What is the appropriate management for a patient with suspected volvulus?

Management of Volvulus

For patients with suspected volvulus, initial management should include urgent diagnostic imaging followed by flexible endoscopy for uncomplicated sigmoid volvulus, while urgent surgical intervention is indicated for cases with suspected ischemia, perforation, or failed endoscopic detorsion. 1, 2

Diagnosis

• Initial diagnostic imaging should be plain abdominal radiographs, looking for the classic "coffee bean" sign projecting toward the upper abdomen 1
• CT imaging with intravenous contrast is indicated when clinical assessment and plain radiographs are insufficient to confirm diagnosis, or when ischemia or perforation is suspected (89% positive diagnostic yield) 1, 2
• 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
• Laboratory tests should include electrolytes, renal function, blood gas, and lactate levels, although bowel ischemia may be present even without hyperlactatemia 1

Management Algorithm

For Sigmoid Volvulus (most common type):

1. Without signs of ischemia or perforation:

   • Urgent flexible endoscopy should be performed as first-line treatment for decompression (60-95% success rate) 1, 2
   • After successful detorsion, a decompression flatus tube should be left in place to maintain reduction and allow for continued colonic decompression 1
   • Successful detorsion requires visualization past the transition points (typically 2 points) 1
   • Endoscopic assessment of mucosa viability is mandatory after detorsion 1

2. With signs of ischemia, perforation, or failed endoscopic detorsion:

   • Urgent sigmoid resection is indicated 1, 2
   • Intraoperative management should include resection of infarcted bowel without detorsion and with minimal manipulation to prevent endotoxin release and perforation 1
   • Surgical options include:
     • Sigmoid resection with end colostomy (Hartmann procedure) - often preferred for non-viable colon or peritonitis 1
     • Sigmoid resection with primary colorectal anastomosis (with or without diverting ostomy) 1

3. After successful endoscopic decompression:

   • Sigmoid colectomy should be performed as early as possible, even during the index admission, to prevent recurrence (recurrence rates of 45-71% with conservative management) 1, 3
   • Elective sigmoid resection has significantly lower mortality (5.9%) compared to emergency surgery (40%) 3

For Cecal Volvulus:

• Right hemicolectomy is the definitive treatment, as endoscopy has no role 4
• Immediate surgical intervention is mandatory if the patient presents with septic shock, bowel ischemia, or perforation 4

Risk Factors for Mortality

• Age over 60 years 2, 3
• Presence of shock on admission 2, 3
• History of previous volvulus episodes 2
• Emergency surgery (24% mortality) versus elective procedures (6% mortality) 5
• Presence of necrotic colon 5

Important Considerations

• Laparoscopic approach may be suitable in select cases when performed by experienced surgeons, though benefits in emergency settings remain unclear 1, 3
• Mortality rate for emergency surgery is significant (12-20%), with surgical site infections being the most common complication 3
• Special attention should be given to medication history, as anticholinergic agents can affect normal peristalsis 6
• Patients with volvulus often have neuropsychiatric issues, making history potentially unreliable 1