Colonic Volvulus
Colonic Volvulus
Andrew M. Holloway, MD and Michael T. Langford, MD
Table of Contents
Definition and Types
Definition: Twisting of the Colon Around Itself
Causes a Closed Loop Obstruction That Can Cause Vascular Compromise with Ischemia, Necrosis, and Perforation
Types
- Sigmoid Volvulus
- The Most Common (30-60%)
- *See Sigmoid Volvulus
- Cecal Volvulus
- Second Most Common (35%)
- *See Cecal Volvulus
- Transverse Colon Volvulus
- Rare (1-4%)
- *See Transverse Colon Volvulus
- Splenic Flexure Volvulus
- Rare (1-2%)
- *See Splenic Flexure Volvulus
- Ileosigmoid Knotting (ISK): Axial Twisting of the Ileum and Sigmoid Colon Around Each Other
- Particularly Rare
- Considered a “Compound” or “Double Volvulus” as Both Segments Twist Around Each Other (Knotted) Causing Closed Loop Obstruction of Both the Small and Large Intestine
- *See Ileosigmoid Knotting (ISK)
Transverse Colon Volvulus Has Much Higher Mortality (3x) than Cecal or Sigmoid Volvulus Due to Late Presentation and High Rates of Ischemia/Perforation
Ileosigmoid Knotting (ISK) Causes Rapid Ischemia and Necrosis Earlier than Isolated Sigmoid Volvulus with Higher Mortality (Up to 73%)
Sigmoid Volvulus 1
Etiology
All are Generally Associated with Chronic Constipation and a High-Fiber Diet – Lengthens the Intestine and Mesentery to Become Chronically Distended and Redundant
Sigmoid Volvulus is Highly Associated with Institutionalized Patients with Neuro-Psych Disorders
Additional Common Risk Factors
- Absence or Disruption of Colonic Attachments/Ligaments
- Adhesions
- Colonic Dysmotility
- Pregnancy
Presentation and Diagnosis
Presentation
- Abdominal Pain
- Abdominal Distention
- Nausea and Vomiting
- Obstipation
Volvulus is the Second Most Common Cause of Large Bowel Obstruction (LBO), Behind Malignancy
Diagnosis
- Generally Diagnosed by CT Abdomen/Pelvis
- Associated Colon is Dilated and Twisted
- “Whirl Sign” with Mesentery Twisted
- Abdominal Plain Film is Generally Poor at Diagnosis and Classic Signs are Neither Sensitive nor Specific
- Sigmoid Volvulus: “Bent Inner-Tube Sign” – Dilated Loop of Colon with Apex in the Right Upper Quadrant
- Also Known as an “Omega Sign” or “Coffee-Bean Sign”
- Cecal Volvulus: “Coffee-Bean Sign” – Dilated Loop of Colon with Apex in the Left Upper Quadrant
- Transverse Colon Volvulus: “Inverted Coffee-Bean Sign” – Dilated Loop of Colon with Apex in the Pelvis
- Suggestive Plain Film Findings Should Be Further Evaluated by CT
- Sigmoid Volvulus: “Bent Inner-Tube Sign” – Dilated Loop of Colon with Apex in the Right Upper Quadrant
Can Be Diagnosed at Surgical Exploration in an Emergent Setting
Sigmoid Volvulus 2
Management
Sigmoid Volvulus
- Stable: Immediate Colonoscopic Decompression with Delayed Sigmoidectomy During the Index Admission
- Unstable, Peritonitis, Necrosis, or Perforation: Emergent Resection
All Other Types
- Endoscopic Detorsion Not Recommended
- Primary Treatment is Immediate Surgical Resection
- Extent of Resection:
- Cecal Volvulus: Right Hemicolectomy vs Ileocecectomy
- Transverse Colon Volvulus: Extended Right Hemicolectomy vs Transverse Colectomy
- Splenic Flexure Volvulus: Generally Requires a More Extensive Resection with Ileosigmoid or Ileorectal Anastomosis
- Ileosigmoid Knotting (ISK): Requires Resection of Both Segments
See Individual Sections
References
- Qadir I, Salick MM, Barakzai A, Zafar H. Isolated adult hypoganglionosis presenting as sigmoid volvulus: a case report. J Med Case Rep. 2011 Sep 8;5:445. (License: CC BY-2.0)
- Elia F, Pagnozzi F, Busolli P, Aprà F. Frail patient with abdominal pain. West J Emerg Med. 2010 Sep;11(4):400-1. (License: CC BY-NC-4.0)