# Volvulus

Volvulus requires rapid anatomic classification and ischemia assessment: uncomplicated sigmoid volvulus usually undergoes urgent endoscopic detorsion, whereas peritonitis, perforation, ischemia, cecal volvulus, and midgut volvulus require operative management.

**Clinical question:** How should physicians diagnose, triage, and definitively manage suspected intestinal volvulus?

Updated: 2026-09-16T01:11:02.656833+00:00

## What matters in practice
- Peritonitis, suspected perforation, shock, or clinical concern for bowel ischemia should bypass nonoperative detorsion and prompt urgent operative management. [4][18][20][21]
- For uncomplicated sigmoid volvulus, urgent endoscopic detorsion with decompression tube placement is first-line treatment; successful detorsion is a bridge, not definitive therapy. [4][11][14][21]
- Offer sigmoid resection after successful decompression, preferably during the index admission, because recurrence without resection is high; reported recurrence after endoscopic detorsion is 43%–86%. [8][21]
- Use contrast-enhanced multidetector CT when anatomy or complications are uncertain; a mesenteric whirl, transition point, bowel dilation, and ischemic complications direct operative urgency and distinguish colonic from small-bowel patterns. [1][3][5]
- Treat neonatal, pediatric, and adult midgut volvulus from malrotation as a surgical emergency because a narrow mesenteric base can rapidly compromise the small-bowel blood supply. [7][22][23][24]

## Identify patients who need immediate laparotomy

The critical distinction is uncomplicated obstruction versus threatened or nonviable bowel.

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. [18][20][21]

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. [3][4][7][23]

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. [11][20]
- Proceed toward urgent operative management for peritonitis, perforation, shock, or bowel ischemia/gangrene. [18][20][21]
- Prioritize urgent surgical management for suspected midgut volvulus at any age. [7][22][24]
- Use serial examination during resuscitation because deterioration changes a potentially endoscopic sigmoid-volvulus pathway to an operative pathway. [4][20]

*Disposition is determined principally by bowel viability and volvulus anatomy. [4][19][21][24]*

| Clinical or imaging pattern | Next action | Rationale |
| --- | --- | --- |
| Sigmoid volvulus without peritoneal irritation or evidence of ischemia | Urgent endoscopic detorsion and colonic decompression; plan definitive sigmoid resection after reduction. [4][11][21] | Endoscopic reduction is first-line in uncomplicated disease, but recurrence after nonresection management is high. [8][21] |
| Sigmoid volvulus with peritonitis, perforation, septic shock, or gangrene concern | Urgent operative management; do not rely on nonoperative detorsion. [18][20][21] | These are markers of complicated obstruction and possible nonviable bowel. [4][18] |
| Cecal volvulus | Obtain urgent surgical management rather than expecting a sigmoid-style endoscopic pathway. [19][24] | Cecal volvulus commonly requires emergency surgery. [19] |
| Midgut volvulus or malrotation with acute obstruction | Emergency surgical management. [7][22][24] | A short mesenteric root and narrow mesenteric base predispose to rapid vascular compromise. [7][23][24] |

## Use imaging to localize the twist and assess complications

Contrast-enhanced CT is most useful when plain radiography does not establish anatomy or complications.

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. [3]

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. [1][3]

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. [5]

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. [6]
- Sigmoid pattern: pelvic-origin dilated sigmoid loop, coffee-bean or inverted-U appearance, collapsed rectum, and CT whirl/transition points. [1][3]
- Small-bowel pattern: proximal stomach, duodenum, and small-bowel dilation with distal bowel collapse may be present on radiography, but radiography is nonspecific; use CT to identify the mesenteric twist. [3]
- Malrotation pattern: right-sided or midline low duodenojejunal flexure with a high cecum indicates abnormal rotation and a short mesenteric root that predisposes to midgut volvulus. [24]

*Imaging patterns that alter the anatomic differential and next intervention. [1][3][5][6][24]*

| Suspected branch | Key imaging clues | Management implication |
| --- | --- | --- |
| Sigmoid volvulus | Coffee-bean or inverted-U dilated sigmoid loop on radiograph; northern exposure sign; CT whirl and transition points. [1][3] | If uncomplicated, proceed to urgent endoscopic detorsion; arrange definitive resection after reduction. [4][21] |
| Cecal volvulus | Whirl-sign location can distinguish cecal from sigmoid volvulus; radiographs may show marked colonic distention or bird-beak appearance. [5][24] | Favor emergency surgical management. [19] |
| Midgut volvulus from malrotation | Mesenteric whirling on CT; abnormal low/right-sided duodenojejunal flexure and high cecum suggest malrotation. [6][24] | Treat as a surgical emergency because extensive small-bowel ischemia can occur. [7][22][24] |
| Equivocal colonic torsion | Water-soluble contrast enema showing bird-beak or mucosal spiral at torsion. [6] | Clarifies obstruction site when plain films are nondiagnostic and perforation is not clinically apparent. [6] |

## Manage uncomplicated sigmoid volvulus with detorsion followed by definitive resection

Endoscopic decompression relieves the acute obstruction but does not eliminate recurrence risk.

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. [2][4][11][14]

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%. [8][21]

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. [21]

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. [21]
- Endoscopic detorsion is appropriate only after excluding peritoneal irritation and other evidence of complicated volvulus. [11][20]
- Leave decompression support temporarily after successful detorsion when using endoscopic reduction as a bridge to elective or index-admission resection. [4]
- Do not discharge a successfully detorsed patient without a definitive operative plan unless surgical risk precludes resection. [8][12][21]

### When endoscopic detorsion should not delay surgery

Escalate directly to surgery when detorsion is not feasible or when ischemia, perforation, peritonitis, or hemodynamic instability is present. Untreated sigmoid volvulus may lead to ischemia, perforation, sepsis, and death; endoscopic treatment is intended for uncomplicated presentations. [4][18][20][21]

*Practical sigmoid-volvulus sequence after diagnostic confirmation. [4][8][11][21]*

| Step | Action | Decision point |
| --- | --- | --- |
| 1. Exclude complicated disease | Assess for peritoneal signs, shock, perforation, and ischemia; obtain CT when it informs anatomy or complications. [3][18][21] | Any concern for nonviable bowel moves the patient to urgent surgery. [20][21] |
| 2. Relieve uncomplicated obstruction | Perform urgent endoscopic detorsion and decompression, with temporary decompression tube placement. [4][11][14] | Successful reduction restores patency but is not curative. [8][21] |
| 3. Prevent recurrence | Offer sigmoid resection, preferably during the index admission. [21] | Reported recurrence after endoscopic detorsion alone is 43%–86%. [8] |
| 4. Modify for colonic phenotype or operative risk | Use subtotal colectomy for concomitant megacolon; consider percutaneous endoscopic colostomy only when operative options are excessively high risk. [21] | Sigmoid resection alone is inadequate for megacolon-associated volvulus. [21] |

## Recognize cecal and midgut volvulus as different emergencies

Anatomic location determines whether endoscopic sigmoid-style management is appropriate.

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. [5][19][24]

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. [3][7][23][24]

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. [7][22][23][24]

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. [7]
- Do not extrapolate sigmoid endoscopic-detorsion algorithms to cecal volvulus. [19][24]
- Consider adult malrotation when recurrent postprandial obstructive symptoms precede an acute small-bowel volvulus presentation. [23]
- Treat bilious vomiting or acute obstructive symptoms in an infant or child with concern for malrotation/midgut volvulus as a surgical emergency. [22][24]

*Major volvulus branches and their procedural implications. [4][7][19][21][24]*

| Branch | Predisposing anatomy | Preferred acute direction |
| --- | --- | --- |
| Sigmoid volvulus | Twist of a redundant sigmoid colon around its mesenteric attachment. [4][19] | Endoscopic detorsion if uncomplicated; urgent surgery if ischemic or perforated; elective/index-admission resection after successful reduction. [4][21] |
| Cecal volvulus | Twisting of ileum, cecum, and proximal ascending colon around mesentery or cephalad cecal folding. [19] | Emergency surgical intervention is often required. [19] |
| Midgut volvulus | Small bowel twists around dorsal mesentery, often with malrotation and a short mesenteric root. [3][23][24] | Emergency surgery, including correction of malrotation anatomy when present. [7][22][24] |

## Plan recurrence prevention before the acute episode ends

Recurrence prevention is a required part of successful sigmoid-volvulus management.

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. [12][21]

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. [21]

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. [4][20]
- Document the post-detorsion plan for sigmoid resection before discharge or transfer. [21]
- Identify megacolon because it changes the definitive operation from segmental sigmoid resection to subtotal colectomy. [21]
- Reserve percutaneous endoscopic colostomy for patients in whom standard operative interventions are too high risk. [21]

*Definitive strategy after sigmoid-volvulus reduction. [8][12][21]*

| Post-reduction finding | Definitive plan | Reason |
| --- | --- | --- |
| Typical sigmoid volvulus after successful detorsion | Offer sigmoid resection, preferably during the index admission. [21] | Nonresection management carries high recurrence risk. [8][21] |
| Concomitant megacolon | Subtotal colectomy. [21] | Sigmoid colectomy alone is insufficient because residual colon can volvulize. [21] |
| Prohibitive operative risk | Consider percutaneous endoscopic colostomy. [21] | This approach should generally be reserved for patients unsuitable for established operative interventions. [21] |

## References
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## Editorial note

Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.