What is the management of sigmoid volvulus?

Management of Sigmoid Volvulus

Sigmoid volvulus requires prompt management with flexible endoscopic decompression as first-line treatment for patients without ischemia or perforation, followed by definitive surgical intervention during the same admission to prevent high recurrence rates. 1

Diagnostic Approach

• Immediate imaging studies:

  • Plain abdominal radiographs (look for "coffee bean" sign)
  • CT scan with IV contrast (89% positive diagnostic yield)
  • Water-soluble contrast enema may show "bird's beak" sign (contraindicated if perforation suspected)

• Laboratory evaluation:

  • Blood tests including lactate levels to assess for bowel ischemia
  • Note: Normal lactate does not rule out ischemia 1

Management Algorithm

Step 1: Initial Assessment and Stabilization

• Assess for signs of peritonitis, ischemia, or perforation
• IV fluid resuscitation
• NPO status
• Nasogastric tube placement for decompression

Step 2: Determine Treatment Path

For Patients WITHOUT Signs of Ischemia/Perforation:

1. Urgent flexible endoscopic decompression (60-95% success rate) 1

   • Flexible endoscopy is superior to rigid sigmoidoscopy (which misses ischemia in up to 24% of cases) 1
   • Unsedated water-immersion colonoscopy has shown good results with minimal complications 2
   • Place decompression flatus tube after successful detorsion 1

2. After successful decompression:

   • Plan for definitive surgical intervention during the same admission
   • Elective surgery should be performed promptly to prevent recurrence (43-75% without surgery) 1, 3

For Patients WITH Signs of Ischemia/Perforation OR Failed Endoscopic Detorsion:

• Immediate surgical intervention 1, 4

Step 3: Surgical Options

• Preferred approach for uncomplicated cases:

  • Sigmoid resection with primary anastomosis 1, 4

• For high-risk patients or compromised bowel:

  • Hartmann's procedure (resection with end colostomy) 1, 5

• Non-definitive procedures (detorsion alone, mesosigmoidopexy):

  • High recurrence rates (up to 60.9%)
  • Generally not recommended 4, 6

Outcomes and Prognosis

• Mortality rates:

  • Emergency surgery: 40% mortality
  • Elective surgery: 5.9% mortality 1, 5

• Recurrence rates:

  • Without definitive surgery: 43-75% 1
  • After successful endoscopic decompression alone: >60% 6
  • After definitive surgical resection: minimal recurrence 3

Important Considerations and Pitfalls

• Do not delay endoscopic decompression in stable patients
• Never use barium contrast if perforation is suspected
• Do not discharge patients without definitive surgical planning after successful decompression
• Do not rely on rigid sigmoidoscopy as it misses ischemia in up to 24% of cases 1
• Consider underlying malignancy in all cases (present in up to 30% of sigmoid strictures) 1
• Recognize high-risk patients: elderly patients (>70 years) have higher surgical risk but also higher recurrence rates without surgery 2, 3

Special Populations

For extremely frail elderly patients with multiple comorbidities who are poor surgical candidates:

• Consider endoscopic decompression as definitive therapy
• Be aware of high recurrence risk (23/42 patients in one study) 3
• Discuss risks/benefits with patient and family, as mortality is higher in the non-surgical group (62% vs. 32%) 3