eMedicine Specialties > Radiology > Gastrointestinal

Sigmoid Volvulus: Follow-up

Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, Consultant Radiologist and Honorary Professor, North Manchester General Hospital Pennine Acute NHS Trust, UK
Coauthor(s): Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute; John MT Howat, MB, BCh, MD, FRCS, Consultant General and Colorectal Surgeon, North Manchester General Hospital, UK
Contributor Information and Disclosures

Updated: Aug 20, 2009

Intervention

With the patient in the left lateral position, decompression and untwisting of the sigmoid loop may be achieved by the passage of a long, soft tube through the obstruction, per rectum, under fluoroscopic or endoscopic control. This procedure allows for rapid decompression of the distended colon, with the immediate relief of symptoms. The tube may be left in situ for 48 hours to allow for complete emptying of the loop and for the resolution of mural edema.

Most patients are elderly persons, and they may be treated conservatively with tube decompression per rectum. However, this form of treatment is controversial because recurrence and mortality rates of sigmoid volvulus are high. If rectal decompression is instituted, the patient should be observed for persistent abdominal pain and blood-stained stools, signs that may herald ischemia and indicate the need for surgical intervention.

Surgery is reserved for patients in whom tube decompression fails to alleviate the patient's symptoms or for those in whom signs of ischemia are suggested. Surgery also has a role in an elective situation when the volvulus repeatedly recurs. After conservative treatment, further episodes of volvulus occur in approximately 60% of patients, and elective surgery is frequently required as prophylaxis against recurrence.

Safioleas et al performed a retrospective review of the clinical presentation and imaging characteristics of 33 sigmoid volvulus patients. The authors determined from the study findings that although sigmoid volvulus causing intestinal obstruction is frequently successfully encountered by endoscopic decompression, the principal therapy remains surgery and that only occasionally in patients with advanced age, lack of bowel symptoms, and multiple comorbidities might surgical repair not be considered.17

Oren et al reviewed the outcomes of emergent treatment of sigmoid volvulus in 827 patients. Nonoperative reduction was used in 575 patients (barium enema in 13, rigid sigmoidoscopy in 351, and flexible sigmoidoscopy in 211, with rectal tube placement in all patients), with a success rate of 78.1%; mortality, 0.9%; complication rate, 3%; and early recurrence rate, 3.3%. Surgical treatment was performed in 393 patients, with a mortality of 15.8%; complication rate, 37.2%; early recurrence rate, 0.8%; and late recurrence rate, 6.7%. 

Oren and coauthors noted that nonoperative reduction is the initial treatment, and flexible sigmoidoscopy with rectal tube placement can be used successfully. However, emergency surgery is necessary in patients in whom bowel gangrene or peritonitis is present or nonoperative treatment is unsuccessful. In surgical treatment, resection with primary anastomosis is the first choice and can be performed with acceptable mortality and morbidity rates in stable patients in whom a tension-free anastomosis is possible.18

Medicolegal Pitfalls

  • Take care not to perform a barium enema examination in patients with suspected gangrenous bowel, a pneumoperitoneum (as seen on plain abdominal radiographs), or clinical signs of peritonitis.
 
Acknowledgments

We would like to gratefully acknowledge Dr. John Howat, MD, FRCS, for his work on this article.



More on Sigmoid Volvulus

Overview: Sigmoid Volvulus
Imaging: Sigmoid Volvulus
Follow-up: Sigmoid Volvulus
Multimedia: Sigmoid Volvulus
References
Further Reading
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References

  1. Atamanalp SS, Yildirgan MI, Basoglu M, et al. Clinical presentation and diagnosis of sigmoid volvulus: outcomes of 40-year and 859-patient experience. J Gastroenterol Hepatol. May 24 2007;epub ahead of print. [Medline].

  2. Kedir M, Kotisso B, Messele G. Ileosigmoid knotting in Gondar teaching hospital north-west Ethiopia. Ethiop Med J. Oct 1998;36(4):255-60. [Medline].

  3. Raveenthiran V. The ileosigmoid knot: new observations and changing trends. Dis Colon Rectum. Aug 2001;44(8):1196-200. [Medline].

  4. Peitz HG. [Volvulus in childhood] [German]. Radiologe. Jun 1997;37(6):439-45. [Medline].

  5. Puthu D, Rajan N, Shenoy GM, Pai SU. The ileosigmoid knot. Dis Colon Rectum. Feb 1991;34(2):161-6. [Medline].

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  7. Larkin JO, Thekiso TB, Waldron R, Barry K, Eustace PW. Recurrent sigmoid volvulus - early resection may obviate later emergency surgery and reduce morbidity and mortality. Ann R Coll Surg Engl. Apr 2009;91(3):205-9. [Medline].

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  11. Feldman D. The coffee bean sign. Radiology. Jul 2000;216(1):178-9. [Medline]. [Full Text].

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  13. Hirao K, Kikawada M, Hanyu H, Iwamoto T. Sigmoid volvulus showing "a whirl sign" on CT. Intern Med. 2006;45(5):331-2. [Medline]. [Full Text].

  14. Shaff MI, Himmelfarb E, Sacks GA, Burks DD, Kulkarni MV. The whirl sign: a CT finding in volvulus of the large bowel. J Comput Assist Tomogr. Mar-Apr 1985;9(2):410. [Medline].

  15. Ogata M, Imai S, Hosotani R, et al. Abdominal sonography for the diagnosis of large bowel obstruction. Surg Today. 1994;24(9):791-4. [Medline].

  16. Lim JH, Ko YT, Lee DH, Lee HW, Lim JW. Determining the site and causes of colonic obstruction with sonography. AJR Am J Roentgenol. Nov 1994;163(5):1113-7. [Medline]. [Full Text].

  17. Safioleas M, Chatziconstantinou C, Felekouras E, Stamatakos M, Papaconstantinou I, Smirnis A, et al. Clinical considerations and therapeutic strategy for sigmoid volvulus in the elderly: a study of 33 cases. World J Gastroenterol. Feb 14 2007;13(6):921-4. [Medline].

  18. 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].

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  22. Carden AB. Acute volvulus of the sigmoid colon. Aust N Z J Surg. May 1966;35(4):307-12. [Medline].

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Further Reading

Related eMedicine topics

Obstruction, Large Bowel [Emergency Medicine]
 
Colonic Obstruction [Gastroenterology]

Megacolon, Toxic [Gastroenterology]

Megacolon, Chronic [Gastroenterology]
 
Toxic Megacolon [Radiology]

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Keywords

sigmoid volvulus, intestinal torsion, gastrointestinal tract, sigmoid colon, large bowel, chronic constipation, roundworm, large bowel obstruction, large-bowel obstruction, pneumoperitoneum

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Contributor Information and Disclosures

Author

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, Consultant Radiologist and Honorary Professor, North Manchester General Hospital Pennine Acute NHS Trust, UK
Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR is a member of the following medical societies: American Association for the Advancement of Science, American Institute of Ultrasound in Medicine, British Medical Association, British Society of Interventional Radiology, Royal College of Physicians, Royal College of Physicians and Surgeons of the United States, Royal College of Radiologists, and Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Coauthor(s)

Sumaira MacDonald, MBChB, PhD, MRCP, FRCR, Lecturer, Sheffield University Medical School; Endovascular Fellow, Sheffield Vascular Institute
Sumaira MacDonald, MBChB, PhD, MRCP, FRCR is a member of the following medical societies: British Medical Association, Royal College of Physicians, and Royal College of Radiologists
Disclosure: Nothing to disclose.

John MT Howat, MB, BCh, MD, FRCS, Consultant General and Colorectal Surgeon, North Manchester General Hospital, UK
John MT Howat, MB, BCh, MD, FRCS is a member of the following medical societies: Royal College of Surgeons of England
Disclosure: Nothing to disclose.

Medical Editor

Eric P Weinberg, MD, Associate Professor, Department of Radiology, University of Rochester Medical Center, Strong Memorial Hospital
Eric P Weinberg, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Spencer B Gay, MD, Professor of Radiology, Director of Body Computed Tomography, Department of Radiology, University of Virginia Health Sciences Center
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

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