with anastomosis) (Fig. 1). Mortality in this group was 17.4% (4/23), occurring exclusively in patients older than 83 years.

Overall recurrence after the initial episode was 23.4% (77/329) (Fig. 1). Among patients initially managed non-operatively, 22.5% (60/267) experienced recurrence during follow-up. Of those with recurrence after initial medical management, 48 (80%) were again managed conservatively, while 12 (20%) required invasive treatment: 5 percutaneous drainages, 1 abdominal lavage and drainage, 4 Hartmann procedures, and 2 resections with primary anastomosis.

On multivariable analysis, age >50 years was independently associated with a lower risk of recurrence (OR 0.47; 95% CI 0.24–0.91; p = 0.025). No other variables included in the model remained statistically significant after adjustment (Table 2).

Table 1. Demographic characteristics, risk factors, and comorbidities in patients with a first episode and recurrence of acute colonic diverticulitis

Variables

Total cases

n = 329

Recurrence

n =77

No recurrence

n = 252

 p

Age, n (%)

≤ 50

> 50

106 (32.2)

223 (67.8)

32 (41.5)

33 (43)

74 (29)

134 (53)

 0.0210

Sex, n (%)

Male

Female

140 (42.5)

189 (57.5)

32 (41.5)

45 (58.5)

108 (42.8)

144 (57.2)

0.8442

0.8442
Overweight/Obesity, n (%) 230 (70) 52 (67) 178 (70) 0.6022
Charlson Comorbidity Index, n (%)
 < 4
 ≥ 4

315 (95.7)

14 (4.2)

76 (99)

1 (1)

239 (94.8)

13 (5.2)

0.1427

0.1427
Immunosuppression / immunosuppressive therapy, n (%) 15 (4) 3 (3) 12 (4.7) 0.7942
Diabetes mellitus, n (%) 60 (18) 11 (3.3) 49 (19.4) 0.3113
Cardiovascular disease, n (%) 94 (28.5) 24 (31) 70 (27.7) 0.5636
Smoking, n (%) 145 (44) 29 (37) 116 (46) 0.1985
Malignancy, n (%) 27 (8) 4 (5) 23 (9) 0.2812
Renal disease, n (%) 18 (4) 2 (2) 16 (6.3) 0.2126

Time-to-event analysis showed a progressive increase in cumulative recurrence over follow-up (Fig. 2). Patients without recurrence remained censored, while groups with a higher number of total episodes demonstrated earlier accumulation of events. However, because groups were defined according to the total number of observed episodes, this figure should be interpreted descriptively rather than as a comparative risk analysis.

Similarly, temporal analysis of recurrence according to initial treatment showed differences in event accumulation between groups (Fig. 3). Patients initially managed medically showed a gradual increase in recurrence over time, whereas those treated with lavage and drainage demonstrated earlier recurrence. The “other” group showed fewer and later events. These findings should be interpreted with caution due to the small number of patients in the surgical and invasive treatment groups.

Table 2. Factors associated with diverticulitis recurrence in the multivariable logistic regression model. Adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) are shown for the five included variables

Variable OR 95% CI p
Age > 50 years 0.47 0.24–0.91 0.025
Male sex 0.82 0.47–1.44 0.489
Charlson Comorbidity Index ≥ 4 0.46 0.13–1.61 0.224
Smoking (yes) 0.81 0.47–1.38 0.435
Hinchey stage ≥ II (vs ≤ I) 1.23 0.62–2.46 0.549

DISCUSSION

Colonic diverticular disease is one of the most common conditions encountered in surgical practice, particularly among older patients. In our series, the mean age at presentation was 65 years, consistent with

previous reports.12–16 Its high prevalence in Western countries and the progressive increase in incidence with age generate a substantial healthcare burden because of both hospital admissions and the potential need for invasive interventions.

Most episodes of acute diverticulitis have a favorable course with medical management, whereas surgery is generally reserved for patients with complicated disease or clinical deterioration. In our cohort, 81% of patients were managed conservatively during the initial episode, consistent with contemporary series and current guideline recommendations that favor a selective and less invasive approach based on individual clinical and radiologic findings.

The Hinchey classification remains a key tool for therapeutic decision-making. Patients with Hinchey Ia diverticulitis were treated exclusively with antibiotics and supportive measures, whereas conservative management was prioritized in patients with Hinchey Ib–II disease and small collections, reserving percutaneous drainage for larger abscesses. This stepwise approach achieved adequate sepsis control in most patients, with a low rate of conversion to surgery, in agreement with previous reports and international recommendations.17–25

C:\Users\lilia\Documents\SACP Revista\Rev 2026\Rev 2026 Vol 37 Nro 2\Artiiculos finales a traducir\Figura 1.png

Figure 1. Recurrence after the first episode of acute diverticulitis according to the initial treatment strategy.

In our experience, percutaneous drainage proved effective in patients with Hinchey II diverticulitis, allowing resolution of the acute episode without immediate surgery in most cases. Although some patients developed recurrence, the subsequent need for emergency surgery was low, supporting the role of percutaneous drainage as a safe and effective therapeutic strategy.

In patients with Hinchey III–IV diverticulitis, surgical management was determined by the patient’s clinical condition and intraoperative findings. In cases of purulent peritonitis without overt perforation, abdominal lavage and drainage achieved effective infection control, with low mortality and more than 80% of patients avoiding subsequent resection. These findings are consistent with reports supporting lavage and drainage as a valid alternative in carefully selected patients, although its indication remains controversial.24,25 In contrast, all patients with feculent peritonitis underwent bowel resection, with a mortality rate of 17.4%.

Recurrence remains one of the major challenges in the long-term management of these patients. In our series, 23% of patients experienced at least 1 recurrent episode after the initial event, a rate comparable to that reported in the literature.2,5,20

Age >50 years was independently associated with a lower risk of recurrence, suggesting that outcomes are not determined exclusively by age. In addition, most recurrent episodes did not require surgical treatment. These findings support an individualized approach to acute diverticulitis, in which the indication for surgery should not be based solely on age or number of episodes, but on disease severity, comorbidities, and impact on quality of life. This strategy is consistent with current recommendations from major scientific societies, which discourage elective resection based on isolated criteria.26–31

Finally, although our study includes a significant number of cases and reflects the actual practice of a general surgery service, it has limitations inherent to its retrospective design. Data obtained from previously completed medical records may be associated with incomplete information, lack of standardization, and information bias. In addition, the absence of prospective patient selection introduces potential selection bias. However, multivariable analysis allowed to identify factors independently associated with recurrence. Prospective studies are needed to validate these findings.

C:\Users\lilia\Documents\SACP Revista\Rev 2026\Rev 2026 Vol 37 Nro 2\Artiiculos finales a traducir\Figura 2.png

Figure 2. Cumulative incidence of acute diverticulitis recurrence (1 − S[t]) according to the total number of episodes (Group 1: no recurrence; Group 2: one recurrence; Group 3: two recurrences; Group 4: three recurrences). Time is expressed in months from the initial episode. Recurrence was defined as a second hospitalization, and “months from the initial episode” refers to the interval between hospitalizations. Patients without recurrence were censored at last follow-up.

C:\Users\lilia\Documents\SACP Revista\Rev 2026\Rev 2026 Vol 37 Nro 2\Artiiculos finales a traducir\Figura 3.png

Figure 3. Cumulative incidence of acute diverticulitis recurrence (1 − S[t]) according to the treatment modality used during the initial episode. Time is expressed in months from the initial episode. Recurrence was defined as a second hospitalization, and “months from the initial episode” refers to the interval between hospitalizations. Patients without recurrence were censored at the last follow-up.

CONCLUSIONS

Acute diverticulitis is a common condition in surgical practice, characterized by a heterogeneous clinical course that requires an individualized approach. In our institutional experience, most patients were successfully managed conservatively during the initial episode, with favorable clinical outcomes and a low need for surgery.

Minimally invasive strategies, such as percutaneous drainage and laparoscopic lavage and drainage, proved to be effective therapeutic

alternatives in selected patients, often avoiding the need for emergency bowel resection.

Recurrence was observed in approximately one quarter of patients. On multivariable analysis, age greater than 50 years was independently associated with a lower risk of recurrence, whereas other clinical variables showed no significant association.

Overall, these findings support a conservative, stepwise therapeutic approach in which the indication for surgery should not be based solely on recurrence, but rather on a comprehensive assessment of the patient and the severity of the clinical presentation.

Contributions:

ASH: research, data curation, data collection, and drafting of the original manuscript.

AAA: conceptualization, methodology, supervision, research, drafting of the original manuscript, revision, and editing of the manuscript.

JAP: supervision, validation, formal analysis, revision, and editing of the manuscript.

LMA: data collection, data curation, and research.

NMM: data collection, data curation, and research.

All authors participated in the critical review of the manuscript and approved its final version.

Conflict of interest statement: None.

Funding: None.

Data availability statement: The data are publicly available.

ORCIDs:

Agustina S. Hermida: 0009-0001-1382-6309

Agustín A. Alesandrini: 0000-0002-9821-8360

Juan A. Perriello: 0009-0000-2798-5979

Lisandro M. Alvarez: 0009-0000-2798-5979

Nadia M Miranda: 0009-0002-6109-6731

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