What is the treatment for volvulus?

Treatment of Volvulus

The treatment of volvulus requires endoscopic decompression as first-line management for uncomplicated cases, followed by definitive surgical resection during the same admission to prevent high recurrence rates of 45-71%. 1

Initial Management

Diagnosis

• Clinical presentation typically includes abdominal pain, distention, and obstipation
• Abdominal CT scan is the gold standard for diagnosis, showing the characteristic "whirl sign" representing twisted bowel and mesentery 1
• Plain abdominal radiographs may show dilated bowel with air/fluid levels

Emergency Management

• Uncomplicated volvulus:

  • Endoscopic decompression/detorsion is first-line treatment with success rates of 70-91% 1
  • Flatus tube placement may be used as an adjunct to decompression 2

• Complicated volvulus (signs of ischemia, perforation, peritonitis, or shock):

  • Immediate surgical intervention is mandatory 1
  • Avoid manipulating or detorsing ischemic/necrotic bowel as this can release endotoxins and bacteria into circulation 1

Definitive Management

Surgical Options

1. For stable patients with viable bowel:

   • Sigmoid resection with primary anastomosis is preferred 1
   • Should be performed during the same admission after successful endoscopic decompression 1

2. For hemodynamically unstable patients or those with significant comorbidities:

   • Hartmann procedure (sigmoid resection with end colostomy) is recommended 1
   • This approach has lower mortality (1.87%) compared to single-stage surgery (8.05%) in patients with poor general condition 3

3. Special considerations:

   • In patients with concomitant megacolon, subtotal colectomy is recommended rather than limited sigmoid resection (recurrence rates: 82% with limited resection vs. 0% with subtotal colectomy) 1
   • For high-risk patients unfit for surgery, percutaneous endoscopic colostomy (PEC) may be considered, though it has complications in up to 47% of cases 1

Pitfalls and Caveats

• Attempting endoscopic decompression in cecal volvulus is ineffective and wastes valuable time 1
• Conservative management alone leads to high recurrence rates (>60%) 2, 4
• Delayed diagnosis increases risk of ischemia, necrosis, and mortality 1
• Risk factors for poor outcomes include:
  • Age over 60 years
  • Presence of shock on admission
  • History of previous episodes of volvulus 1
  • Emergent surgery (24% mortality) vs. elective surgery (6% mortality) 4
  • Presence of necrotic colon 4

Special Populations

Elderly and High-Risk Patients

• Endoscopic decompression may be the only treatment option for patients not fit for surgery 5
• Consider the higher surgical mortality in emergency settings (17.6%) when planning management 2

Pregnant Patients

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

Follow-up and Prevention

• Close monitoring for recurrence is essential
• Patient education about symptoms of recurrence
• Consider elective repair of predisposing factors (hiatal hernia, redundant colon) 1