Sigmoid Volvulus


Article Author:
Bettina Lieske


Article Editor:
Catiele Antunes


Editors In Chief:
Silvio de Melo Jr.
Vittorio Giuliano
Truptesh Kothari


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
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Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
2/17/2019 9:14:18 AM

Introduction

A volvulus is a twist of the intestine around the axis of its blood supply. In the case of a sigmoid volvulus, the twist occurs in the sigmoid mesentery at its base. Sigmoid volvulus is the most common type of volvulus of the colon. Less common are caecal volvulus and volvulus of the transverse colon. It presents most commonly in patients who are less mobile, bed bound and institutionalized, usually with a background of chronic constipation.[1][2][3][4][5]

Etiology

In order for a volvulus to occur, the bowel needs to be able to twist around a narrow-based mesentery. This occurs mostly in less mobile patients with a history of chronic constipation, where the sigmoid colon becomes chronically distended and redundant.

Epidemiology

Sigmoid volvulus is more common in Africa, as the food intake is of high fiber and the base of the sigmoid mesentery in the African population is narrow compared with other ethnic groups, leading to an anatomical situation that makes the population more susceptible to developing a sigmoid volvulus.

Pathophysiology

Volvulus is a classical example of a large bowel closed loop obstruction. If inflow and outflow of the colon are both obstructed, the obstructed bowel will continue to distend, due to a large amount of gas forming bacteria trapped inside. This will eventually lead to a perforation of the obstructed segment.

While the colon is obstructed and distending, there is impaired blood supply, leading to ischemia, as well as bacterial translocation of the gut flora. Usually, the venous outflow is compromised first, increasing congestion even further, until arterial supply stops. The colonic mucosa is most susceptible to ischaemic insult, leading to an impaired barrier and translocation of bacteria, until the ischemia affects muscular and serosa, leading to necrosis and perforation.

Sigmoid volvulus can become a recurrent situation, and in those patients treated conservatively, the base of mesentery will eventually become fibrotic and the bowel chronically distended.

History and Physical

Patients presenting with volvulus are usually of an older age group with potential other comorbidities, often have reduced mobility or are bed bound and commonly get referred from residential and nursing homes. A history of chronic constipation is common. The symptoms usually leading to acute hospital admission are a loss of appetite and reduced oral intake, increasing abdominal distension, and cessation of bowel output. Patients complain of discomfort due to the significant distension, but are rarely in pain, unless ischemia and/or a perforation have occurred. They can, however, have respiratory compromise due to the splinting of the diaphragm that is a result of the colonic distension.

Patients may present with sigmoid volvulus as a recurrent problem if they have been treated with conservative measures in the past. A recurrent episode of volvulus needs to be taken a seriously as a first presentation and requires the same attention to history and physical examination as a patient presenting with volvulus for the first time.

Examination of the abdomen reveals significant distension, a generalized tympanitic percussion note and potentially guarding and rebound over areas of ischemia or impending perforation. If a perforation has already occurred, the patient will be grossly peritonitic. Digital rectal examination reveals an empty and often capacious rectum.

Evaluation

The patient should have the standard blood work (full blood count and renal function tests), to aid in resuscitation and assess the kidney function for a potential CT scan with contrast. Plain abdominal radiographs will show the classical coffee bean or kidney bean sign, and often dilatation of the proximal colon. Depending on the duration of symptoms, the proximal colon can decompress into the distal small bowel, as long as the ileocaecal valve is incompetent. CT scan shows the characteristic "whirl" appearance of the twisted mesentery, as well as the distended loop of sigmoid colon with an air-fluid level. Free air on either the abdominal radiograph or the CT scan indicates a more serious bowel perforation and requires immediate action.[6][7][8][9]

A CT scan is recommended to establish the diagnosis and distinguish the etiology from other causes of large bowel obstruction, such as a malignant tumor. This is especially the case if the patients present with symptoms for the first time and have not had any previous colonic investigations such as a colonoscopy.

Treatment / Management

Before any surgical intervention, the patient needs to be adequately resuscitated with intravenous fluids, and electrolyte imbalances should be corrected. A nasogastric tube can aid proximal decompression. Decompression of the sigmoid volvulus should be attempted with a soft rectal flatus tube by the bedside, ideally feeding the tube under direct vision through a rigid sigmoidoscope. Flexible Sigmoidoscopy with gentle insufflation is indicated if the bedside decompression fails or if there are concerns about the viability of the bowel wall, as the mucosa can be inspected during the sigmoidoscopy and areas of mucosal ischemia will become obvious.[10][11][12]

Those patients who cannot be decompressed or who have progressed to compromised viability of the colon will need surgical intervention. The surgery of choice is a sigmoid colectomy with either a primary anastomosis or an end colostomy, depending on findings during the surgery and the individual patients’ physiological reserves. 

A patient presenting with bowel perforation will require aggressive resuscitation and an immediate laparotomy to control the fecal contamination and remove the perforated segment of bowel.

Patients presenting with recurrent episodes of sigmoid volvulus that can be decompressed should have an informed discussion about the benefits and risks of an elective resection of the sigmoid to prevent further episodes of volvulus leading to emergency admission to hospital. In the elective situation, a sigmoid colectomy can usually be performed with a primary anastomosis instead of an end colostomy, unless the patient has significant comorbidities.

Pearls and Other Issues

Bedside decompression with a flatus tube should only be carried out by experienced physicians, and under no circumstance against resistance, as there is a risk of inadvertent iatrogenic perforation. The safest method to decompress the sigmoid colon is under direct vision with rigid or flexible sigmoidoscopy.

A successful decompression will immediately result in the evacuation of liquid and gas per rectum with subsequent resolution of the abdominal distension, resulting in a soft abdomen.

This resolution can be documented on a repeat abdominal radiograph.

It is important to assess the patient for sustained resolution once the flatus tube has been removed and the patient is started on oral intake, to avoid the volvulus recur before the patient is even discharged.

Enhancing Healthcare Team Outcomes

The diagnosis and management of sigmoid volvulus is with a multidisciplinary team that consists of a surgeon gastroenterologist, primary care provider, nurse practitioner, and an internist. The initial treatment is decompression with a flexible endoscope but because of recurrence, surgery is recommended. Most of the patients are old and frail with several comorbidities. Hence, great caution should be used in recommending aggressive treatments. The outcomes for healthy patients after surgery are excellent. [13][14](Level V)


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Sigmoid Volvulus - Questions

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A 71-year-old nursing home patient is found to have sigmoid volvulus. What is the initial management of this disorder?



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Which of the following is not true about sigmoid volvulus?



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A 74-year-old female nursing home resident has a 3-day history of progressive abdominal distention. Vital signs are stable but WBC is 12.5/microliter and lactate level is 1.2 mg/dL. The abdomen is massively distended, soft, and diffusely tender. Plain radiograph shows sigmoid volvulus. Intravenous fluids and antibiotics are started. What is the best next step in treatment?



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A 74-year-old female nursing home resident has recurrent hospital admissions for sigmoid volvulus. She suffers from dementia after a stroke that occurred five years previously, has well-controlled hypertension on medication and no other medical conditions. You consider elective surgery. What would be the most appropriate operation for her?



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Which of the following is a major concern in a patient presenting with sigmoid volvulus of uncertain duration?



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Sigmoid Volvulus - References

References

Tejera Hernández AA,Betancort Rivera N,Pérez Alonso E,Hernández Hernández JR, Sigmoid volvulus due to Chagas disease. Emergencias : revista de la Sociedad Espanola de Medicina de Emergencias. 2018 Dic;     [PubMed]
Sahu KK,Sherif AA,Lopez CA, Omega sign: Radiological appearance of sigmoid volvulus. Journal of medical imaging and radiation oncology. 2019 Feb;     [PubMed]
Ishibashi R,Niikura R,Obana N,Fukuda S,Tsuboi M,Aoki T,Yoshida S,Yamada A,Hirata Y,Koike K, Prediction of the Clinical Outcomes of Sigmoid Volvulus by Abdominal X-Ray: AXIS Classification System. Gastroenterology research and practice. 2018;     [PubMed]
Atamanalp SS, Comments on Contemporary Management of Sigmoid Volvulus. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2018 Nov 21;     [PubMed]
Bauman ZM,Evans CH, Volvulus. The Surgical clinics of North America. 2018 Oct;     [PubMed]
Mba EL,Obiano SK,Mshelia NM, Compound volvulus: a case report and literature review. Journal of surgical case reports. 2018 Nov;     [PubMed]
Carmo L,Amaral M,Trindade E,Henriques-Coelho T,Pinho-Sousa J, Sigmoid Volvulus in Children: Diagnosis and Therapeutic Challenge. GE Portuguese journal of gastroenterology. 2018 Sep;     [PubMed]
Motsumi MJ,Tlhomelang O, Synchronous volvulus of the sigmoid and transverse colon in a 26-year-old male. Journal of surgical case reports. 2018 Nov;     [PubMed]
Xiang H,Han J,Ridley WE,Ridley LJ, Horseshoe sign: Sigmoid volvulus. Journal of medical imaging and radiation oncology. 2018 Oct;     [PubMed]
Frank L,Moran A,Beaton C, Use of percutaneous endoscopic colostomy (PEC) to treat sigmoid volvulus: a systematic review. Endoscopy international open. 2016 Jul;     [PubMed]
Echenique Elizondo M,Amondaraín Arratíbel JA, Colonic volvulus. Revista espanola de enfermedades digestivas : organo oficial de la Sociedad Espanola de Patologia Digestiva. 2002 Apr;     [PubMed]
Garfinkle R,Morin N,Ghitulescu G,Vasilevsky CA,Boutros M, From Endoscopic Detorsion to Sigmoid Colectomy-The Art of Managing Patients with Sigmoid Volvulus: A Survey of the Members of the American Society of Colon and Rectal Surgeons. The American surgeon. 2018 Sep 1;     [PubMed]
Quénéhervé L,Dagouat C,Le Rhun M,Perez-Cuadrado Robles E,Duchalais E,Bruley des Varannes S,Touchefeu Y,Chapelle N,Coron E, Outcomes of first-line endoscopic management for patients with sigmoid volvulus. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver. 2018 Oct 11;     [PubMed]
Dolejs SC,Guzman MJ,Fajardo AD,Holcomb BK,Robb BW,Waters JA, Contemporary Management of Sigmoid Volvulus. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2018 Aug;     [PubMed]

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