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How complicated is complicated diverticulitis?--phlegmonous diverticulitis revisited.
Christian F Jurowich1, Stefanie Jellouschek, Ralf Adamus
1Department of General-, Visceral-, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.
International Journal of Colorectal Disease
|August 11, 2011
Summary
Phlegmonous diverticulitis (type IIA) is frequently understaged, often concealing covered perforations (type IIB). This highlights the need to classify phlegmonous diverticulitis as complicated acute diverticulitis.
Area of Science:
- Gastroenterology
- Surgical Diagnostics
- Medical Imaging
Background:
- Acute diverticulitis classification systems are crucial for guiding treatment decisions.
- The Hansen and Stock (H&S) classification is widely used in Germany for staging diverticulitis.
- Phlegmonous diverticulitis (type IIA) presents diagnostic challenges within current classification frameworks.
Purpose of the Study:
- To evaluate the accuracy of the Hansen and Stock (H&S) clinical classification system for acute diverticulitis.
- To specifically assess the diagnostic precision regarding phlegmonous diverticulitis (type IIA).
- To determine if phlegmonous diverticulitis should be reclassified as a form of complicated diverticulitis.
Main Methods:
- A retrospective analysis of 318 consecutive patients diagnosed with acute diverticulitis between January 2004 and December 2006.
- Preoperative classification using 4/16-slice spiral CT scans based on the Hansen and Stock (H&S) system.
- Comparison of preoperative CT-based classification with histopathological findings for accuracy assessment.
Main Results:
- The overall accuracy for complicated diverticulitis staging varied significantly: type IIC (free perforations) at 100.0%, type IIB (covered perforations) at 91.0%, and type IIA (phlegmonous diverticulitis) at 36.1%.
- Phlegmonous diverticulitis (type IIA) was frequently understaged, with 53.0% of these patients actually having covered perforations (type IIB).
- Neither laboratory markers (CRP/WBC) nor clinical signs could reliably differentiate correctly staged from falsely staged type IIA patients.
Conclusions:
- Phlegmonous diverticulitis (type IIA) poses the greatest challenge in acute diverticulitis management due to frequent understaging.
- The high rate of concealed covered perforations (type IIB) within the type IIA group suggests a need for reclassification.
- Reclassifying phlegmonous diverticulitis (type IIA) under the umbrella of complicated diverticulitis is supported by these findings.
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