Sigmoid and Cecal Volvulus Workup

  • Author: Neelu Pal, MD; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Mar 17, 2008
 

Laboratory Studies

  • CBC with differential count: An elevated WBC count and left shift indicate bowel ischemia, peritoneal infection, or systemic sepsis.
  • Comprehensive metabolic profile: Bowel obstruction may cause significant changes in electrolyte levels.
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Imaging Studies

  • Plain abdominal radiography
    • Massive dilation of the sigmoid colon loop arising from the pelvis and extending to the diaphragm is a typical finding of sigmoid volvulus. The walls of the loop are evident as 3 bright lines converging in the pelvis to create a beaklike appearance (see the image below). Plain abdominal radiograph demonstrating massivelyPlain abdominal radiograph demonstrating massively dilated sigmoid colon loop and convergence of the walls of the colon into a beaklike formation.
    • Cecal volvulus produces large and small bowel obstruction. Radiographic findings reveal a markedly distended loop of bowel extending from the right lower quadrant upward to the left upper quadrant. The small bowel is distended, whereas the distal colon is decompressed (see the image below). Cecal volvulus with associated small bowel obstrucCecal volvulus with associated small bowel obstruction.
    • A detailed overview of the radiologic findings of colonic volvulus can be found in Sigmoid Volvulus and Cecal Volvulus.
  • CT scanning of the abdomen and pelvis
    • CT scanning is not often needed, since the plain radiographic findings are typical for sigmoid volvulus. The findings for cecal volvulus may be less diagnostic on plain abdominal radiographs. In these cases, CT scanning can delineate the exact site of the torsion and reveal evidence of ischemia.
    • Upward displacement of the appendix with large bowel obstruction is a definitive sign of cecal volvulus. Additionally, decompressed transverse and descending colon are apparent.
  • Barium enema: Perform a contrast enema in patients with no evidence of peritonitis and in whom plain abdominal radiographs are not diagnostic. The contrast demonstrates a beaklike termination at the point of the sigmoid volvulus (see the image below). Similarly, a foldlike termination may be observed at the point of obstruction in the ascending colon in patients with cecal volvulus. Barium enema of sigmoid volvulus revealing terminaBarium enema of sigmoid volvulus revealing termination of contrast in a bird beak formation at the base of the volvulus.
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Diagnostic Procedures

  • Sigmoidoscopy and colonoscopy
    • Both sigmoidoscopy and colonoscopy are used to successfully detorse and decompress sigmoid colon volvulus in as many as 90% of patients.
    • The sigmoidoscope or colonoscope is advanced into the rectum under direct vision. The rectum is insufflated to allow good visibility and identification of the apex of the volvulus. Occasionally, the pressure of the air causes detorsion, reducing the volvulus.
    • If detorsion does not occur, the spiraling rectal mucosa is followed upward to the apex, and a soft rectal tube is passed up through this under direct vision. The tip of the endoscope can also be used to apply constant pressure at the apex, which can lead to detorsion and decompression.
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Contributor Information and Disclosures
Author

Neelu Pal, MD  Fellow in Bariatric Surgery, Department of Surgery, University Medical Center at Princeton

Neelu Pal, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Brian James Daley, MD, MBA, FACS, FCCP, CNSC  Professor, Associate Program Director, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

David L Morris, MD, PhD, FRACS  Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: RFA Medical None Director; MRC Biotec None Director

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA  Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

References

  1. Drapanas T, Stewart JD. Acute sigmoid volvulus. Concepts in surgical treatment. Am J Surg. Jan 1961;101:70-7. [Medline].

  2. Hendrick JW. Treatment of volvulus of the cecum and right colon. A report of six acute and thirteen recurrent cases. Arch Surg. Mar 1964;88:364-73. [Medline].

  3. Vaez-Zadeh K, Dutz W, Nowrooz-Zadeh M. Volvulus of the small intestine in adults: a study of predisposing factors. Ann Surg. Feb 1969;169(2):265-71. [Medline].

  4. Grossmann EM, Longo WE, Stratton MD, Virgo KS, Johnson FE. Sigmoid volvulus in Department of Veterans Affairs Medical Centers. Dis Colon Rectum. Mar 2000;43(3):414-8. [Medline].

  5. Alshawi JS. Recurrent sigmoid volvulus in pregnancy: report of a case and review of the literature. Dis Colon Rectum. Sep 2005;48(9):1811-3. [Medline].

  6. Arnold GJ, Nance FC. Volvulus of the sigmoid colon. Ann.Surg. 1972;177:527-537.

  7. Ballantyne GH, Brandner MD, Beart RW Jr, Ilstrup DM. Volvulus of the colon. Incidence and mortality. Ann Surg. Jul 1985;202(1):83-92. [Medline].

  8. De U, Ghosh S. Single stage primary anastomosis without colonic lavage for left-sided colonic obstruction due to acute sigmoid volvulus: a prospective study of one hundred and ninety-seven cases. ANZ J Surg. Jun 2003;73(6):390-2. [Medline].

  9. Jone IT, Fazio VW. Colonic volvulus. Etiology and management. Dig Dis. 1989;7(4):203-9. [Medline].

  10. Kerry RL, Ransom HK. Volvulus of the colon. Arch Surg. Aug 1969;99(2):215-22. [Medline].

  11. Kuzu MA, Aslar AK, Soran A, Polat A, Topcu O, Hengirmen S. Emergent resection for acute sigmoid volvulus: results of 106 consecutive cases. Dis Colon Rectum. Aug 2002;45(8):1085-90. [Medline].

  12. Liang JT, Lai HS, Lee PH. Elective laparoscopically assisted sigmoidectomy for the sigmoid volvulus. Surg Endosc. Nov 2006;20(11):1772-3. [Medline].

  13. Madiba TE, Thomson SR. The management of cecal volvulus. Dis Colon Rectum. Feb 2002;45(2):264-7. [Medline].

  14. Mallick IH, Winslet MC. Ileosigmoid knotting. Colorectal Dis. Jul 2004;6(4):220-5. [Medline].

  15. Mangiante EC, Croce MA, Fabian TC, Moore OF 3rd, Britt LG. Sigmoid volvulus. A four decade experience. Am Surg. Jan 1989;55(1):41-4. [Medline].

  16. Oren D, Atamanalp SS, Aydinli B, Yildirgan MI, Basoglu M, Polat KY, et al. An algorithm for the management of sigmoid colon volvulus and the safety of primary resection: experience with 827 cases. Dis Colon Rectum. Apr 2007;50(4):489-97. [Medline].

  17. Tsai MS, Lin MT, Chang KJ, Wang SM, Lee PH. Optimal interval from decompression to semi-elective operation in sigmoid volvulus. Hepatogastroenterology. May-Jun 2006;53(69):354-6. [Medline].

 
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Sigmoid volvulus. A: Counterclockwise torsion at the base of the mesentery. B: Adhesions at base of sigmoid mesocolon leading to formation of a fixed omega loop that is susceptible to repeat torsion.
Cecal volvulus. A: Clockwise torsion of the mesentery of the cecum, ascending colon, and terminal ileum. B: Absence of dorsal mesenteric attachments of the cecum and the proximal ascending colon leading to lack of fixation to the retroperitoneum.
Cecal bascule. A: Anterior folding of the cecum. B: Lack of dorsal mesenteric fixation of cecum to retroperitoneum.
Plain abdominal radiograph demonstrating massively dilated sigmoid colon loop and convergence of the walls of the colon into a beaklike formation.
CT scan of the abdomen demonstrating massive dilation of the sigmoid colon and normal caliber of the proximal bowel.
Barium enema of sigmoid volvulus revealing termination of contrast in a bird beak formation at the base of the volvulus.
Cecal volvulus with associated small bowel obstruction.
Extent of resection required for sigmoid volvulus is limited to resection of omega loop of sigmoid volvulus and resection of sigmoid mesentery.
The divided descending colon and rectum is reanastomosed in a hand-sewn manner or with a GI stapling device.
Hartman procedure for sigmoid volvulus.
The extent of resection for cecal volvulus is similar to that for a right hemicolectomy for benign disease.
The terminal ileum is anastomosed to the transverse colon in the reconstruction after a right hemicolectomy.
Algorithm for treatment of patients with sigmoid and cecal volvulus.
Variable degrees of attachment of the ascending colon to the abdominal wall by reflection of the overlying parietal peritoneum. A: Normal attachment. B: Reflection of peritoneum to create a paracolic gutter. C: Mobile colon with reflection of the peritoneum to create a colonic mesentery.
Jackson veil over the ascending colon contains numerous small blood vessels from the renal and lumbar arteries.
Average measurements of the sigmoid mesocolon.
Arterial blood supply to the colon.
A cecal volvulus, with ischemic changes of the distended cecum and terminal ileum is shown. The remainder of the small bowel involved in the volvulus appears distended but not ischemic. No obvious peritoneal contamination is observed.
 
 
 
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