Management of Sigmoid Volvulus
Urgent flexible endoscopy should be performed as first-line treatment for sigmoid volvulus without signs of ischemia or perforation, followed by elective sigmoid resection to prevent recurrence. 1, 2
Diagnosis
- Initial imaging should be plain abdominal radiographs, looking for the classic "coffee bean" sign projecting toward the upper abdomen 1, 2
- CT imaging with intravenous contrast is indicated when clinical assessment and plain radiographs are insufficient or when ischemia/perforation is suspected, with 89% positive diagnostic yield 1, 2
- Water-soluble contrast enema may help confirm diagnosis by demonstrating a "bird's beak" sign, but is strictly contraindicated if perforation is suspected 1, 2
Management Algorithm
For Uncomplicated Sigmoid Volvulus
- Perform urgent flexible endoscopy for decompression if no signs of ischemia or perforation are present 1, 2
- Successful detorsion requires visualization past the transition points, with success rates of 60-95% 1, 2
- After detorsion, leave a decompression flatus tube in place to maintain reduction and allow continued colonic decompression 1
- Flexible endoscopy is superior to rigid sigmoidoscopy for assessing ischemia and has lower perforation rates 2
- Unsedated water-immersion colonoscopy can be a safe approach for elderly patients with high surgical risk 3
Post-Endoscopic Management
- Long-term recurrence occurs in 43-75% of patients after successful endoscopic detorsion 1
- Elective sigmoid resection should be performed during the index admission or soon thereafter to prevent recurrence 1, 2, 4
- For patients unfit for surgery, endoscopic fixation of the colon can be considered 2
For Complicated Sigmoid Volvulus
- Urgent sigmoid resection is indicated when:
- Emergency surgery carries a mortality rate of up to 17.6%, significantly higher than elective procedures 4
Special Considerations
- Sigmoid volvulus predominantly affects elderly patients with comorbidities, requiring careful risk assessment 3, 4, 7
- Risk factors for mortality include age over 60 years, presence of shock on admission, and history of previous volvulus episodes 2
- Contrast enema studies and colonoscopy are absolutely contraindicated when perforation is suspected as they can worsen contamination 5, 6
- In cases of perforation, management includes nil by mouth, intravenous fluid resuscitation, broad-spectrum antibiotics, and prompt surgical intervention 6
Pitfalls to Avoid
- Delaying diagnosis despite absence of peritoneal signs, as bowel ischemia can occur without obvious clinical signs 1
- Relying solely on endoscopic management without planning definitive surgery, given the high recurrence rate 1, 2, 4, 7
- Attempting endoscopic procedures when signs of perforation are present, which can convert a contained perforation into a free perforation 5, 6
- Underestimating the mortality risk in emergency surgery (up to 17.6%) compared to elective procedures (significantly lower) 4