Edit concept Question Editor Create issue ticket

Sigmoid Volvulus

Colon Sigmoid Volvulus

Sigmoid colon is characterized by torsion of the sigmoid loops of the colon, causing mechanical obstruction of the passage leading to the rectum and restriction of blood supply.


Presentation

The classical clinical symptoms of acute SV include abdominal pain and constipation. Most of the acute episodes of SV are sudden in onset and present with additional symptoms of vomiting, nausea, anorexia and hematemesis.

Physical examination of the abdomen reveals a distended, soft and palpable abdomen along with abnormal bowel sounds and noticeable peristalsis. Retention of feces in the sigmoid colon is manifested by an empty rectum and presence of fecal odor on the patient's breath.

Obvious signs of sustained, long-term SV are colonic gangrene and peritonitis. Morphological changes consist of a hypertrophied colonic wall and a narrowed mesentery resulting from a distended colon and visibly clear vasculature.

Disability
  • A patient with mild learning disability and paranoid schizophrenia developed catatonia. The marked emaciation associated with catatonia resulted in intestinal obstruction secondary to sigmoid volvulus.[ncbi.nlm.nih.gov]
  • A 39-year-old, mentally disabled man was presented to the emergency department with progressive abdominal distension and pain since day 1. He complained of nausea, vomiting and fever of up to 38.5 C. Time of last bowel movement was unclear.[link.springer.com]
Splenectomy
  • Detorsion of sigmoid occurred while undergoing exploratory laparotomy and splenectomy was performed.[ncbi.nlm.nih.gov]
  • Also, an accidental splenectomy was occurred. Postoperative period was uneventful and the patient was discharged 2 weeks after admission.[pubs.sciepub.com]
Epilepsy
  • He had a medical history of chronic constipation, epilepsy and hydrocephalus with placement of two ventriculoperitoneal (VP) shunts at a young age. These drains needed revision because of dysfunction a few times thereafter.[link.springer.com]
Respiratory Distress
  • RESULTS: Results show significant improvement in postoperative tachycardia, respiratory distress and urine output in Group I patients as compared to those in Group II.[ncbi.nlm.nih.gov]
  • Postoperatively, there was a complicated disease course with septic shock and acute respiratory distress syndrome. Twenty-one days after first cranial surgery, a second craniotomy was performed due to recurrent and progressive subdural hematoma.[karger.com]
Constipation
  • Another extremely common cause of SV is long-term constipation. In the presence of chronic constipation, the sigmoid colon lengthens which increases the risk for SV to a large extent.[symptoma.com]
  • A 38-year-old male presented with acute intestinal obstruction and a history of chronic constipation since childhood. Abdominal radiographs showed megarectum and megacolon with dissipated feces.[ncbi.nlm.nih.gov]
Abdominal Pain
  • Patient 1, a 9-year-old boy, presented with acute abdominal pain and vomiting. Patient 2, an 11-year-old boy, presented with abdominal pain, abdominal distention, and bloody mucoid stool.[ncbi.nlm.nih.gov]
Abdominal Distension
  • Postoperative course was uneventful and on postoperative visit to the hospital he reported resolution of abdominal distension.[ncbi.nlm.nih.gov]
Severe Abdominal Pain
  • Clinical manifestations vary with disease progression, but it typically presents with a triad of constipation, progressive abdominal distension, and severe abdominal pain.[ncbi.nlm.nih.gov]
Abdominal Tenderness
  • The initial symptoms were abdominal pain (13/13), abdominal distension (11/13), and vomiting (7/13), which were associated with abdominal tenderness in all patients. Abdominal X-ray showed dilated sigmoid loops and air-fluid levels in all patients.[ncbi.nlm.nih.gov]
  • The physical examination revealed hypoactive bowel sounds and diffuse abdominal tenderness with rebound; there was no fever, abdominal rigidity, or guarding.[nejm.org]
  • Abdominal tenderness with tympanitic distension. Peritoneal signs, fever, tachycardia ischemia or infarction, 7% of patient present with gangrene. Young patients may have recurrent attacks due to spontaneous torsion and detorsion.[medigoo.com]
  • tenderness is NOT a prominent finding . [ Salas, 2000 ] Can be missed on initial presentation and ultimate diagnosis can be significantly delayed. [ Colinet, 2015 ] Sigmoid Volvulus: Management Clinical Suspicion is imperative ![pedemmorsels.com]
Hypotension
  • Patients typically show features of bowel obstruction (abdominal pain, distension, bilious vomiting) or of bowel ischemia and gangrene ( tachycardia, hypotension, hematochezia, peritonitis ) in severe cases.[amboss.com]
  • Fever, hypotension,and signs ofperitonitis usually indicate bowel gangrene.[cancertherapyadvisor.com]
Myopathy
  • METHODS: We compared 14 patients with SV (10 men and 4 women; median age, 78.5 years) with 14 age- and sex-matched control patients for differences in clinical characteristics, focusing on dysmotility (enteric visceral myopathy, neuropathy, and mesenchymopathy[ncbi.nlm.nih.gov]
  • Primary CIPO, can be congenital or acquired, due to known histopathological abnormalities: neuropathies (intrinsic and extrinsic gastrointestinal nerve pathways affected), mesenchymopathies (interstitial cells of Cajal affected) and myopathies (smooth[pubs.sciepub.com]
Narrow Pelvis
  • Several factors are correlated with redundant sigmoid colon and narrow pelvis, some of which are discussed below. Typically, narrow pelvic inlet is common in males and sigmoid colon redundancy has been shown to occur in elderly patients.[symptoma.com]
Catatonia
  • A patient with mild learning disability and paranoid schizophrenia developed catatonia. The marked emaciation associated with catatonia resulted in intestinal obstruction secondary to sigmoid volvulus.[ncbi.nlm.nih.gov]
Meningism
  • There were no signs of meningitis. The abdomen was very much distended, with high-pitched bowel sounds and diffusely localized pain during palpation.[link.springer.com]

Workup

Several imaging tests coupled with typical clinical findings of SV aid in establishing an accurate diagnosis.

Computed tomography (CT) scan and magnetic resonance imaging (MRI) serve as important diagnostic tools for SV. Both CT scan and MRI show twisted sigmoid mesentery and dilated loops, which are the characteristic features of SV.

The X-ray of the abdomen has proven as successful diagnostic aid for SV in 57%-90% of the patients. An abdominal X-ray shows a dilated sigmoid colon and several intestinal air fluid levels. Laboratory tests are of no value in diagnosing SV.

Endoscopic evaluation of the sigmoid colon shows characteristic spiral sphincter twist in the mucosa of the obstructed sigmoid colon.

In the absence of serious complications such as gangrene, peritonitis and perforation, barium contrast enemas are used to observe obstruction. Barium enemas have been found to be useful in about 20%-30% of the cases.

Ischemic Changes
  • Prompt diagnosis is essential for adequate treatment, and colonoscopy aids in the diagnosis of ischemic changes in patients without definitive findings of a gangrenous colon.[ncbi.nlm.nih.gov]
  • Cecal volvulus with ischemic changes of distended cecum and terminal ileum. Remainder of small bowel involved in volvulus appears distended but not ischemic. No obvious peritoneal contamination is observed.[emedicine.medscape.com]

Treatment

Treatment options depend on the severeness of the disease. The treatment of choice for SV is flexible endoscopic detorsion which has proven to be successful in about 33%-91% of the cases. In emergency situations such as bowel gangrene, peritonitis and bowel perforation, surgical intervention is required. Common surgical procedures employed in SV include sigmoidopexy, mesosigmoidoplasty, anastamosis and sigmoid resection. Resection of the gangrenous site of the bowel is followed by Hartmann's procedure specifically in unstable patients. Alternative surgical procedures that may be applied comprise percutaneous endoscopic colostomy, tube sigmoidostomy and extraperitonealization of the sigmoid colon.

Prognosis

The mortality rate of treated cases of SV has been reported to be 12%-15% with an increase in figures to approximately 24% in emergency cases. The mortality range for elective procedures has been reported to be 6%.

Moreover, SV shows a high risk of morbidity and mortality when diagnosis and treatment are delayed. In the absence of prompt diagnosis and early management, mortality rate reaches up to 40%.

Etiology

Several etiologic factors have been recognized that may predispose an individual to develop SV. Variation in the normal anatomy of the colon such as redundancy of the sigmoid colon, presence of a mesentery that is wider in appearance and a tapered base of sigmoid mesentery may lead to SV [8] [9]. Several factors are correlated with redundant sigmoid colon and narrow pelvis, some of which are discussed below.

Typically, narrow pelvic inlet is common in males and sigmoid colon redundancy has been shown to occur in elderly patients. Therefore, the risk of SV is proposed to be slightly higher in males and among the elderly [9]. In some cases, twisting of the sigmoid colon has been reported to occur during pregnancy [10]. The incidence of developing a redundancy of the sigmoid colon is also thought to be associated with high altitudes and an intake of a high-fiber vegetable diet. Therefore, individuals living at elevated heights and consuming a vegetarian diet show an increased risk of SV [11]. Another extremely common cause of SV is long-term constipation. In the presence of chronic constipation, the sigmoid colon lengthens which increases the risk for SV to a large extent. Less common etiologies for SV include internal herniations, postsurgical adhesions, congenital megacolon, malrotations, appendicitis and malignancies.

Epidemiology

SV is predominant among males between 40-80 years of age [3]. The disease is more common among Eastern countries and accounts for 20%-50% cases of colonic obstructions. However, SV is responsible for about 2%-5% of colonic obstruction cases in the Western world [5]. In the United States, the annual incidence of SV has been reported to be 1.67 in 100,000 persons [3]. 

Sex distribution
Age distribution

Pathophysiology

The twisting of the sigmoid colon in SV causes mechanical obstruction. Persistent obstruction results in bacterial infiltration and fermentation inside the colon, causing distention of the sigmoid colon and the proximal colon. This leads to an increased pressure build up within the colon coupled with decreased capillary perfusion due to occlusion of the blood vessels supplying the colon. This is ultimately followed by ischemia of the intestinal mucosa. Sustained ischemic damage causes increased bacterial infiltration inside the sigmoid colon, leading to colonic gangrene.

Based on disease severeness and pathophysiologic events presenting overtime in the sigmoid colon, SV can be categorized into five distinct classes. Class I is characterized by the presence of SV alone with no coexisting morbidity. In Class II, comorbidities may present but bowel gangrene and shock do not develop. In class III, patients will present with both shock and associated disease. Class IV patients usually suffer from bowel gangrene, shock as well as other illnesses. The last and more severe stage of Class V comprises all findings described above.

Prevention

As already described, constipation is one of the leading causes of SV especially among adults and elderly patients. Therefore, avoiding constipation by increasing water intake and following a high-fiber diet can help in preventing SV.

Summary

Sigmoid volvulus (SV) is referred to as twisting of the sigmoid colon which results in large bowel obstruction [1] [2]. Volvulus can develop in any segment of the alimentary canal although the most common affected areas include the sigmoid colon and cecum [3] [4] [5] [6].

Colonic obstruction resulting from sigmoid volvulus can be either acute, subacute or chronic [1] [2] and one of the leading causes is chronic constipation. In severe cases of SV related to constipation, the sigmoid segment distends with retained feces and gas and twists, resulting in a closed loop obstruction. The site also becomes devoid of blood supply. Consequently, venous infarction occurs in the sigmoid colon which ultimately leads to fecal peritonitis and perforation.

Based on etiology, SV has been classified as primary or secondary. Anatomical variations in SV can be congenital or acquired [7]. Primary SV mainly occurs due to a congenital anatomic variation of the sigmoid loop. SV as consequence of an existing disease condition such as internal herniations or postoperative conditions is termed secondary SV.

SV is commonly found in middle aged and elderly males, although rare cases among children have also been reported. Endemic regions for SV include Asian, Eastern and Middle Eastern and Northern European countries.

Typical symptoms of SV comprise constipation, abdominal pain, nausea, vomiting, hematemesis and anorexia. The physical examination of patients reveals abdominal distension, abnormal bowel sounds and increased peristalsis. Complications arising from retention of feces include colonic gangrene and peritonitis which leads to a fecal odor of the patient's breath.

Definite clinical findings along with X-ray and imaging studies help develop precise diagnosis of SV. Abdominal X-ray detects SV in the majority of the cases although computed tomography (CT) scan and magnetic resonance imaging (MRI) may be conducted to confirm a suspected diagnosis. In advanced cases, endoscopic evaluation can be performed to identify potential complications of the disease.

Treatment requires employment of surgical intervention and often includes resection of the sigmoid colon. SV does not necessarily have a good prognosis and mortality even after surgery lies around 25%-30% whereas the probability of disease recurrence is around 40%-50%.

Patient Information

Sigmoid volvulus (SV) is a disease of the lower S-shaped portion of the large intestine. In SV, the sigmoid colon becomes twisted, causing obstruction in the pathway leading to the rectum. The disease is more common among elderly persons and extremely rare among infants and children. SV is typically found in African, Asian, South American, Middle Eastern and Northern European countries. About 50% of the colon obstruction cases reported in Asian countries result from SV whereas in North America, SV is the third leading cause of bowel obstruction.

The exact cause of SV remains unknown. In most cases, SV results from elongation and twisting of the sigmoid segment (known as redundant colon). Sigmoid redundancy can be present since birth or may develop late in life. Long term constipation is one of the factors that lead to the development of redundant colon which ultimately causes bowel obstruction. Abdominal pain and constipation are the common symptoms of SV. Findings on physical examination comprise abdominal distension and abnormal bowel sounds. Diagnosis is based on X-ray radiographs while CT scan and MRI can be used for confirmation.

The most accurate therapy of SV requires surgical intervention. Common surgical procedures include sigmoid resection and primary anastamosis. Other procedures that may be applied to treat SV are still under clinical trials to prove their effectiveness. The mortality rate in SV is reported to be 14%-45%.

References

Article

  1. Lianos G, Ignatiadou E, Lianou E, Anastasiadi Z, Fatouros M. Simultaneous volvulus of the transverse and sigmoid colon: case report. G Chir. 2012;33(10):324-326. 
  2. Elsharif M, Basu I, Phillips D. A case of triple volvulus. Ann R Coll Surg Engl. 2012;94(2):e62-64.
  3. Ballantyne GH, Brandner MD, Beart RW Jr, Ilstrup DM. Volvulus of the colon. Incidence and mortality. Ann Surg. 1985;202(1):83.
  4. Friedman JD, Odland MD, Bubrick MP. Experience with colonic volvulus. Dis Colon Rectum. 1989;32(5):409.
  5. Hiltunen KM, SyrjäH, Matikainen M. Colonic volvulus. Diagnosis and results of treatment in 82 patients. Eur J Surg. 1992;158(11-12):607.
  6. Påhlman L, Enblad P, Rudberg C, Krog M. Volvulus of the colon. A review of 93 cases and current aspects of treatment. Acta Chir Scand. 1989;155(1):53.
  7. Northeast AD, Dennison AR, Lee EG. Sigmoid volvulus: new thoughts on the epidemiology. Dis Colon Rectum. 1984;27:260–261.
  8. Raveenthiran R, Madiba TE, Atamanalp SS, De U. Volvulus of the sigmoid colon. Colorectal Dis.2010;12:1–17
  9. Madiba TE, Haffajee MR, Sikhosana MH. Radiological anatomy of the sigmoid colon. Surg Radiol Anat. 2008;30:409–415.
  10. Lord SA, Boswell WC, Hungerpiller JC. Sigmoid volvulus in pregnancy. Am Surg. 1996;62:380–382.
  11. Shepherd JJ. The epidemiology and clinical presentation of sigmoid volvulus. Br J Surg. 1969;56:353–359.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2019-07-11 21:41