What is the management of sigmoid volvulus?

Management of Sigmoid Volvulus

The initial management of sigmoid volvulus should be urgent endoscopic detorsion using flexible endoscopy in patients without signs of ischemia or perforation, followed by elective sigmoid resection during the same hospitalization to prevent recurrence. 1

Diagnostic Approach

• Plain abdominal radiographs should be the initial imaging modality, looking for the classic "coffee bean" sign projecting toward the upper abdomen (sometimes called the "northern exposure sign") 1
• CT imaging with intravenous contrast is indicated when:
  • Clinical assessment and plain radiographs are insufficient to confirm diagnosis
  • Ischemia or perforation is suspected
  • CT has a 89% positive diagnostic yield for sigmoid volvulus 1
• Water-soluble contrast enema may help confirm diagnosis by demonstrating a "bird's beak" sign at the point of colonic torsion, but is strictly contraindicated if perforation is suspected 1

Management Algorithm

For Uncomplicated Sigmoid Volvulus (no ischemia/perforation):

1. First-line treatment: Flexible endoscopic detorsion 1

   • Success rate: 60-95% of patients
   • Morbidity rate: approximately 4%
   • Mortality rate: up to 3%
   • Flexible endoscopy is superior to rigid sigmoidoscopy for assessing ischemia and has lower perforation rates 1

2. Technical aspects of endoscopic detorsion:

   • Endoscopist must visualize and pass beyond the transition points (typically 2 points) 1
   • Mandatory assessment of mucosal viability at the end of the procedure 1
   • Leave a decompression flatus tube in place to maintain reduction and allow continued colonic decompression 1

3. After successful detorsion:

   • Long-term recurrence rate: 43-75% of patients 1
   • Elective sigmoid resection should be performed during the index admission to prevent recurrence 1, 2
   • In high-risk patients not fit for surgery, endoscopic fixation of the colon (percutaneous endoscopic colostomy) can be considered 1

For Complicated Sigmoid Volvulus:

1. Urgent sigmoid resection is indicated when: 1

   • Endoscopic detorsion fails
   • Colonic ischemia is present
   • Perforation has occurred
   • Patient presents with peritonitis or septic shock (5-25% of patients) 1

2. Surgical approach:

   • For infarcted bowel: resection without detorsion and with minimal manipulation to prevent endotoxin release 1
   • Decision between isolated sigmoid colectomy versus high anterior resection should consider vascular supply of the remnant colon 1
   • Hartmann procedure (sigmoid resection with end colostomy) is preferred for non-viable colon or peritonitis 3

Important Considerations and Pitfalls

• Flexible endoscopy is superior to rigid endoscopy, which can fail to diagnose sigmoid volvulus and miss ischemia in up to 24% of cases 1
• If advanced mucosal ischemia, perforation, or impending perforation is discovered during endoscopy, the procedure should be aborted immediately and emergency colectomy performed 1, 3
• Contrast enema studies are strictly contraindicated when perforation is suspected as they can worsen contamination 3
• Factors predicting successful endoscopic detorsion include: absence of abdominal tenderness, use of laxatives, and history of open abdominal surgery 4
• Post-detorsion management should include fluid resuscitation and broad-spectrum antibiotics to control bacterial translocation across the ischemic intestinal wall 1

Risk Factors for Mortality

• Age over 60 years
• Presence of shock on admission
• Positive history of previous episode of volvulus 1

Recurrence Management

• Without definitive surgery, recurrence rates are high (46-61%) 5, 4
• Repeat endoscopic detorsion can be performed with similar efficacy and safety if recurrence occurs before definitive surgery 6
• Elective sigmoid resection remains the definitive treatment to prevent recurrence 2, 6