Volvulus (Sigmoid / Cecal) — Bedside Protocol

Overview

Volvulus is a closed-loop obstruction that occurs when a segment of the colon (most frequently the sigmoid, second most often the cecum) twists around its own mesenteric pedicle; as the twist progresses, venous return is first impaired, leading to congestion and edema, followed by obstruction of arterial flow, resulting in ischemia, transmural necrosis, and, in the final stage, perforation. SIGMOID volvulus is the most common form of colonic volvulus and typically occurs in elderly patients with chronic constipation, a long and mobile sigmoid colon, who are bedridden or in institutional care, or who have neurological-psychiatric disorders (e.g., Parkinson’s disease, multiple sclerosis, severe dementia, use of psychotropic drugs).

CECAL volvulus, on the other hand, occurs in younger patients and women, on a congenitally mobile cecum; this form is managed surgically from the outset because it responds less to endoscopic reduction and carries a higher risk of ischemia. The clinical picture consists of gradually increasing abdominal distension, colicky or cramp-like pain, obstipation (cessation of gas and stool), and vomiting; peritoneal findings and rectal bleeding are indicators of ischemia or perforation.

The diagnosis can be made with a plain abdominal X-ray; the 'coffee bean' sign seen on imaging is the classic finding in sigmoid volvulus, but the definitive diagnostic test is computed tomography (CT). On CT, the whirl sign, bird’s beak sign, and a clear transition point both confirm the diagnosis and assess for ischemia and the presence of a closed loop.

In a multicenter CT study for cecal volvulus, it was reported that the sensitivity, specificity, and positive/negative predictive values of the transition point, bird’s beak, and 'X sign' findings alone were over 70%, and in a model where four findings (transition point, bird’s beak, coffee bean, whirl) were evaluated together, the area under the curve reached 0.979; the whirl sign, ileocecal twisting, transition points, and 'X sign' are particularly highly specific. In a historical Mayo Clinic series, the overall mortality for cecal volvulus was reported to be approximately 17%, and for sigmoid volvulus approximately 7%; whether the bowel remains viable significantly affects mortality, and in the same series, when a gangrenous colon developed, mortality rose to approximately 33%; if treatment is delayed, reported mortality can be even higher.

Key considerations

• Mechanical colonic obstruction — obstructive colorectal malignancy, stricture, or fecal impaction blocks the bowel lumen and creates a distension-constipation picture similar to volvulus; differentiation is made by demonstrating a mass or stricture on imaging.
• Acute colonic pseudo-obstruction (Ogilvie syndrome) — here there is NO mechanical blockage, cecal distension is functionally caused; this distinction is critically important because neostigmine, the first-line treatment for Ogilvie syndrome, may trigger perforation in a patient with mechanical volvulus.
• Mechanical small bowel obstruction — adhesions from previous abdominal surgery or a hernia block the bowel; the small intestine appears dilated, not the colon, and the level of obstruction differs on X-ray/CT.
• Toxic megacolon — the colon excessively dilates against the background of Clostridioides difficile colitis or inflammatory bowel disease; fever, systemic toxicity, and a history of underlying colitis distinguish it from volvulus.
• Complicated diverticulitis — stricture or pelvic abscess may lead to obstruction; on CT, diverticula, wall thickening, and inflammatory changes are visible, whirl sign is absent.
• Acute mesenteric ischemia — causes abdominal pain disproportionately severe relative to examination findings and can be easily missed early because the abdomen may remain soft; mesenteric vessel obstruction is sought on CT angiography.
• Incarcerated or strangulated hernia — bowel entrapment at the abdominal wall or internal hernia site causes closed-loop obstruction; a non-reducible, tender hernia mass is distinctive on examination.
• Secondary forms of acute colonic pseudo-obstruction due to hypothyroidism, electrolyte imbalance (especially hypokalemia), or opioid use should also be considered; in these patients, the condition may resolve when the underlying metabolic cause is corrected.
• Sigmoid stricture related to endometriosis or pelvic malignancy — in female patients with recurrent colicky pain and constipation, especially with a gynecological history, this should be included in the differential diagnosis.

Why it matters

The first step of the management algorithm is complication screening; patients with findings of ischemia, gangrene, perforation, or peritonitis are directly referred to emergency surgery (resection), and endoscopy is not attempted. In uncomplicated SIGMOID volvulus, the first step is endoscopic detorsion and decompression; flexible sigmoidoscopy or colonoscopy is used to both untwist the torsion and directly evaluate mucosal viability, followed by placement of a rectal decompression tube to reduce early recurrence.

However, endoscopic detorsion is a temporary solution: according to the ASCRS 2021 guideline, recurrence rates in patients who do not undergo further intervention after successful endoscopic detorsion have been reported between 43% and 75%. Due to this high recurrence risk, the ASCRS 2021 guideline (Dis Colon Rectum 2021;64(9):1046-1057) recommends considering sigmoid colectomy during the SAME (index) hospital admission for operable patients after successful endoscopic detorsion; the same guideline clearly states that non-resection interventions (detorsion alone, sigmoidopexy, mesosigmoidoplasty) are inferior to sigmoid colectomy in preventing recurrence.

In percutaneous endoscopic colostomy or endoscopic fixation techniques using a T-fastener, the major complication rate can reach up to 25%, whereas the recurrence rate within twelve months ranges from 0% to 17%; therefore, fixation is an alternative only in selected patients for whom surgical risk is unacceptable. In CAECAL volvulus, the situation is different: the success rate of endoscopic reduction is low in this form, and it carries a risk of perforation and delayed surgery, so in operable patients, treatment is directly right hemicolectomy or ileocolic resection.

According to ASCRS 2021 data, the recurrence rate after cecopexy in cecal volvulus is approximately 13%, whereas no recurrence has been reported in the resection group; this difference explains why resection is the preferred method in cecal volvulus. Cecostomy, on the other hand, is chosen only in high-risk or hemodynamically unstable patients, knowing that it has a high complication rate.

Throughout the entire process, NPO, nasogastric decompression, IV fluids, and electrolyte resuscitation are maintained, and serial reassessment for ischemia or perforation is performed; in the presence of contamination or hemodynamic instability, the Hartmann procedure stands out as a safe option.

Critical complications

• Bowel ischemia and transmural necrosis — develops in the affected segment first with venous congestion, followed by arterial flow interruption; recognized by continuous-severe pain, tachycardia, rising lactate, and leukocytosis, and requires emergency resection once diagnosed.
• Perforation and peritonitis — occurs with the rupture of the necrotic bowel wall; free air on plain radiography or pneumoperitoneum and free fluid on CT are seen, clinically supported by guarding and rebound; treatment is emergency laparotomy and source control.
• Sepsis and septic shock — develop following bacterial translocation after perforation or transmural necrosis; manifests with hypotension, tachycardia, and organ dysfunction, managed with early broad-spectrum antibiotics and emergency source control (surgery).
• Anastomotic leak — occurs after resection with primary anastomosis, especially in a contaminated field or in hemodynamically unstable patients; recognized with fever, increasing abdominal pain, and enteric content from drain or wound, generally requiring reoperation or percutaneous drainage.
• Early recurrence — frequently seen in patients discharged after endoscopic detorsion without definitive resection (according to ASCRS 2021, 43-75%); presents with recurrent distension and pain, elective colectomy should be planned during the same admission to prevent it.
• Iatrogenic perforation with neostigmine — occurs due to accidental neostigmine administration to a mechanical volvulus misdiagnosed as Ogilvie syndrome; mechanical obstruction and peritonitis are absolute contraindications for neostigmine, therefore it should not be administered without excluding mechanical obstruction on imaging.
• Stoma-related complications — in patients undergoing Hartmann procedure due to contamination or instability, stoma ischemia, retraction, or parastomal hernia may develop; managed with stoma care and regular surgical follow-up.
• Short bowel syndrome — arises especially when extensive resection is required in midgut volvulus; less common in colonic volvulus but may result in malabsorption and need for nutritional support after extensive segmental resection.

Special considerations

• Pregnancy — sigmoid volvulus is the most common cause of antepartum gastrointestinal obstruction and usually occurs in the second or third trimester due to increased intra-abdominal pressure and anatomical displacement of the uterus; recurrent endoscopic decompression has been reported to carry a low maternal-fetal risk regardless of gestational week, but in the presence of peritonitis or gangrene, sigmoid colectomy is indicated in the third trimester, and if sufficient space for bowel exploration cannot be provided, laparotomy with cesarean section may be required.
• Pediatric patient — colonic (sigmoid/cecal) volvulus is rare in children; in an infant with sudden bilious vomiting, upper abdominal distention, or hematochezia, this presentation should be considered as MIDGUT volvulus on the basis of malrotation, because a narrow mesenteric root allows the entire midgut to rotate around the superior mesenteric artery and transmural necrosis can develop within hours; in this patient, the adult sigmoid algorithm (endoscopic detorsion) is not applied, and if peritonitis or instability is present, the patient is taken directly to the operating room without waiting for imaging.
• Geriatric and frail patient — each recurrence episode in elderly individuals, institutionalized patients, or those with neurological disease, who are the typical population for sigmoid volvulus, carries a significant risk of morbidity and mortality; the ASCRS 2021 guideline recommends operative intervention to prevent recurrence during the index admission or shortly thereafter in this frail group, as long as surgical risk is acceptable; in patients not eligible for surgery, repeated endoscopic decompression or endoscopic fixation (with a high complication rate) may be the only remaining option.
• Kidney failure — caution should be exercised in the choice and amount of resuscitation fluids; excessive crystalloid loading can lead to volume overload and pulmonary edema in patients with acute kidney injury or dialysis dependence, therefore, instead of a fixed 30 mL/kg bolus, smaller volumes should be started and titrated according to dynamic response criteria; additionally, antibiotic doses should be adjusted according to kidney function.
• Elderly patient with heart failure — even when sepsis-related hypoperfusion is present, it is recommended to start with a smaller bolus of 250-500 mL instead of the standard 30 mL/kg and to reassess frequently, as large-volume rapid infusion can lead to acute heart failure decompensation and pulmonary edema.
• Patients using immunosuppressive drugs or chronic steroids — since peritoneal signs (defense, rebound) may be masked, the reliability of clinical examination decreases; in these patients, low-threshold CT imaging should be performed, and laboratory findings such as lactate/white blood cell count should be monitored more carefully.

Follow-up plan

After endoscopic detorsion, the patient is closely monitored both clinically and with serial radiographs; the rectal tube is kept in place, and the patient is evaluated for ischemia or early recurrence. In operable patients, elective colectomy is planned during the same hospitalization, because if definitive treatment is delayed, the post-discharge recurrence rate ranges from 43% to 75% according to ASCRS 2021 data, and the risk of urgent readmission is high.

In the postoperative period, anastomotic leak, ileus, wound site or stoma care, and the viability of resection margins are monitored regularly. Underlying predisposing factors (chronic constipation, immobilization, neurological disease, psychotropic drug use) are corrected as much as possible; colon malignancy and accompanying pathology are excluded with colonoscopic and pathological evaluation when appropriate.

At discharge, it should be clearly explained to the patient and their relatives that they must immediately go to the emergency department in case of increasing abdominal pain, distension, fever, bloody stool, or deterioration in general condition. Any sign of worsening (increasing pain, distension, fever, rising lactate, hemodynamic deterioration) warrants urgent surgical re-evaluation for ischemia or perforation.

In the long term after sigmoid colectomy, changes in bowel habits can be observed, and chronic constipation management (fiber, laxatives, mobilization) should be maintained to reduce recurrence risk.