Volvulus

Obtain immediate surgical assessment when examination shows peritoneal irritation or when the patient has septic shock, pneumoperitoneum, suspected perforation, or suspected gangrene/ischemia. These features indicate complicated volvulus and favor operative rather than endoscopic management. Perforation, peritonitis, and septic shock have been reported in approximately 5%–25% of adults with sigmoid volvulus. PubMed+2PubMedSigmoid Volvulus in Children: A Structured Diagnostic and Therapeutic ApproachPubMedRecurrent Sigmoid Volvulus in Children—Our Experience and Systematic Review of the Current LiteraturePubMedWSES consensus guidelines on sigmoid volvulus management

In parallel, establish IV access, resuscitate and reassess hemodynamics, and obtain urgent cross-sectional imaging when it will not delay surgery. Volvulus can progress from closed-loop obstruction to ischemia, perforation, sepsis, and death; the urgency is greatest with small-bowel or midgut involvement because mesenteric vascular compromise may involve extensive bowel. ScienceDirect+3ScienceDirectSmall and large bowel volvulus: Clues to early recognition and complications - ScienceDirectScienceDirectEndoscopic Decompression, Detorsion, and Reduction of Sigmoid Volvulus - ScienceDirectWolters KluwerManagement of midgut volvulus in an incomplete... : International Journal of Surgery Case ReportsPubMedMidgut Malrotation - StatPearls - NCBI Bookshelf

Do not attempt endoscopic detorsion as definitive treatment in a patient with peritoneal signs. Absence of clinical peritonitis is a useful indicator against gangrene in reported sigmoid-volvulus series, but it does not replace repeated abdominal examination and imaging assessment for ischemic complications. Wiley+1WileyEndoscopic Detorsion Results in Sigmoid Volvulus: Single‐Center ...PubMedRecurrent Sigmoid Volvulus in Children—Our Experience and Systematic Review of the Current Literature

For suspected intestinal volvulus, multidetector CT with IV contrast is the preferred imaging modality for defining the transition point, twisted mesentery, involved bowel segment, and complications. Multiplanar reconstructions improve recognition because the twist is best seen perpendicular to the axis of rotation. ScienceDirectScienceDirectSmall and large bowel volvulus: Clues to early recognition and complications - ScienceDirect

In sigmoid volvulus, abdominal radiography may show a markedly dilated sigmoid loop with an inverted-U, coffee-bean, or bent-inner-tube configuration; the loop may extend cephalad over the liver, termed the northern exposure sign. CT can show a whirl sign and transition points. These findings support the diagnosis but do not determine bowel viability alone. BMJ+1BMJDiagnosis of sigmoid volvulus using the coffee bean, northern exposure sign, whirl sign and transition point | BMJ Case ReportsScienceDirectSmall and large bowel volvulus: Clues to early recognition and complications - ScienceDirect

Search CT at the obstruction point for the whirl sign, defined as spiraled collapsed bowel loops and engorged vessels radiating from the twisted bowel. Its location helps discriminate sigmoid from cecal volvulus, which changes the initial procedural plan. ScienceDirectScienceDirectCan the location of the CT whirl sign assist in differentiating sigmoid from caecal volvulus? - ScienceDirect

If plain radiography is equivocal in suspected colonic volvulus, a water-soluble contrast enema may demonstrate the torsion point as a bird-beak or mucosal spiral pattern. Water-soluble contrast avoids the risk of barium impaction and barium peritonitis if perforation is unrecognized. ScienceDirectScienceDirectIntestine Volvulus - an overview | ScienceDirect Topics

For hemodynamically stable sigmoid volvulus without peritoneal irritation, perform urgent flexible endoscopic detorsion/decompression. Endoscopic visualization permits assessment of the twisted segment and decompression; placement of a temporary rectal or colonic decompression tube after successful reduction is used as bridge therapy to surgery. Wolters Kluwer+3Wolters KluwerSigmoid Volvulus: Diagnosis and Management of a... : American Journal of GastroenterologyScienceDirectEndoscopic Decompression, Detorsion, and Reduction of Sigmoid Volvulus - ScienceDirectWileyEndoscopic Detorsion Results in Sigmoid Volvulus: Single‐Center ...Oxford AcademicRecurrent sigmoid volvulus relieved by transanal ileus tube ...

After successful detorsion, offer sigmoid colectomy and preferably perform it during the index admission. WSES guidance strongly recommends resection after resolution because recurrence remains high without resection, and a reported recurrence range after endoscopic detorsion is 43%–86%. Oxford Academic+1Oxford AcademicConcurrent sigmoid volvulus and caecal adenocarcinoma in a ...PubMedWSES consensus guidelines on sigmoid volvulus management

If the patient has concomitant megacolon, perform subtotal colectomy rather than sigmoid colectomy alone because remaining colonic segments are prone to recurrent volvulus. This is a strong recommendation based on low-quality evidence. PubMedPubMedWSES consensus guidelines on sigmoid volvulus management

For patients in whom established operative procedures are judged prohibitively high risk, percutaneous endoscopic colostomy may be considered to maintain reduction; reserve it for this limited population rather than using it routinely. PubMedPubMedWSES consensus guidelines on sigmoid volvulus management

Cecal volvulus involves the ileum, cecum, and proximal ascending colon twisting around the mesentery or folding upward. In contrast to uncomplicated sigmoid volvulus, cecal volvulus commonly requires emergency surgical intervention; identify the location of the CT whirl and the involved colonic segment before selecting an endoscopic approach. ScienceDirect+2ScienceDirectCan the location of the CT whirl sign assist in differentiating sigmoid from caecal volvulus? - ScienceDirectPubMedNavigating Abdominal Volvulus: A Comprehensive Review of Management StrategiesPubMedThe Pediatric Gastrointestinal Tract: What Every Radiologist Needs to Know - Diseases of the Abdomen and Pelvis 2018-2021 - NCBI Bookshelf

Midgut volvulus occurs when small bowel twists around the dorsal mesentery and is strongly associated with intestinal malrotation. Malrotation produces abnormal positioning and a narrow mesenteric base; abnormal peritoneal attachments, including Ladd bands, can further predispose to torsion and obstruction. ScienceDirect+3ScienceDirectSmall and large bowel volvulus: Clues to early recognition and complications - ScienceDirectWolters KluwerManagement of midgut volvulus in an incomplete... : International Journal of Surgery Case ReportsPubMedMidgut Malrotation - StatPearls - NCBI BookshelfPubMedThe Pediatric Gastrointestinal Tract: What Every Radiologist Needs to Know - Diseases of the Abdomen and Pelvis 2018-2021 - NCBI Bookshelf

In neonates, infants, children, and adults with suspected malrotation-associated midgut volvulus, expedite operative management rather than pursuing prolonged diagnostic observation. In adults, malrotation may first manifest as chronic intermittent postprandial pain, nausea, bloating, vomiting, weight loss, or food avoidance, but acute severe pain with vomiting and rapid hemodynamic decline signals acute obstruction or volvulus. Wolters Kluwer+3Wolters KluwerManagement of midgut volvulus in an incomplete... : International Journal of Surgery Case ReportsPubMedMidgut Volvulus - StatPearls - NCBI BookshelfPubMedMidgut Malrotation - StatPearls - NCBI BookshelfPubMedThe Pediatric Gastrointestinal Tract: What Every Radiologist Needs to Know - Diseases of the Abdomen and Pelvis 2018-2021 - NCBI Bookshelf

A Ladd procedure addresses midgut volvulus related to malrotation; in a reported adolescent case with extensive mesenteric ischemia, a damage-control Ladd procedure resulted in resolution of ischemia. The operative priority is timely correction before irreversible small-bowel injury. Wolters KluwerWolters KluwerManagement of midgut volvulus in an incomplete... : International Journal of Surgery Case Reports

After endoscopic reduction of sigmoid volvulus, use the hospitalization to determine candidacy for definitive resection rather than treating decompression as endpoint care. Primary endoscopic detorsion followed by elective surgery during a subsequent hospital admission was associated with the best survival in a 342-patient study, while WSES recommends offering sigmoid resection and preferably performing it during the index admission. Oxford Academic+1Oxford AcademicManagement and risk factors for colonic volvulus - Oxford AcademicPubMedWSES consensus guidelines on sigmoid volvulus management

Use the extent of colonic disease to choose the definitive operation. Concomitant megacolon favors subtotal colectomy because sigmoid colectomy alone leaves recurrence-prone colon behind; patients at excessive operative risk may be candidates for percutaneous endoscopic colostomy, recognizing that this is a selective salvage strategy. PubMedPubMedWSES consensus guidelines on sigmoid volvulus management

Monitor closely after detorsion for recurrent obstruction, evolving abdominal tenderness, or systemic deterioration, because these changes may indicate recurrent torsion or previously unrecognized ischemic injury and require repeat surgical evaluation. ScienceDirect+1ScienceDirectEndoscopic Decompression, Detorsion, and Reduction of Sigmoid Volvulus - ScienceDirectPubMedRecurrent Sigmoid Volvulus in Children—Our Experience and Systematic Review of the Current Literature