Sigmoid Volvulus

Epidemiology

Incidence

  • Sigmoid Volvulus Accounts for <10% of Intestinal Obstructions in the US
    • However, Sigmoid Volvulus is a More Common Etiology (Accounting for 50-80% of Cases) of Intestinal Obstruction in Other Parts of the World
  • Clinical Data
    • Incidence of Sigmoid Volvulus Has Remained Stable from 2002-2010 (Ann Surg, 2014) [MEDLINE]
      • In Contrast, the Incidence of Cecal Volvulus Has Increased Approximately 5.5% Per Year in this Period of Time (see Cecal Volvulus, [[Cecal Volvulus]])
      • Sigmoid Volvulus was More Common in Older Males >70 y/o, African-Americans, Patients with Diabetes Mellitus, and Patients with Neuropsychiatric Disorders
      • Cecal Volvulus was More Common in Younger Females (see Cecal Volvulus, [[Cecal Volvulus]])

Risk Factors for Sigmoid Volvulus

  • Chagas Disease (see Chagas Disease, [[Chagas Disease]])
  • Chronic Constipation (see Constipation, [[Constipation]])
  • Crohn’s Disease (see Crohn’s Disease, [[Crohns Disease]])
  • Debilitated State Due to Underlying Neuropsychiatric Disease: may predispose to chronic constipation
  • Institutionalization: may predispose to chronic constipation
  • Male Sex: controversial risk factor
    • Physiology: due to longer sigmoid colon and mesentery (especially in males of black African race)
  • Older Age
    • Mean Age of Presentation: 70 y/o
    • However, Sigmoid Volvulus Has Also Been Reported in Select Groups of Younger Patients and in Children with Colonic Dysmotility
  • Pregnancy (see Pregnancy, [[Pregnancy]])

Site of Volvulus of the Gastrointestinal Tract

  • Volvulus of the Gastrointestinal Tract May Occur in the Colon, Stomach, Gallbladder, and Small Intestine (see Gastric Volvulus, [[Gastric Volvulus]])
    • Colon is the Most Common Site of Volvulus
      • Cecum and Sigmoid Colon are the Most Common Sites of Colonic Volvulus (see Cecal Volvulus, [[Cecal Volvulus]])

Physiology

Twisting of Loop of Sigmoid Around its Mesentery

  • Obstruction of the Sigmoid Lumen and Impairment of Vascular Perfusion May Occur
  • “Ileosigmoid Knotting”: variant of sigmoid volvulus where the ileum is wrapped around the sigmoid (usually clockwise)

Etiologic Factors

Anatomic Factors

  • Long, Redundant Sigmoid Colon Due to Chronic Constipation
    • Chronic Constipation, with Fecal Overloading, May Result in Elongation and Dilation of the Sigmoid Colon (see Constipation, [[Constipation]]): may explain the increased incidence of sigmoid volvulus in older institutionalized adults

Colonic Dysmotility

  • Hirschsprung Disease (Congenital Aganglionic Megacolon) (see Hirschsprung Disease, [[Hirschsprung Disease]])
    • Sigmoid Volvulus May Be the Initial Presentation in Children with Hirschsprung’s Disease: aganglionic segment below the sigmoid colon and a mobile mesosigmoid may increase the risk of development of sigmoid volvulus
  • Prolonged Colonic Transit Due to Chronic Constipation (see Constipation, [[Constipation]])

Diagnosis

Upright Kidneys-Ureters-Bladder X-Ray (see Kidneys-Ureters-Bladder X-Ray, [[Kidneys-Ureters-Bladder X-Ray]])

  • May Be Useful Prior to CT Scan to Identify Pneumoperitoneum
    • When Pneumoperitoneum is Found, Surgery is Indicated and Further Imaging with CT Scan is Usually Not Necessary (see Pneumoperitoneum, [[Pneumoperitoneum]])
    • Upright KUB is Diagnostic in Only 60% of Cases of Sigmoid Volvulus
  • Findings
    • “Bent Inner Tube”: U-shaped distended (ahaustral) sigmoid colon which may extend from the pelvis to right upper quadrant

Abdominal-Pelvic CT (see Abdominal-Pelvic Computed Tomography, [[Abdominal-Pelvic Computed Tomography]])

  • Findings
    • “Whirl Pattern”: due to dilated sigmoid colon around its mesocolon and vasculature
    • Bird-Beak Appearance of Afferent and Efferent Colonic Segments
    • “Split Wall Sign”: apparent separation of the sigmoid walls by adjacent mesenteric fat due to incomplete twisting or folding
    • Two Crossing Sigmoid Transition Points Which Project from a Single Location
    • Absence of Rectal Gas

Barium Enema (see Barium Enema, [[Barium Enema]])

  • Indications
    • May Be Used in Some Cases Where CT is Non-Diagnostic
  • Contraindications
    • Presence of Peritonitis (see Peritonitis, [[Peritonitis]])
  • Technique
    • Although Barium Enema May Result in Detorsion of Sigmoid Volvulus in Some Cases, Due to Risk of Perforation, This is Not Recommended
  • Findings
    • “Twisted Taper” or “Birds-Beak” Sign
  • Adverse Effects/Complications
    • Perforation

Clinical Manifestations

Gastrointestinal Manifestations

  • General Comments
    • Most Cases Present 3-4 Days After the Onset of Symptoms: some cases have a more acute presentation
  • Abdominal Distention (see Abdominal Distention, [[Abdominal Distention]])
    • Clinical
      • Tympanitic Abdomen
  • Abdominal Pain (see Abdominal Pain, [[Abdominal Pain]])
    • Clinical
      • Insidious Onset and Slowly Progressive: usually
      • Continuous: usually
        • Superimposed Colicky Pain: during peristalsis
        • Younger Patients May Manifest an Atypical Pattern of Intermittent Abdominal Pain: due to spontaneous detorsion of the sigmoid
      • Severe: usually
      • Rebound Tenderness: may occur in cases with sigmoid ischemia/infarction or perforation
  • Constipation (see Constipation, [[Constipation]])
  • Nausea (see Nausea and Vomiting, [[Nausea and Vomiting]])
    • Clinical
      • Vomiting Usually Occurs Several Days After the Onset of Abdominal Pain
  • Obstipation: absence of passage of stools or flatus

Hematologic Manifestations

  • Leukocytosis (see Leukocytosis, [[Leukocytosis]]): may occur in cases with sigmoid ischemia/infarction or perforation

Other Manifestations

  • Fever (see Fever, [[Fever]]): may occur in cases with sigmoid ischemia/infarction or perforation
  • Hypotension (see Hypotension, [[Hypotension]]): may occur in cases with sigmoid ischemia/infarction or perforation

Treatment

Colonoscopic or Sigmoidoscopic Detorsion (see Colonoscopy, [[Colonoscopy]])

  • Indications
    • Recommended Whenever Feasible
  • Technique
    • Allows Both Detorsion and Assessment of Colonic Viability
    • Following Colonoscopic Detorsion, Rectal Tube Can Be Left in Place with the Tip Beyond the Region of Torsion to Prevent Short-Term Recurrence of the Sigmoid Volvulus
  • Clinical Efficacy
    • Successful in 75-95% of Cases

Laparoscopy or Laparotomy (see Laparoscopy, [[Laparoscopy]] and Laparotomy, [[Laparotomy]])

  • Timing
    • Surgical Intervention May Be Performed 24-72 hrs After Colonoscopic Detorsion to Prevent Recurrence of Sigmoid Volvulus: this 24-72 hrs time delay allowed by prior colonoscopic detorsion allows time for adequate bowel preparation
      • However, it is Controversial as to Whether Surgery is Required in Cases of Successful Colonoscopic Detorsion, Since Approximately 40-50% of These Patients Will Not Have a Recurrence of the Sigmoid Volvulus (Am Surg, 1989) [MEDLINE]
    • Surgical Intervention is Required Immediately in Cases Where Colonoscopic Detorsion is Impossible/Unsuccessful or When Peritonitis is Present (see Peritonitis, [[Peritonitis]])
  • Technique
    • Sigmoid Resection with Primary Anastomosis or Hartmann’s Procedure

References

  • Sigmoid volvulus. A four-decade experience. Am Surg. 1989;55(1):41 [MEDLINE]
  • Colonic volvulus in the United States: trends, outcomes, and predictors of mortality. Ann Surg. 2014 Feb;259(2):293-301 [MEDLINE]