Sigmoid Volvulus Management

Algorithm Steps

1. ▶

   Start

   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.

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      Action

      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.

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         Decision

         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.

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            Warning

            ⚠️ 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.

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            Action

            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.

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               Action

               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.

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                  Action

                  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.

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                     Outcome

                     Volvulus Resolved

                     Definitive treatment achieved. Low recurrence after resection. Continue postoperative recovery.

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            Action

            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.

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               Action

               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%.

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                  Decision

                  Endoscopic Derotation Successful?

                  SUCCESS: Colon decompressed, viable mucosa, twist reduced. FAILURE: Cannot pass twist, ischemic mucosa, bleeding, perforation. Failure → Urgent surgery.

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                     Action

                     Failed Derotation → Urgent Surgery

                     Endoscopic derotation failed. Proceed to laparotomy. Assess viability. Sigmoid resection (Hartmann's or primary anastomosis based on clinical situation).

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                     Action

                     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.

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                        Decision

                        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.

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                           Action

                           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.

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                           Action

                           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.