What is the management of sigmoid volvulus?

Management of Sigmoid Volvulus

Flexible endoscopic decompression should be the first-line treatment for patients with 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

Diagnostic Approach

• Obtain immediate diagnostic imaging:
  • Plain abdominal radiographs (look for "coffee bean" sign)
  • CT scan with IV contrast (89% positive diagnostic yield) to confirm diagnosis and rule out complications 1
  • Water-soluble contrast enema may show "bird's beak" sign (strictly contraindicated if perforation is suspected) 1
• Blood tests including lactate levels to assess for bowel ischemia 1

Treatment Algorithm

Step 1: Initial Assessment

• Evaluate for signs of peritonitis, perforation, or ischemia
• If present → immediate surgical intervention
• If absent → proceed with endoscopic decompression

Step 2: Endoscopic Management

• Flexible endoscopy is superior to rigid sigmoidoscopy (which misses ischemia in up to 24% of cases) 1
• Success rates of 60-95% for flexible endoscopic decompression 1
• Leave a decompression flatus tube in place after successful detorsion 1
• If endoscopy reveals advanced mucosal ischemia, perforation, or impending perforation → abort procedure and proceed to emergency surgery 2

Step 3: Definitive Management

• After successful endoscopic decompression:

  • Plan for elective sigmoid resection during the same admission or soon after
  • High recurrence rate without surgery (43-75%) 1
  • Recurrent volvulus occurs in approximately 61% of patients at a median of 31 days after successful endoscopic detorsion without further intervention 2

• Surgical options:

  • Segmental colectomy with primary anastomosis (preferred for stable patients without compromised bowel) 1
  • Hartmann's procedure (sigmoid resection with end colostomy) for high-risk patients or compromised bowel 2, 1

• Immediate surgical intervention required for:

  • Failed endoscopic detorsion
  • Signs of colonic ischemia
  • Perforation
  • Peritonitis or septic shock 2, 1

Evidence Strength and Considerations

• Flexible endoscopy has shown better outcomes compared to rigid sigmoidoscopy and barium enema:

  • Flexible endoscopy: 76% successful decompression, 2% morbidity, 0.3% mortality 2
  • Rigid sigmoidoscopy: 78% successful decompression, 3% morbidity, 1% mortality 2
  • Barium enema: 69% successful decompression, 23% morbidity, 8% mortality 2

• Recent evidence suggests that sigmoid distension ≥9 cm on initial CT is associated with increased risk of recurrence (OR: 3.23; 95%CI: 1.39-7.92), which may help identify patients who would benefit from more urgent definitive surgical management 3

Common Pitfalls to Avoid

• Delaying endoscopic decompression in stable patients
• Using rigid sigmoidoscopy instead of flexible endoscopy
• Using barium contrast if perforation is suspected
• Discharging patients without definitive surgical planning after successful decompression
• Failing to consider underlying malignancy (preoperative colonoscopy if clinically suspected) 1
• Performing preoperative total colonoscopy is generally not recommended due to technical difficulty in the extremely redundant colon, unless there is clinical or radiological suspicion of underlying neoplasia 2

Mortality Considerations

• Mortality rates are significantly higher for emergency surgery (40%) compared to elective surgery (5.9%) 1
• Delayed intervention increases the risk of complete obstruction, perforation, and emergency surgery with higher morbidity and mortality 1