Hinchey classification of acute diverticulitis

Last revised by Andrew Murphy on 21 Apr 2022

The Hinchey classification for acute diverticulitis (anywhere along the bowel, not just the colon) has been variously adapted and modified since its original description, and is useful not only in academia but also in outlining successive stages of severity 3,5,6.  Adoption and utility of the various modified classifications is variable, and some aspects of diverticular disease such as fistula formation or obstruction are not addressed by most classifications.

  • stage 0:
    • clinical: mild clinical diverticulitis
    • CT finding: diverticula with colonic wall thickening
  • stage Ia: 
    • clinical: confined pericolic inflammation or phlegmon
    • CT finding: pericolic soft tissue changes
  • stage Ib: 
    • clinical: pericolic or mesocolic abscess
    • CT finding: Ia changes and pericolic or mesocolic abscess
  • stage II: 
    • clinical: pelvic, distant intra-abdominal or retroperitoneal abscess
    • CT finding: Ia changes and distant abscess, usually deep pelvic
  • stage III: 
    • clinical: generalized purulent peritonitis
    • CT finding: localized or generalized ascites, pneumoperitoneum, peritoneal thickening
  • stage IV: 
    • clinical: generalized fecal peritonitis
    • CT finding: same as stage III

In general, abscesses in stage Ib and II may be drained by interventional radiology, and stage III and IV disease is managed with emergent surgery.

The original surgical Hinchey classification was developed in 1978, by E John Hinchey et al. 3, categorizing four stages of acute diverticulitis7. In the 1980s, with the introduction of CT, some modifications were made to the original surgical classification system as a radiological staging system was required for the management of acute diverticulitis, leading to the most recent modification made by Kaiser et al 6  in 2015. 

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Cases and figures

  • Case 1: stage 0
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  • Case 2: stage Ia
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  • Case 3: stage Ia
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  • Case 4: stage Ib
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  • Case 5: stage Ib
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  • Case 6: stage Ib
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  • Case 7: stage II
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  • Case 8: stage III/IV
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  • Case 9: stage III/IV
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