Hinchey Classification of Diverticulitis
The Hinchey classification is the most widely used system for categorizing the severity of acute colonic diverticulitis, consisting of four stages that guide treatment decisions based on the extent of infection and inflammation beyond the colon. 1
Original Hinchey Classification
The original Hinchey classification categorizes diverticulitis into four progressive stages:
- Stage 1: Pericolic abscess 2, 1
- Stage 2: Pelvic, intra-abdominal, or retroperitoneal abscess 2, 1
- Stage 3: Generalized purulent peritonitis 2, 1
- Stage 4: Fecal peritonitis 2, 1
Modified Hinchey Classification (Kaiser et al., 2005)
This modification incorporates CT findings for more precise diagnosis:
- Stage 0: Mild clinical diverticulitis 2
- Stage 1a: Confined pericolic inflammation 2
- Stage 1b: Confined pericolic abscess 2
- Stage 2: Pelvic or distant intra-abdominal abscess 2
- Stage 3: Generalized purulent peritonitis 2
- Stage 4: Fecal peritonitis at presentation 2
Mora Lopez Classification (2013)
This classification divides Neff stage 1 into:
- Stage 1a: Localized pneumoperitoneum in the form of gas bubbles 2
- Stage 1b: Abscess < 4 cm 2
- Stage 2: Complicated diverticulitis with pelvic abscess (> 4 cm in pelvis) 2
- Stage 3: Complicated diverticulitis with distant abscess (in abdominal cavity outside pelvis) 2
- Stage 4: Complicated diverticulitis with other distant complications (abundant pneumoperitoneum and/or intra-abdominal free liquid) 2
Sallinen Classification (Recent)
This classification is based on clinical, radiologic, and physiologic parameters:
- Stage 1: Uncomplicated diverticulitis 2
- Stage 2: Complicated diverticulitis with small abscess (< 6 cm) 2
- Stage 3: Complicated diverticulitis with large abscess (≥ 6 cm) or distant intraperitoneal or retroperitoneal gas 2
- Stage 4: Generalized peritonitis without organ dysfunction 2
- Stage 5: Generalized peritonitis with organ dysfunction 2
WSES CT-Guided Classification (2015)
This classification divides acute diverticulitis into uncomplicated and complicated forms:
Uncomplicated Acute Diverticulitis
- Stage 0: Diverticula, thickening of the wall, increased density of the pericolic fat 2
Complicated Acute Diverticulitis
- Stage 1A: Pericolic air bubbles or small amount of pericolic fluid without abscess (within 5 cm from inflamed bowel segment) 2
- Stage 1B: Abscess ≤ 4 cm 2
- Stage 2A: Abscess > 4 cm 2
- Stage 2B: Distant gas (> 5 cm from inflamed bowel segment) 2
- Stage 3: Diffuse fluid without distant free gas 2
- Stage 4: Diffuse fluid with distant free gas 2
Clinical Implications
- CT imaging is essential for accurate classification and management planning of diverticulitis 1
- Relying solely on clinical examination for diagnosis is not recommended due to poor accuracy 1
- The accuracy of predicting Hinchey's classification by preoperative CT scanning ranges from 71% to 92%, with positive predictive values between 45% and 89% 3
- Free intra-abdominal air in combination with diffuse fluid is a reliable indication for surgery as it strongly correlates with generalized peritonitis (Hinchey 3 or 4) 3
- CT evidence of a diverticular abscess has prognostic impact as it correlates with a high risk of failure from nonoperative management 4
Management Based on Classification
- For Hinchey 1b (small abscess < 4 cm), non-operative management with bowel rest and antibiotics is recommended 1
- For Hinchey 2 (larger abscess > 4 cm), percutaneous drainage is recommended 1
- Primary resection with anastomosis has shown advantages over Hartmann's procedure in terms of lower mortality rates and shorter hospital stays for selected patients with Hinchey III-IV diverticulitis 5