Suspected Sigmoid Volvulus
Elderly, institutionalized, neuropsychiatric conditions. Symptoms: Acute abdominal distension, obstipation, pain (may be less severe than expected). X-ray: Coffee bean sign, bent inner tube sign, apex pointing to RUQ.
All Pathways
General SurgeryEmergency
Sigmoid Volvulus Management
Sigmoid Volvulus Management: Suspected Sigmoid Volvulus → Diagnostic Confirmation → Signs of Ischemia or Perforation? → ⚠️ Don't Miss Ischemia.
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Action Diagnostic Confirmation
1) Abdominal X-ray: Coffee bean/omega loop sign (classic). 2) CT abdomen/pelvis if diagnosis uncertain: Whirl sign, point of torsion, bowel wall thickening. 3) Labs: CBC, BMP, lactate, type & screen. 4) Assess for signs of ischemia/perforation.
03Decision Signs of Ischemia or Perforation?
ISCHEMIA: Peritonitis, guarding, elevated lactate, fever, tachycardia, leukocytosis, CT findings (wall thickening, pneumatosis, portal venous gas). PERFORATION: Free air, peritonitis. If any present → Emergency surgery.
04Warning ⚠️ Don't Miss Ischemia
Delayed recognition of gangrenous bowel dramatically increases mortality (up to 50%). High index of suspicion for ischemia. When in doubt, operate. The elderly and neuropsychiatric patients may not manifest typical signs of peritonitis.
05Action Emergency Laparotomy
Signs of ischemia/perforation = NO endoscopic attempt. Proceed directly to surgery. Midline laparotomy, assess bowel viability. Resect if necrotic. Sigmoid colectomy with: Hartmann's (safest) or Primary anastomosis if tissue healthy and patient stable.
06Action Emergency Sigmoid Resection
After laparotomy and detorsion: 1) Assess viability - color, bleeding, peristalsis. 2) If viable: Resect sigmoid, may attempt primary anastomosis ± ileostomy. 3) If necrotic: Resect necrotic segment, Hartmann's procedure (end colostomy, rectal stump). Consider damage control if unstable.
07Action Postoperative Care
Enhanced recovery protocol. Stoma education if applicable. DVT prophylaxis. Monitor for complications: Leak, ileus, wound infection. If Hartmann's: Plan reversal 3-6 months.
08Outcome Volvulus Resolved
Definitive treatment achieved. Low recurrence after resection. Continue postoperative recovery.
09Action No Signs of Ischemia: Attempt Endoscopic Derotation
First-line management for sigmoid volvulus without peritonitis. Goal: Decompress and untwist. Options: Rigid sigmoidoscopy (traditional) or flexible sigmoidoscopy/colonoscopy.
10Action Endoscopic Decompression/Derotation
Procedure: 1) Minimal insufflation. 2) Advance scope gently through twist. 3) Aspirate gas and fluid. 4) May place rectal tube to maintain decompression. Success: Return of blood flow, viable mucosa, passage of flatus/stool. Success rate: 60-95%.
11Decision Endoscopic Derotation Successful?
SUCCESS: Colon decompressed, viable mucosa, twist reduced. FAILURE: Cannot pass twist, ischemic mucosa, bleeding, perforation. Failure → Urgent surgery.
12Action Failed Derotation → Urgent Surgery
Endoscopic derotation failed. Proceed to laparotomy. Assess viability. Sigmoid resection (Hartmann's or primary anastomosis based on clinical situation).
- Path rejoins step 07Shared downstream outcome
13Action Successful Derotation - Post-Procedure Care
Leave rectal tube in place 24-48h. NPO then clear liquids. Serial abdominal exams. Bowel prep when tolerating diet. Plan for definitive surgery.
14Decision Definitive Surgery Planning
WITHOUT surgery: Recurrence rate 40-60%. MOST patients need sigmoid resection. Timing: Same admission (after bowel prep) or delayed 1-2 weeks. Consider patient fitness for surgery.
15Action Semi-Elective Sigmoid Resection
After successful derotation + bowel prep: Laparoscopic or open sigmoid colectomy. Primary anastomosis (preferred in elective setting). Avoid recurrence. Consider in same admission if patient stable and facility allows.
- Path rejoins step 07Shared downstream outcome
16Action Non-Operative (High-Risk Patients)
For patients unfit for surgery: Accept recurrence risk. Rectal tube decompression. Consider endoscopic colopexy (limited data). Long-term bowel regimen. Repeat endoscopic derotation if recurs. Document discussion of risks.
- Path rejoins step 07Shared downstream outcome
Guideline Source
WSES 2017 Guidelines on Colon and Rectal Cancer Emergencies + ACG Guidelines
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Endoscopic derotation expertise varies by institution
- Timing of semi-elective surgery after derotation is debated
- Cecal volvulus management differs (see separate algorithm)
- Recurrence after non-operative management is common
- High-risk patients may need individualized approach
Applicable Regions
USEUGlobal
Global: More common in developing countries; principles apply universally
Version 1Next review: 2028-01-01
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Frequently Asked Questions
What is the Sigmoid Volvulus Management?
The Sigmoid Volvulus Management is a emergency clinical algorithm for General Surgery. It provides a structured decision tree to guide clinical decision-making, based on WSES 2017 Guidelines on Colon and Rectal Cancer Emergencies + ACG Guidelines.
What guideline is the Sigmoid Volvulus Management based on?
This algorithm is based on WSES 2017 Guidelines on Colon and Rectal Cancer Emergencies + ACG Guidelines (DOI: 10.1186/s13017-018-0192-3).
What are the limitations of the Sigmoid Volvulus Management?
Known limitations include: Endoscopic derotation expertise varies by institution; Timing of semi-elective surgery after derotation is debated; Cecal volvulus management differs (see separate algorithm); Recurrence after non-operative management is common; High-risk patients may need individualized approach. Individual patient factors may require deviation from these recommendations.
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