1.

General Surgery

2. Gastrointestinal Tract

3. Management of Sigmoid Volvulus

4. Col Rajan Chaudhry, VSM

Professor & Head of Department

Maj AK Shah

Asst Professor, Dept of Surgery

5. Department of Surgey

Armed Forces Medical College

Pune 40

e mail: [email protected]
Introduction: Volvulus is derived from the Latin word volvere, which means
“to twist upon”. In the colon, it refers to a condition in which the colon is
twisted on its mesentery causing acute, subacute, or chronic colonic
obstruction. For a volvulus to occur, the colon must be mobile and have
sufficient length to rotate around a relatively narrow and fixed mesenteric
base. As a result, the most commonly involved sites are the sigmoid colon and
the caecum.
Incidence: It varies widely in different parts of the world. It is very common
in India, Pakistan, Africa, Russia, Eastern Europe, and Scandinavia (volvulus
belt), where as its incidence is very low in Britain, most European countries,
and America. Volvulus of the colon accounts for approximately5% of
intestinal obstructions and 10 – 15% of colonic obstructions in patients in the
United States [1, 2]. Its exact incidence in India is not available but is said to
vary between 12 – 30% of colonic obstructions [3]. Sigmoid volvulus is the
most common form of volvulus of the gastrointestinal tract and is responsible
for 8% of all intestinal obstructions. It accounts for 75% of all colonic
volvulus, and 10% of all colonic obstructions.

Mortality/Morbidity: Mortality rates are 20-25%, depending on the interval

between diagnosis and treatment. Therefore, radiographic recognition of
sigmoid volvulus is important [5].

Risk factors: The risk factors that can make a person more likely to have
sigmoid volvulus are Hirschsprung’s disease, intestinal pseudo-obstructions,
and megacolon. Adults, children, and infants can all have sigmoid volvulus. It
is more common in men than in women, possibly because men have longer
sigmoid colon. It is also more common in people over age 60, in African
Americans, and in institutionalized individuals who are on medications for
psychiatric disorders. The common factor is chronic constipation. In addition,
children with malrotation are more likely to get sigmoid volvulus.

Anatomy: Examination of the base of the sigmoid at the time of surgery for
volvulus may show that the 2 limbs of colon are bound closed, usually by
fibrous adhesions within the peritoneum. Two anatomic differences can
increase the risk of sigmoid volvulus. One is an elongated or movable sigmoid
colon that is unattached to the left sidewall of the abdomen. Another is a
narrow mesentery that allows twisting at its base. Sigmoid volvulus, however,
can occur even without an anatomic abnormality. This, plus the dependent
position of a redundant sigmoid loop, predisposes patients to the volvulus.
The most common and clinically significant twist of the sigmoid occurs in the
mesenteric axis, although a less frequent and more benign form of the twist
may occur around the longitudinal axis of the sigmoid loop. This longitudinal
twist has been variably termed as the kink, axial torsion, or physiologic
incomplete torsion. Patients with this twist are usually not symptomatic, and it
may be an incidental finding on routine barium enema examination [5].
In acute sigmoid volvulus, the degree of torsion varies from 180º (35% of
cases) to 540º (10% of cases). 360 º torsion is seen in 50% of patients. The
torsion is usually counterclockwise. The common form of volvulus around the
mesenteric axis usually is sited 15-25 cm from the anus and is therefore
accessible with sigmoidoscopic examination.

Pathophysiology: An unusually narrow attachment of the root of the sigmoid

mesentery to the posterior abdominal wall permits close approximation of the
2 limbs of the sigmoid colon. This in turn may predispose patients to a
twisting in the sigmoid colon around its mesenteric axis. The anatomic defect
may be complicated by predisposing factors, including a high-roughage diet,
chronic constipation, and lead poisoning. Bowel gas may be able to enter the
closed sigmoid loop through the twist, but it cannot escape. This condition
results in massive dilatation of the sigmoid loop and further tightening of the
obstructive twist leading to complete obstruction. The part of the digestive
system above the volvulus continues to function and may swell as it fills with
digested food, fluid, and gas. Failure in providing prompt diagnosis and
treatment ultimately leads to colonic ischemia with perforation and peritonitis.
The extent of sigmoid colon ischemic changes must be determined prior to
resection to prevent anastomosis of the ischemic colon and subsequent
stenosis or anastomotic leak.

Clinical Details: The clinical presentation of volvulus of the colon is

similar regardless of the site of the twist. Although a sigmoid volvulus may
present insidiously with chronic abdominal distension, constipation, vague
lower abdominal discomfort, and vomiting, it is seen more often as an
abdominal emergency where a crampy abdominal pain, distension, diminished
stool output, and nausea and vomiting consistent with obstruction are the
hallmark complaints. Progress to constant abdominal pain implies the
development of serositis of the involved segment, which may act as a closed-
loop obstruction increasing intraluminal pressure that leads to ischaemia.
Furthermore, the mesenteric vasculature may be compromised by mechanical
torsion of the volvulus around the mesenteric pedicle. Acute presentations
such as this represent more than half of the total episodes of volvulus.
Vomiting occurs late, and the distension may be gross enough to compromise
respiratory and cardiac function. A subgroup of patients with colonic volvulus
describes similar episodes in the past that resolved spontaneously, often with
an associated explosive bowel movements or passage of gas. Patients with
recurrent volvulus need a careful assessment to rule out the diagnosis of
colonic inertia and megacolon, which may mandate a more extensive colonic
resection.

Predisposing factors common to all sites of volvulus include previous

abdominal surgery and a history of chronic constipation. A detailed history
should include potential comorbidities that must be incorporated into the
overall treatment plan as many of these patients are elderly, debilitated, and
have multiple coexisting medical conditions. Physical examination reveals a
distended abdomen which is tympanitic, varying degrees of tenderness over
the obstructed segment and a palpable mass may be present. Shock and an
elevation of temperature may be present in instances of vascular compromise
or colonic perforation. Rectal examination shows only an empty rectal
ampulla.
Sigmoid Volvulus – Varieties
1. Acute Fulminating Type
 Mortality 37-80%
 Younger patient, sudden onset, rapid course
 Early vomiting, severe pain, peritonitis, and gangrene
 Minimal distension often, hard to diagnose
2. Subacute Progressive Type
 Generally older pt., more gradual onset
 History of prior attacks, chronic constipation
 Abdominal distension often extreme
 Late vomiting, pain is minimal, no peritonitis

Investigation: The diagnosis of sigmoid volvulus is usually made on plain

abdominal radiographs.

Radiographic Findings: The key radiological features are those of a double-

loop obstruction, which has been reported in approximately 50% of patients.
The key finding consists of a dilated loop of pelvic colon, associated with
features of small bowel obstruction and retention of feces in an undistended
proximal colon. The dilated loop usually lies in the right side of the abdomen,
and the limbs taper inferiorly into the right lower quadrant. Medial deviation
of the distal descending colon is a rare but highly specific finding.

Plain radiographs show a markedly distended sigmoid loop, which assumes a

bent inner tube or inverted U-shaped appearance, with the limbs of the
sigmoid loop directed towards the pelvis. The colonic haustra are lost, and
progressive distension elevates the sigmoid loop under one of the diaphragms.

An upright radiograph shows a greatly distended sigmoid loop with air-fluid

levels mainly on the left side of the abdomen extending toward the right
hemidiaphragm. The involved bowel walls are edematous, and the contiguous
walls form a dense white line on radiographs. This line is surrounded by the
curved and dilated gas-filled lumen, resulting in a coffee bean–shaped
structure; this is the coffee bean sign [6].

A dilated sigmoid colon that ascends to the transverse colon (northern

exposure sign) is said to be a reliable sign of a sigmoid volvulus on a supine
abdominal radiograph [7]. If more fluid than air is in the obstructed loop of
the sigmoid, the volvulus may be demonstrable by a soft-tissue mass or a
pseudotumor sign.

Single-contrast barium enema examination is adequate because the barium

readily enters the empty rectum and usually encounters a complete stenosis,
which is likened to a beak, the so-called bird's beak or bird-of-prey sign.
Barium enema examination can also demonstrate obstruction at the
rectosigmoid junction.

If barium can enter the obstructed segment, spiraling of the mucosal folds may
be seen. Signs of bowel ischemia, such as thumbprinting, transverse ridging,
and mucosal ulceration, may be observed.

Limitations of Radiography: Diagnostic difficulties may occur with plain

abdominal radiographs if the degree of proximal dilatation is so marked that
the sigmoid loop may not be recognized as such. Similar difficulties may be
encountered when a large amount of fluid is associated with a small amount of
air. This situation causes poor definition of the sigmoid colon on a supine
radiograph, and the high air-fluid level demonstrated on erect images may be
inadequate to define the sigmoid loop accurately.

However, in 60-70% of patients, diagnosis of sigmoid volvulus can be made

by using plain abdominal radiographic findings. In 20-30% of patients, the 2
limbs of the twisted sigmoid colon may overlap or deviate to the right or left,
obscuring the remainder of the colon. In these instances, the findings are those
of a nonspecific large-bowel obstruction, and barium enema examination is
required for confirmation of the diagnosis.

Barium enema examination is contraindicated in patients in whom a

gangrenous bowel is suggested or when a pneumoperitoneum is noted on a
plain abdominal radiograph or erect chest radiograph. The examination is also
contraindicated in patients with clinical signs of peritonitis.

Sigmoidoscopy, rather than barium enema examination, is the procedure of

choice if an ileosigmoid knot is suspected [8].

CT Findings: CT is the least invasive imaging technique that allows

assessment of mural ischemia and helps in identifying the cause of an acute
large bowel obstruction in most of cases.

CT findings of sigmoid volvulus include the whirl sign, which represents

tension on the tightly twisted mesocolon by the afferent and efferent limbs of
the dilated colon. It may also be useful in identifying the etiology and site of
obstruction resulting from other pathologies and in demonstrating ischemia
resulting from strangulation. CT signs of ischemia include a serrated beak at
 the site of obstruction, mesenteric edema or engrossment, and moderate-to-
severe thickening of the bowel wall [9].

Intramural gas or portal venous gas may be seen (grave prognostic signs), and
in patients in whom a perforation has occurred, a large amount of free
intraperitoneal gas or fluid may be noted.

MRI Findings: MRI has been used successfully in the assessment of large-
bowel obstruction (not specifically in sigmoid volvulus). These examinations
are performed with the retrograde insufflations of 1000-1200 mL of air
through a Foley catheter placed in the rectum and with scopolamine to inhibit
peristalsis to demonstrate the site of bowel obstruction. In addition, MRI has
been used in the diagnosis of mural necrosis in infants, and theoretically, it
can be used in adults [10]. However, with the limited experience at the present
stage, routine use of MRI in cases of intestinal obstruction is not
recommended.

USG Findings: Sonography might occasionally be useful in assessing large-

bowel obstruction. But the experience in diagnosing sigmoid volvulus by
using ultrasonography is limited as the images fail to depict the cause in most
patients [11, 12].

Differential Diagnosis: Other problems to be considered are:

• Other forms of large-bowel obstruction, especially carcinoma of the

sigmoid colon
• Pseudo-obstruction
• Giant sigmoid diverticulum
• Ileosigmoid knot
• Constipation

Management: The initial treatment in the patient with no evidence of

bowel necrosis based on history and physical examination should involve an
urgent non operative endoscopic attempt at reduction of volvulus. Failure to
successfully reduce the volvulus endoscopically or clinical evidence of vascularly
compromised bowel mandates emergent exploration [13].

Non operative intervention: Since its introduction by Bruusgaard in 1947, non

operative decompression has become the treatment of choice for patients without
any signs of peritonitis. 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. If rectal decompression is instituted, the patient
should be observed for persistent abdominal pain and bloodstained stools, signs
that may herald ischemia and indicate the need for surgical intervention.

Surgical management: Surgery is reserved for patients in who tube

decompression fails or for those in whom signs of ischemia are suggested. After
conservative treatment, further episodes of volvulus occur in approximately 60%
of patients. Such a high recurrence rate justifies an elective prophylactic sigmoid
resection during the same hospitalization after the first episode of volvulus in all
patients except in high – risk surgical candidates [13].

Elective Surgery: Following successful decompression patient is planned for

an elective resection of sigmoid colon. If associated with megacolon, total
colectomy or subtotal colectomy is advised. One problem frequently encountered
at laparotomy, especially when the volvulus is recurrent or chronic is the
discrepancy between the proximal and distal bowel lumen. Moreover, the wall of
the proximal bowel may be much thicker making it difficult for stapling. If a
primary anastomosis has been decided upon, this can be undertaken by a hand
sutured end - to - end anastomosis by taking wider bites of the proximal bowel.
Alternatively, a stapled end - to - side anastomosis using a circular stapler is also
recommended. This is fashioned by placing the anvil into the rectal stump, using a
purse string and passing the gun into the open end of proximal bowel. The spike is
advanced to pass through the anti – mesenteric aspect of the bowel leaving
enough length beyond the staple line for subsequent closure once the gun is fired.
The open end is closed using a linear stapler. Laparoscopic resection of the
sigmoid colon for decompressed sigmoid volvulus may be a useful alternative in
high risk patients or in the elderly who may not tolerate conventional colonic
surgery.
Non Resection Surgery:
1. Colopexy: is said to have advantage of not requiring resection of the
sigmoid colon and not requiring bowel preparation. Percutaneous endoscopic
colopexy using PEG Kit is also in vogue.
2. Mesosigmoidoplasty; first described by Tiwary and Prasad in 1976 which
constitutes broadening the base of the mesosigmoid and reduction of its length. It
is a simple operation with low rate of operative morbidity and mortality. Also has
advantage of no likelihood of anastomotic leakage and sepsis. Undue post-
operative constipation is not a problem. In Subrahmanyam’s series of 126 pts with
an average follow up of 8.2 years showed a recurrence rate of 1.6% and no
mortality. However, the lack of verification of Subrahmanyam’s results in other
surgeons’ hands and a high recurrence rate counts against its routine use [14, 15,
16]
3. Extraperitonealization for Sigmoid Volvulus: Bhatnagar et al introduced
the technique of extraperitonealizing the whole segment of the sigmoid colon with
favorable results [17].
 But recent literature show that fixation procedures for the management of
sigmoid volvulus are associated with high recurrence rates and are not
recommended [15].

Emergency Surgery: The indications for emergency laparotomy are:

• The presence of peritonitis.

• The failure to decompress endoscopically.
• When ischaemia or strangulation is suspected.

The exact procedure will depend upon the viability of the colon. If the colon is
gangrenous, there is no alternative to resection, taking care not to untwist the
torsion. Resection of gangrenous bowel is done, with creation of an end
colostomy and a Hartmann’s or mucus fistula being the safest option in absence of
formal mechanical bowel preparation. There are insufficient trials comparing
patients treated with or without a primary anastomosis in this condition. Similarly,
on – table lavage has not been widely employed for volvulus.

If the bowel is of questionable viability, derotation usually in counterclockwise

manner with observation for the return of adequate perfusion may avoid resection.
Often the use of Doppler probe or wood’s lamp following intravenous
administration of fluorescein can help in further evaluating for bowel viability
[13]. If the colon remains viable following derotation, primary resection and
anastomosis may be performed in favorable circumstances. However, if there is
slightest fear of a leak, exteriorizing both the ends is safest option.

Outcomes Following Treatment:

Operative mortality rates for emergent surgery for sigmoid volvulus are
considerably higher in presence of intestinal gangrene or failed non operative
reduction, approximating 40%. In comparison, the mortality rate for an elective
resection following successful endoscopic reduction is less than 10% [13].
 References

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3. Sinha RS. Colonic Volvulus, In; AA Hai, RB Shrivastava eds. Textbook of

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