What is the management of sigmoid volvulus?

Management of Sigmoid Volvulus

Flexible endoscopic decompression is the first-line treatment for sigmoid volvulus without signs of ischemia or perforation, followed by definitive surgical intervention during the same admission or soon after to prevent high recurrence rates (43-75%). 1, 2

Diagnostic Approach

• Clinical presentation: Abdominal distension (hallmark finding), abdominal pain, constipation, and vomiting
• Risk factors: Elderly patients, institutionalized individuals, neuropsychiatric disorders, chronic constipation, history of previous volvulus
• Diagnostic imaging:
  • Plain abdominal radiographs: "Coffee bean" sign projecting toward upper abdomen
  • CT scan with IV contrast: 89% diagnostic yield, preferred when diagnosis is uncertain or complications suspected
  • Water-soluble contrast enema: May show "bird's beak" sign (strictly contraindicated if perforation suspected)

Treatment Algorithm

Step 1: Initial Assessment

• Evaluate for signs of ischemia, perforation, or peritonitis
• Check blood tests including electrolytes, renal function, lactate (though normal lactate does not exclude ischemia)

Step 2: Management Based on Clinical Status

1. No signs of ischemia or perforation:

   • Urgent flexible endoscopic decompression (60-95% success rate) 1
   • Visualize and pass transition points (typically 2 points)
   • Assess mucosal viability
   • Leave decompression flatus tube in place after successful detorsion

2. Signs of ischemia, perforation, or failed endoscopic detorsion:

   • Immediate surgical intervention
   • For infarcted bowel: Resection without detorsion and minimal manipulation
   • Options include sigmoid resection with primary anastomosis or Hartmann's procedure 1, 2

Step 3: Definitive Management

• Elective surgery during index admission or soon after successful decompression
• High recurrence rate without surgery (43-75%) 1
• Each recurrence carries risk of ischemia/perforation
• Mortality rates: 5.9% for elective surgery vs 40% for emergency surgery 3

Evidence-Based Considerations

Endoscopic Decompression

• Flexible endoscopy superior to rigid sigmoidoscopy (which misses ischemia in up to 24% of cases) 1
• Unsedated water-immersion colonoscopy has shown success in elderly patients without necrosis 4
• Endoscopic decompression carries 4% morbidity and up to 3% mortality 1

Recurrence Risk

• Without definitive surgery, recurrence occurs in 60.9% of patients 5
• In one study, 23/42 patients (55%) managed conservatively without surgery had recurrence 6
• Male patients more likely to experience three or more recurrent episodes 4

Surgical Options

• Segmental colectomy preferred over total colectomy if no other colonic issues present
• Primary anastomosis suitable for uncomplicated cases
• Hartmann's procedure for compromised bowel or high-risk patients

Pitfalls to Avoid

• Delaying endoscopic decompression in stable patients
• Missing signs of bowel ischemia (can occur without hyperlactatemia)
• Using rigid sigmoidoscopy instead of flexible endoscopy
• Using barium contrast if perforation is suspected (use water-soluble contrast only)
• Discharging patients without definitive surgical planning after successful decompression
• Failing to consider underlying malignancy (preoperative colonoscopy if clinically suspected)

By following this evidence-based approach, sigmoid volvulus can be managed effectively to reduce morbidity and mortality while preventing recurrence.