What is the management of organic volvulus?

Management of Organic Volvulus

The management of organic volvulus requires prompt intervention with endoscopic decompression as first-line treatment for uncomplicated cases, followed by definitive surgical management to prevent recurrence. 1

Initial Assessment and Diagnosis

• Clinical presentation: Abdominal pain, distention, obstipation
• Imaging:
  • Abdominal CT scan is the gold standard for diagnosis
  • Look for characteristic "whirl sign" representing twisted bowel and mesentery
  • Plain radiographs may show dilated bowel with air-fluid levels (classic "coffee bean sign" in sigmoid volvulus)

Management Algorithm

1. Acute Management of Uncomplicated Volvulus

• First-line treatment: Endoscopic decompression/detorsion

  • Success rates of 70-91% for initial decompression 1, 2
  • Low complication rates (2-4.7%) 2
  • Contraindicated if signs of peritonitis, perforation, or severe ischemia

• Immediate post-decompression care:

  • Fluid resuscitation
  • Broad-spectrum antibiotics if signs of bacterial translocation
  • Close monitoring for signs of recurrence or complications

2. Indications for Immediate Surgery (Do Not Attempt Endoscopic Decompression)

• Failed endoscopic decompression
• Evidence of bowel ischemia, necrosis, or perforation
• Peritonitis or septic shock
• Recurrent volvulus after previous endoscopic management

3. Definitive Management Based on Type of Volvulus

Sigmoid Volvulus

• Uncomplicated first episode:

  • Endoscopic decompression followed by elective sigmoid resection
  • High recurrence rate (up to 61%) if only endoscopic management without definitive surgery 1, 3

• Complicated or recurrent cases:

  • Sigmoid resection with primary anastomosis or Hartmann procedure depending on patient condition
  • Consider patient factors: hemodynamic stability, comorbidities, nutritional status

• With concomitant megacolon:

  • Subtotal colectomy rather than limited sigmoid resection
  • Recurrence rates of 82% with limited resection vs. 0% with subtotal colectomy in patients with megacolon 1

Gastric Volvulus

• Acute presentation:

  • Immediate surgical intervention if signs of strangulation
  • Reduction of volvulus, gastropexy, and repair of any associated hiatal hernia 2, 4

• Chronic presentation:

  • Elective surgical repair with gastropexy
  • Consider laparoscopic approach for chronic cases 4

Ileosigmoid Volvulus

• Rare but severe form:
  • Requires urgent surgical decompression
  • Often requires double resection (ileum and sigmoid) with or without primary anastomosis
  • High mortality rate (up to 73%) 1

4. Special Considerations

Elderly or High-Risk Patients

• Consider percutaneous endoscopic colostomy (PEC) for high-risk patients unfit for surgery
  • Maintains reduction in most cases when left in place
  • Associated with complications in up to 47% of cases 1, 5

Pregnant Patients

• Multidisciplinary approach involving obstetricians
• MRI preferred for diagnosis
• Endoscopic decompression as first-line treatment
• Definitive surgery ideally after childbirth if possible
• High maternal (6-12%) and fetal (20-26%) mortality rates 1

Post-Treatment Monitoring

• Close follow-up to detect early recurrence
• Patient education about symptoms of recurrence
• Consider elective repair of predisposing factors (hiatal hernia, redundant colon)

Pitfalls and Caveats

• Delayed diagnosis: Increases risk of ischemia, necrosis, and mortality
• Overreliance on conservative management: High recurrence rates (up to 86%) after endoscopic decompression alone 6
• Failure to recognize ischemia: Endoscopy should be aborted if mucosal ischemia is identified
• Underestimating surgical risk: Despite high-risk status of many patients, definitive surgical management has shown better outcomes than repeated endoscopic procedures 3
• Inadequate extent of resection: In patients with megacolon, limited sigmoid resection leads to high recurrence rates 1

Recent evidence suggests that even in elderly high-risk patients, definitive surgical management should be considered after initial successful endoscopic decompression to prevent recurrence and associated morbidity and mortality 3, 5.