What is the treatment for volvulus?

Treatment for Volvulus

For sigmoid volvulus without ischemia or perforation, perform endoscopic decompression immediately followed by definitive sigmoid resection during the same hospital admission; for cecal volvulus, proceed directly to right hemicolectomy as endoscopy has no role. 1, 2, 3

Sigmoid Volvulus Management Algorithm

Immediate Assessment

• Evaluate for signs of septic shock, bowel ischemia, or perforation on presentation 2
• Confirm diagnosis with plain abdominal radiographs (looking for "coffee bean sign") or abdominal CT showing the "whirl sign" of twisted mesentery 2, 4

Treatment Based on Clinical Presentation

If septic shock, ischemia, or perforation present:

• Proceed immediately to emergency surgery without attempting endoscopic decompression 2, 4
• Surgical options include sigmoid resection with Hartmann's procedure (for unstable patients) or sigmoid resection with primary anastomosis (for stable patients) 2
• Critical pitfall: Emergency surgery carries 12-20% mortality versus 5.9% for elective surgery, emphasizing the importance of early intervention before complications develop 2
• For infarcted bowel, resect without detorsion and with minimal manipulation to prevent release of endotoxins and bacteria 2

If uncomplicated (no ischemia/perforation):

• First-line treatment is endoscopic decompression with 70-91% success rate 2
• Mandatory next step: Perform definitive sigmoid resection during the same hospital admission after successful decompression 1, 2
• Critical warning: Without resection, recurrence rates are catastrophically high at 45-71%, and each recurrence increases risk of ischemia, perforation, and mortality 2, 5
• Exclusively endoscopic therapy without subsequent surgery should only be reserved for patients with prohibitive surgical risk 1

Surgical Approach Considerations

• For benign sigmoid volvulus, full oncological high ligation is not required; focus on ensuring adequate vascular supply to remnant colon 2
• Laparoscopic approach may be suitable in select cases with experienced surgeons, though benefits in emergency settings remain unclear 2
• Common pitfall: The absence of peritoneal signs does not rule out bowel ischemia, so maintain high suspicion even without overt peritonitis 4

Cecal Volvulus Management

Cecal volvulus requires immediate surgical intervention:

• Right hemicolectomy is the only definitive treatment 1, 3
• Endoscopy has no role in cecal volvulus management 1, 3
• Laparoscopic exposure is often difficult due to the absence of colonic fixation and excessive length 1

Small Bowel Volvulus Management

Small bowel volvulus is a surgical emergency:

• Diagnosis can only be definitively made at laparotomy 6
• Early exploratory laparotomy is mandatory when suspected, as delay increases morbidity and mortality 6
• Treatment involves reduction, assessment of bowel viability, and resection with anastomosis if necrosis is present 1
• Internal hernias causing volvulus require prompt reduction, suture repair, and bowel resection if intestinal necrosis is present 1

Gastric Volvulus Management

Gastric volvulus requires surgical intervention:

• Laparoscopic reduction with anterior gastropexy is safe and feasible, particularly beneficial for high-risk and elderly patients 7
• Untreated gastric volvulus will progress to ischemia, necrosis, and perforation 7

Key Risk Factors for Poor Outcomes

• Age over 60 years, presence of shock on admission, and history of previous volvulus episodes significantly increase mortality risk 2
• Patients with neuropsychiatric conditions on chronic psychotropic medications are at higher risk for sigmoid volvulus 4