Suspected sigmoid volvulus (adult)
Adults only. Typical patient: older, institutionalised, neuropsychiatric illness, chronic constipation. Distension, obstipation, pain; vomiting is late. Signs may be mild. Empty rectum on PR is common.
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General SurgeryEmergency
Sigmoid Volvulus Management
Sigmoid Volvulus Management: Suspected sigmoid volvulus (adult) → Resuscitate and call the surgical team now → Child, pregnancy, caecal or ileosigmoid v...
Pathway Overview
19 steps
Algorithm Steps
19 total
01Start 02Action Resuscitate and call the surgical team now
IV access and IV fluids. Correct electrolytes and renal function. NG tube if vomiting. Bloods: FBC, UEC, CRP, blood gas with lactate, coagulation, group and hold.
- Frail, heart failure or CKD: give fluid in small boluses and reassess often
- Anticoagulant or antiplatelet: record it and plan reversal with the surgical team; do not delay theatre
- Urinary catheter and fluid balance chart
- Early senior surgical review
03Warning Child, pregnancy, caecal or ileosigmoid volvulus: different plan
This pathway is for adults with sigmoid volvulus who are not pregnant. Child: paediatric surgical team. Transverse colon volvulus: surgical team; this pathway does not apply.
- Caecal volvulus: no endoscopic detorsion; surgical resection
- Ileosigmoid volvulus (CT): resuscitate, then surgery; necrosis is common
- Pregnancy: obstetric and surgical teams together; MRI may replace CT; definitive colectomy ideally after birth
04Action Confirm with abdominal X-ray; CT if unsure or complication suspected
Abdominal X-ray: coffee bean (bent inner tube) sign. CT with IV contrast if the diagnosis is in doubt or ischaemia or perforation is suspected: whirl sign, bowel wall changes, pneumatosis, portal venous gas, free gas. CT also shows other causes (cancer, pseudo-obstruction).
- Contrast enema only if CT is not clear: water-soluble contrast only, never barium
- Never give a contrast enema if perforation is suspected
- Pregnancy: discuss imaging with obstetrics and radiology; MRI is an option
05Warning Do not miss ischaemia: when in doubt, operate
Missed gangrene greatly increases mortality. Older and neuropsychiatric patients may show few signs.
- No peritonitis does not exclude ischaemia
- A normal lactate does not exclude ischaemia
- Ischaemic, necrotic or perforated colon: no endoscopic detorsion
06Decision Ischaemia, perforation, peritonitis or septic shock?
Yes if any: peritonitis, septic shock or haemodynamic instability, free gas, CT signs of ischaemia, or rising lactate.
- If Yes
07Action Ischaemia, perforation or shock: urgent laparotomy and sigmoid resection
No endoscopic attempt. Resuscitate on the way to theatre; do not delay surgery. Senior surgeon and anaesthetist. Antibiotics as for colonic perforation or peritonitis. On an anticoagulant: plan reversal with the team, but do not delay theatre.
- Frail, advanced dementia or severe comorbidity: agree goals of care and treatment limits with the patient or substitute decision-maker; do this quickly and do not delay theatre if surgery is wanted
- Surgery not wanted or not in the patient's interest: comfort-focused (palliative) care
08Action Operative plan for urgent sigmoid resection
Resect the volvulised sigmoid. Choose the reconstruction by patient condition and state of the colon.
- Gangrenous colon: resect without detorsion, with minimal handling
- Unstable, septic, acidotic, coagulopathic or high ASA: end colostomy (Hartmann procedure)
- Stable with healthy colon: primary anastomosis, with or without defunctioning stoma, is an option
- Megacolon or volvulus in other segments: consider subtotal colectomy
09Action After resection: postoperative care
Enhanced recovery. VTE prophylaxis. Watch for anastomotic leak, ileus and wound infection. Stoma education if a stoma was made. After Hartmann procedure: discuss later reversal.
10Outcome Volvulus treated by resection
Recurrence after sigmoid colectomy is low.
If No11Action No ischaemia or perforation: urgent endoscopic detorsion
First-line treatment. Flexible sigmoidoscopy is preferred (better view of ischaemia, fewer perforations); rigid only if flexible is not available. Succeeds in 60-95%.
- No endoscope or endoscopist on site (for example rural or remote): discuss with the surgical team and arrange urgent transfer
12Action Endoscopic detorsion: technique
Minimal insufflation. Pass the twist (usually 2 transition points). Aspirate gas and fluid. At the end, inspect the mucosa for viability: mandatory.
- Stop at once if the mucosa is ischaemic or necrotic, or perforation is seen or likely
- After success, leave a decompression (flatus) tube to keep the reduction
- Full colonoscopy only if cancer is suspected
13Decision Detorsion successful and mucosa viable?
Yes: twist passed, colon decompressed, viable mucosa. No: cannot pass the twist, ischaemic or necrotic mucosa, bleeding or perforation.
- If Yes
14Action Detorsion successful: keep tube in, watch closely, plan colectomy
Leave the decompression tube in place. Continue IV fluids and correct electrolytes. Re-examine the abdomen often. New pain, peritonitis, fever or rising lactate: urgent surgical review. Bowel preparation before colectomy as needed.
15Decision Fit for sigmoid colectomy and agrees to it?
Recurrence after detorsion alone is 43-75%. Each recurrence risks ischaemia, and emergency surgery for recurrence has higher mortality. Assess fitness and discuss with the patient and family.
- If Yes
16Action Fit: sigmoid colectomy in the same admission
Offer sigmoid colectomy as early as possible, during the index admission. Open or laparoscopic by surgeon choice. Primary anastomosis is usual; a stoma is not usually needed.
- Megacolon or previous volvulus in other segments: consider subtotal colectomy
- Do not use detorsion alone, sigmoidopexy or mesosigmoidoplasty: higher recurrence
- Pregnancy: plan timing with obstetrics; ideally after birth
- Path rejoins step 09Shared downstream outcome
If No17Action Unfit or declines colectomy: non-operative plan
Shared decision; record goals of care and a plan for recurrence. Tell the patient and carers to return at once if distension, pain or obstipation recurs.
- Selected patients with prohibitive surgical risk: consider endoscopic fixation (percutaneous endoscopic colostomy)
- Recurrence without ischaemia: repeat endoscopic detorsion
- Treat constipation; review drugs that cause it
18Outcome Non-operative management
High recurrence risk. Plan for recurrence and goals of care recorded.
If No19Action Failed detorsion or non-viable mucosa: urgent sigmoid resection
Stop the endoscopy. Urgent laparotomy and sigmoid resection. Use the operative plan above.
- Path rejoins step 08Shared downstream outcome
Guideline Source
WSES consensus guidelines on sigmoid volvulus management (Tian et al., World J Emerg Surg 2023;18:34) + ASCRS Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction (Alavi et al., Dis Colon Rectum 2021;64:1046-57)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults with sigmoid volvulus only. Not for caecal, transverse or ileosigmoid volvulus, or children.
- Evidence is low quality (GRADE 1C-2C); based on WSES 2023 and ASCRS 2021.
- Endoscopic detorsion expertise and access vary by site.
- Recurrence after detorsion alone is 43-75%.
Contraindicated Populations
ChildrenCaecal volvulusTransverse colon volvulusIleosigmoid volvulus
Applicable Regions
AUUSUKEUGlobal
Global: More common in the volvulus belt (Africa, Asia, Middle East): younger patients, more gangrene at presentation, and ileosigmoid volvulus is more frequent.
Version 2Next review: 2027-09-30
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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 consensus guidelines on sigmoid volvulus management (Tian et al., World J Emerg Surg 2023;18:34) + ASCRS Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction (Alavi et al., Dis Colon Rectum 2021;64:1046-57).
What guideline is the Sigmoid Volvulus Management based on?
This algorithm is based on WSES consensus guidelines on sigmoid volvulus management (Tian et al., World J Emerg Surg 2023;18:34) + ASCRS Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction (Alavi et al., Dis Colon Rectum 2021;64:1046-57) (DOI: 10.1186/s13017-023-00502-x).
What are the limitations of the Sigmoid Volvulus Management?
Known limitations include: Adults with sigmoid volvulus only. Not for caecal, transverse or ileosigmoid volvulus, or children.; Evidence is low quality (GRADE 1C-2C); based on WSES 2023 and ASCRS 2021.; Endoscopic detorsion expertise and access vary by site.; Recurrence after detorsion alone is 43-75%.. Individual patient factors may require deviation from these recommendations.
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