Sigmoid Volvulus

Sigmoid Volvulus

Andrew M. Holloway, MD and Michael T. Langford, MD

Table of Contents

Definition
Etiology
Presentation and Diagnosis
Management

See Also:
*See Colonic Volvulus

Definition

Sigmoid Volvulus: Twisting of the Sigmoid Colon Around Itself

Causes a Closed Loop Obstruction That Can Cause Vascular Compromise with Ischemia, Necrosis, and Perforation

The Most Common Colonic Volvulus (30-60%)

Sigmoid Volvulus 1

Etiology

Chronic Constipation and a High-Fiber Diet is the Most Common Risk Factor – Lengthens the Intestine and Mesentery to Become Chronically Distended and Redundant

More Common in the 6th-8th Decade of Life (Compared to Cecal Volvulus Which is Most Common in the 4th-6th Decade of Life) – Due to Degenerative Colonic Disease Rather than Congenital Cecal Mobility

Highly Associated with Institutionalized Patients with Neuro-Psych Disorders

  • Neurologic Dysfunction
    • Dementia
    • Parkinson Disease
    • Multiple Sclerosis
    • Spinal Cord Injury
  • Psychiatric Disorders
    • Schizophrenia
    • Bipolar Disorder
    • Depression/Anxiety
    • Chronic Antipsychotic Use
    • Intellectual Disability/Developmental Delay
  • Long-Term Institutionalization

Risk Factors

  • Adhesions
  • Male Sex
  • More Common in African, Middle Eastern, and South American Populations
  • Laxative Abuse
  • Colonic Dysmotility
  • Immobility

Presentation and Diagnosis

Presentation

  • Abdominal Pain
  • Abdominal Distention
  • Nausea and Vomiting
  • Obstipation
  • May See an Explosive Bowel Movement if Spontaneously Detorses

Diagnosis

  • Generally Diagnosed by CT Abdomen/Pelvis
    • Sigmoid Colon is Dilated and Twisted
    • “Whirl Sign” with Mesentery Twisted
  • Abdominal Plain Film is More Sensitive (60-75%) than in Cecal Volvulus But is Still Generally Considered Poor at Diagnosis
    • Classic “Bent Inner-Tube Sign” (Dilated Loop of Colon with Apex in the Right Upper Quadrant) is Rarely Seen
      • Also Known as an “Omega Sign” or “Coffee-Bean Sign”
    • Suggestive Plain Film Findings Should Be Further Evaluated by CT

Can Be Diagnosed at Surgical Exploration in an Emergent Setting

Sigmoid Volvulus 2

Management

Hemodynamically Stable: Immediate Colonoscopic Decompression with Delayed Sigmoidectomy During the Index Admission

  • Endoscopic Detorsion:
    • Do Not Detorse and Proceed with Emergent Surgery if Any Signs of Ischemia or Perforation are Seen on Endoscopy
    • Mucosal Pinwheel/Spiral Seen at the Site of Obstruction Before Detorsion – Typically at the Rectosigmoid Junction
    • Insufflation and Gentle Pressure Can Untwist the Colon
    • Suction the Dilated Bowel of All Accumulated Gas and Stool to Decompress and Reduce
    • May See a Second Area of Spiral at the Point of Proximal Obstruction
    • Consider Leaving a Decompression Tube (Red Rubber Catheter or Rectal Tube) to Prevent Retorsion Prior to Surgery
  • Endoscopic Detorsion Outcomes:
    • 80-95% Success Rate
    • 40-75% Recur if Not Resected
  • Perform Surgical Resection During the Index Admission
  • Primary Anastomosis is Generally Preferred if Stable

Hemodynamically Unstable, Peritonitis, Ischemia/Necrosis, or Perforation: Emergent Resection

  • Hartmann Procedure with End Colostomy is Generally Preferred Over Primary Anastomosis

Sigmoid Volvulus Swirl on Sigmoidoscopy 3

References

  1. 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)
  2. 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)
  3. Atamanalp SS, Atamanalp RS. The role of sigmoidoscopy in thediagnosis and treatment of sigmoid volvulus. Pak J Med Sci. 2016 Jan-Feb;32(1):244-8. (License: CC BY-3.0)