What is the appropriate emergency management for a patient presenting with acute abdominal pain, abdominal distension, obstipation, and vomiting suggestive of a volvulus?

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Emergency Management of Volvulus

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

Initial Assessment and Diagnosis

Clinical Recognition

The presentation typically includes the classic triad of abdominal pain, constipation, and abdominal distension, with vomiting appearing as a late sign 2. Key historical features to elicit include:

  • Previous abdominal distention episodes (reported in 30-41% of cases) 2
  • Chronic constipation with frequent laxative use (particularly in sigmoid volvulus) 2
  • Age and gender patterns: Sigmoid volvulus preferentially affects elderly males (age >70 in Western countries), while cecal volvulus typically presents in younger females (age ≤60) 2, 3
  • Neuropsychiatric conditions and chronic psychotropic medications (higher risk for sigmoid volvulus) 1

Physical Examination Findings

  • Pronounced asymmetric abdominal distension with diminished bowel sounds 2
  • Empty rectum on digital examination is characteristic 2
  • Asymmetric gaseous distention with emptiness of the left iliac fossa is pathognomonic for sigmoid volvulus 2
  • Signs of peritonitis or shock suggest colonic necrosis or perforation, though absence of peritoneal signs does not rule out bowel ischemia 2

Imaging Strategy

Plain abdominal radiographs should be obtained first-line 2:

  • "Coffee bean sign" projecting toward the upper abdomen indicates sigmoid volvulus 3
  • "Northern exposure sign" where the dilated sigmoid extends above the transverse colon 3

Abdominal CT is the gold standard 2:

  • "Whirl sign" representing twisted colon and mesentery 2, 3
  • Dilated colon with air/fluid levels 3
  • Evaluate for complications: free air (perforation), bowel wall thickening, pneumatosis, or lack of enhancement (ischemia) 3

Management Algorithm by Type

Sigmoid Volvulus Management

Without ischemia or perforation:

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

With ischemia, perforation, or septic shock:

  • Urgent upfront surgery is mandatory 2
  • Emergency surgical options include Hartmann's procedure (associated with lowest mortality despite higher wound infection rates) or sigmoid resection with primary anastomosis 4, 5

Cecal Volvulus Management

Cecal volvulus requires immediate surgical intervention 1:

  • Right hemicolectomy is the only definitive treatment 1
  • Endoscopy has no role in cecal volvulus management 1
  • Do not attempt endoscopic decompression as it is ineffective and delays definitive treatment 1

Risk Stratification for Poor Outcomes

Identify high-risk patients with the following characteristics 1:

  • Age over 60 years
  • Presence of shock on admission
  • History of previous volvulus episodes
  • Delayed presentation permitting bowel ischemia to develop 1

Critical Pitfalls to Avoid

  • Do not confuse midgut volvulus with sigmoid volvulus: The former involves the small intestine and requires emergency surgery, whereas the latter affects the large bowel and can be managed endoscopically initially 1
  • Do not discharge patients after successful endoscopic decompression of sigmoid volvulus without definitive resection: This leads to recurrence rates of 45-71% with increased mortality risk 1, 2
  • Do not attempt endoscopic management of cecal volvulus: This wastes time and has no therapeutic benefit 1
  • Do not rely on absence of peritoneal signs to rule out bowel ischemia: Ischemia can be present without overt peritonitis 2
  • History may be unreliable in patients with neuropsychiatric issues, and abdominal examination may be difficult due to massive distension 2

References

1
Guideline

Volvulus Management Guidelines

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Sigmoid Volvulus Clinical Presentation and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Radiological Diagnosis of Colonic Volvulus

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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