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ORIGINAL ARTICLE

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

To cite:

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.

Hermida AS, Alesandrini AA, Perriello JA,

Alvarez LM, Miranda NM. Acute Colonic

Diverticulitis: Experience in Its Treatment

and Predictors of Recurrence in a General

Surgery Service. Rev Argent Coloproctol.

2026; 37(2)9-14.

doi:10.46768/wwpxhp83

Additional supplemental material, when

applicable, is published online only. To

view, please visit the journal online:

https://doi.org/10.46768/wwpxhp83

Received: September 29, 2025.

Accepted: May 11, 2026.

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

INTRODUCTION

MATERIALS AND METHODS

Colonic diverticular disease is a common condition

A retrospective observational cohort study was

in Western countries, with prevalence increasing

conducted including patients admitted with acute

with age, reaching 60–65% in individuals over 60

diverticulitis between 2013 and 2020 at the General

years.^1,2Although most patients with diverticulosis

Surgery Service of Hospital Privado de Comunidad.

remain asymptomatic, a proportion develop acute

Patients aged ≥18 years with a diagnosis of acute

diverticulitis, the main clinical complication of the

diverticulitis confirmed by computed tomography

disease.

(CT) were included. Patients managed on an

Acute diverticulitis encompasses a wide clinical

outpatient basis and those who developed

spectrum, ranging from uncomplicated disease to

diverticulitis during hospitalization for another

severe cases with abscesses, perforation, and

condition were excluded.

peritonitis, requiring different management

Argentine Journal of Coloproctology. This

article is distributed under the Creative

Commons Attribution–NonCommercial–

NoDerivatives 4.0 International License

(CC BY-NC-ND 4.0).

Management was performed according to an

strategies. The Hinchey classification and its

institutional protocol based on clinical severity and

modifications remain a fundamental tool for severity

CT findings, using the modified Hinchey

stratification, particularly in computed tomography–

classification for stratification.

based assessment.^3,6Although most cases are

Patients classified as Hinchey Ia were managed

managed conservatively, recurrence and optimal

https://creativecommons.org/licenses/by-nc-

nd/4.0/

conservatively with broad-spectrum antibiotics,

patient selection for more aggressive interventions

analgesia, and supportive care, including bowel rest

remain clinical challenges.^7-11

or a liquid diet according to clinical course. In

In this context, important questions remain

regarding predictors of recurrence and optimal

patients with Hinchey Ib and II disease, initial

conservative management was indicated in those

management strategies in real-world practice. There

with abscesses smaller than 2–3 cm and without

is limited data from local institutional series.

signs of persistent sepsis. In cases of larger or

The primary objective of this study was to

medically refractory abscesses, CT-guided

retrospectively describe the experience in the

percutaneous drainage was performed when

management of patients hospitalized with acute

anatomically feasible and clinically indicated.

diverticulitis at the General Surgery Service of

Correspondence to

Agustina S. Hermida

hermidaagustinasol@gmail.com

Patients

with

Hinchey

III

diverticulitis,

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.

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

hospitalization for acute diverticulitis.

subsequent

REV ARGENT COLOPROCTOL | 2026 | VOL 37, No. 2

ORIGINAL ARTICLE

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

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

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.

first episode of acute

conservatively, while 12 (20%) required invasive treatment:

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

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

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

Immunosuppression /

immunosuppressive therapy, n (%)

15 (4)

3 (3)

12 (4.7)

0.7942

Diabetes mellitus, n (%)

Cardiovascular disease, n (%)

Smoking, n (%)

60 (18)

94 (28.5)

145 (44)

27 (8)

11 (3.3)

24 (31)

29 (37)

4 (5)

49 (19.4)

70 (27.7)

116 (46)

23 (9)

0.3113

0.5636

0.1985

0.2812

0.2126

Malignancy, n (%)

Renal disease, n (%)

18 (4)

2 (2)

16 (6.3)

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.

ACUTE COLONIC DIVERTICULITIS: TREATMENT AND PREDICTORS OF RECURRENCE

Hermida AS, et al.

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ORIGINAL ARTICLE

previous reports.^12–16Its 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.

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

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.

Variable

Age > 50 years

Male sex

Charlson Comorbidity Index ≥ 4

Smoking (yes)

Hinchey stage ≥ II (vs ≤ I)

95% CI

0.47

0.82

0.46

0.81

1.23

0.24–0.91

0.47–1.44

0.13–1.61

0.47–1.38

0.62–2.46

0.025

0.489

0.224

0.435

0.549

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

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

agreement

with

reports

and

international

recommendations.^17–25

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.^24,25In contrast, all

patients with feculent peritonitis underwent bowel resection, with a

mortality rate of 17.4%.

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.

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

ACUTE COLONIC DIVERTICULITIS: TREATMENT AND PREDICTORS OF RECURRENCE

Hermida AS, et al.

REV ARGENT COLOPROCTOL | 2026 | VOL 37, No. 2

ORIGINAL ARTICLE

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.

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.

alternatives in selected patients, often avoiding the need for emergency

bowel resection.

CONCLUSIONS

Recurrence was observed in approximately one quarter of patients. On

multivariable analysis, age greater than 50 years was independently

Acute diverticulitis is a common condition in surgical practice,

associated with a lower risk of recurrence, whereas other clinical

characterized by a heterogeneous clinical course that requires an

variables showed no significant association.

individualized approach. In our institutional experience, most patients

Overall, these findings support a conservative, stepwise therapeutic

were successfully managed conservatively during the initial episode,

approach in which the indication for surgery should not be based

with favorable clinical outcomes and a low need for surgery.

solely on recurrence, but rather on a comprehensive assessment of the

Minimally invasive strategies, such as percutaneous drainage and

patient and the severity of the clinical presentation.

laparoscopic lavage and drainage, proved to be effective therapeutic

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.

Contributions:

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

manuscript.

ACUTE COLONIC DIVERTICULITIS: TREATMENT AND PREDICTORS OF RECURRENCE

Hermida AS, et al.

REV ARGENT COLOPROCTOL | 2026 | VOL 37, No. 2

ORIGINAL ARTICLE

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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