Correct Answer: A. Stage 4
Hinchey's classification stages acute diverticulitis by severity and presence of purulent/fecal peritonitis. Stage 4 represents fecal peritonitis—the most severe stage where perforation has occurred with gross contamination of the peritoneal cavity by fecal material. This is the discriminating finding in the question: the patient has both diverticular perforation AND fecal peritonitis on intraoperative exploration. Stage 4 is characterized by free perforation with fecal soiling of the peritoneal cavity, indicating complete loss of containment. Clinically, these patients present with acute peritonitis (as stated in the stem), systemic toxicity, and hemodynamic instability. The management is emergency surgical intervention with primary resection (Hartmann's procedure or primary anastomosis with diverting colostomy depending on patient factors and surgeon preference). In Indian practice, given the delayed presentation common in resource-limited settings, Stage 4 diverticulitis often requires aggressive resuscitation, broad-spectrum antibiotics (ceftriaxone + metronidazole or piperacillin-tazobactam), and urgent surgical intervention. The presence of fecal material in the peritoneum is the key finding that defines Stage 4 and mandates immediate surgical management.
Why the other options are wrong
B. Stage 2 — Stage 2 represents purulent peritonitis (pericolic abscess formation) without fecal contamination. The question explicitly states fecal peritonitis is present, which is more severe than purulent peritonitis alone. Stage 2 patients may be managed conservatively with antibiotics and percutaneous drainage in selected cases, whereas fecal peritonitis mandates emergency surgery. This is a common trap—students may confuse purulent with fecal peritonitis. C. Stage 3 — Stage 3 represents generalized purulent peritonitis from rupture of a pericolic abscess, but still without gross fecal soiling. The key discriminator is the presence of fecal material in the peritoneal cavity, which elevates the severity to Stage 4. Stage 3 may occasionally be managed with percutaneous drainage and antibiotics in carefully selected patients, but fecal peritonitis (Stage 4) always requires emergency surgery. NBE may use Stage 3 to trap students who recognize peritonitis but miss the fecal component. D. Stage 1 — Stage 1 represents uncomplicated diverticulitis with inflammation confined to the colon wall, without perforation or peritonitis. The question clearly describes a patient with peritonitis and intraoperative perforation, making Stage 1 impossible. This option is too mild and serves as a distractor for students who do not understand the Hinchey classification hierarchy.
High-Yield Facts
- Hinchey Stage 4 = fecal peritonitis from free perforation; always requires emergency surgery (Hartmann's or primary resection).
- Hinchey Stage 3 = generalized purulent peritonitis (no fecal soiling); may be managed conservatively in selected cases with antibiotics + percutaneous drainage.
- Hinchey Stage 2 = pericolic abscess (purulent peritonitis); percutaneous drainage + antibiotics may avoid surgery in 60–70% of cases.
- Fecal peritonitis is the discriminating finding that defines Stage 4 and mandates immediate surgical intervention regardless of patient age or comorbidities.
- In India, delayed presentation of diverticulitis is common; Stage 4 cases often present with septic shock and require aggressive resuscitation + emergency colonic resection.
Mnemonics
Hinchey Stages (1–4 Severity Ladder) 1 = Inflammation (no perforation) | 2 = Pericolic abscess (purulent) | 3 = Generalized purulent peritonitis | 4 = Fecal peritonitis (free perforation). Remember: Fecal = Final/Worst stage. Fecal vs. Purulent Peritonitis Purulent (Stage 2–3) = pus, may drain; Fecal (Stage 4) = stool in belly, must cut. Fecal peritonitis = emergency surgery always.
NBE Trap
NBE pairs "peritonitis" with Stage 3 to trap students who recognize peritonitis but miss the critical detail of fecal (vs. purulent) contamination. The question emphasizes "fecal peritonitis" explicitly to test whether candidates understand the Hinchey hierarchy and the distinction between purulent and fecal soiling.
Clinical Pearl
In Indian tertiary centers, diverticulitis is less common than in Western populations but presents late (often Stage 3–4) due to delayed healthcare access. A patient with acute peritonitis and intraoperative fecal soiling requires Hartmann's procedure (colostomy + distal rectal closure) as the safest option, with reversal planned 3–6 months later after sepsis resolution and nutritional recovery.
_Reference: Bailey & Love's Short Practice of Surgery (Diverticular Disease chapter); Sabiston Textbook of Surgery (Colon and Rectum chapter)_