What are the strategies to reduce pain from sigmoid volvulus?

Strategies to Reduce Pain from Sigmoid Volvulus

The most effective strategy to reduce pain from sigmoid volvulus is prompt endoscopic decompression followed by definitive surgical resection, ideally during the same hospitalization. 1, 2

Initial Management of Sigmoid Volvulus Pain

For Uncomplicated Sigmoid Volvulus

1. Fluid and electrolyte resuscitation - Essential first step to stabilize the patient 1
2. Endoscopic decompression - First-line treatment for immediate pain relief
   • Success rate of approximately 83.2% 3
   • Reduces intraluminal pressure that impairs capillary perfusion
   • Relieves mechanical obstruction caused by twisting
   • Immediately addresses pain from distension

For Complicated Cases (Signs of Peritonitis, Perforation, or Ischemia)

• Immediate surgical intervention - Do not attempt endoscopic decompression
• Double resection with or without restoration of continuity depending on patient condition 1

Definitive Management to Prevent Recurrence and Pain

Surgical Options

• Elective sigmoid resection - Should be performed during index admission after successful decompression 1, 2
  • Laparoscopic sigmoidectomy is the procedure of choice for elective cases 2
  • Removes the entire redundant sigmoid colon to prevent recurrence
  • Mortality rate is significantly lower with elective surgery compared to emergency surgery (0% vs 17.6% in one series) 4

Rationale for Early Definitive Surgery

• High recurrence rate (60.9%) after conservative management alone 4
• Recurrence typically occurs within a median of 31 days after conservative treatment 5
• Each recurrence carries cumulative risk of complications and mortality 6

Special Considerations for High-Risk Patients

• Percutaneous Endoscopic Colostomy (PEC) - For extremely high-risk patients who cannot tolerate surgery 1, 2
  • Associated with major (10%) and minor (37%) complications 2
  • Should be considered only when surgical options are prohibitive

Pitfalls and Caveats

1. Avoid delay in treatment - Increasing intraluminal pressure rapidly impairs capillary perfusion and can lead to ischemia 1

2. Do not rely solely on conservative management - Despite successful initial decompression, recurrence rates are high (>60%) without definitive surgery 4, 6, 5

3. Watch for signs of non-viable bowel - A silent abdomen is the most valuable indication of gangrenous bowel 7

4. Risk factors for mortality that require special attention:

   • Age over 60 years
   • Presence of shock on admission
   • History of previous episodes of volvulus 1

5. Do not discharge patients without a definitive plan - Either perform surgery during the same admission or schedule an early elective procedure 2, 6

Pain Management Algorithm

1. Acute presentation:

   • Assess for peritonitis/perforation
   • If absent → endoscopic decompression
   • If present → emergency surgery

2. After successful decompression:

   • Offer definitive surgery during same hospitalization
   • Explain high recurrence risk (>60%) if surgery is declined

3. For recurrent cases:

   • More strongly recommend definitive surgical management
   • Each recurrence increases cumulative risk of complications