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Sigmoid volvulus — Clinical Guidelines

Overview

Sigmoid volvulus is a condition characterized by the twisting of the sigmoid colon upon itself, leading to bowel obstruction and potentially bowel ischemia or necrosis if untreated 1 2 3 4.

Diagnosis

Clinical Presentation: Abdominal pain, distension, and vomiting 1 2.

Imaging: Contrast-enhanced CT scans are crucial; look for reduced bowel wall enhancement, increased bowel wall thickness, and the dark torsion knot sign indicating complicated cases 2.

Endoscopic Findings: Initial endoscopic detorsion may be attempted, but failure suggests surgical intervention 2.

Management

Initial Treatment: Nonoperative decompression (e.g., endoscopic detorsion) is often attempted first with a success rate of around 92% 3.

Surgical Intervention: Emergency sigmoid colectomy may be required for complicated cases or failed decompression; choice between primary anastomosis and end colostomy varies 1 4.

Primary Anastomosis vs. End Colostomy: No statistically significant difference in major complications noted between primary anastomosis and end colostomy, though complication rates are comparable 1.

Recurrence Management: High recurrence rate (84%) after successful nonoperative decompression; planned definitive surgery may be necessary to prevent recurrence 3.

Special Populations

Elderly: Commonly affected, with 79% of patients in one study being fully independent preoperatively 4.

Comorbidities: Elevated markers like sepsis, elevated C-reactive protein, and lactic acid levels predict complicated cases requiring surgery 2.

Key Recommendations

Attempt Nonoperative Decompression Initially: Endoscopic detorsion is recommended as the first-line treatment 2 3.

Consider Surgical Intervention for Complicated Cases: Emergency sigmoid colectomy is advised for cases with irreversible bowel ischemia or necrosis 2 3.

Evaluate Recurrence Risk Post-Decompression: Plan definitive surgery after successful nonoperative decompression due to high recurrence rates 3.

(Evidence: Moderate)

References

1 Yang P, Ang ZH, Berney CR. Restoration of intestinal continuity following emergency sigmoid colectomy for sigmoid volvulus: An American College of Surgeons National Surgical Quality Improvement Program analysis using coarsened exact matching. World journal of surgery 2024. link 2 Heo S, Kim HJ, Oh BJ, Kim SJ, Kim B, Huh J et al.. Sigmoid volvulus: identifying patients requiring emergency surgery with the dark torsion knot sign. European radiology 2019. link 3 Johansson N, Rosemar A, Angenete E. Risk of recurrence of sigmoid volvulus: a single-centre cohort study. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2018. link 4 Dolejs SC, Guzman MJ, Fajardo AD, Holcomb BK, Robb BW, Waters JA. Contemporary Management of Sigmoid Volvulus. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 2018. link

Sigmoid volvulus