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Sigmoid Volvulus: Symptoms, Diagnosis, and Surgical Treatment

Sigmoid Volvulus: A Surgical Emergency

Sigmoid volvulus is a twisting of the sigmoid colon on its mesentery, causing closed-loop obstruction and vascular compromise. It accounts for 5–10% of large bowel obstructions and is more common in elderly, institutionalized, or neurologically impaired patients.

Clinical Presentation

  • Abdominal distension (often massive)
  • Colicky abdominal pain
  • Nausea/vomiting (late sign)
  • Absolute constipation / obstipation
  • Tympanic abdomen, minimal tenderness initially
  • Signs of peritonitis/sepsis if ischemic/perforated (late)

Diagnosis

  • Abdominal X-ray: "Coffee bean" sign—massive dilated sigmoid loop arising from pelvis, medial walls apposed.
  • CT Abdomen/Pelvis (with contrast): Gold standard—shows "whirl sign" of twisted mesentery, transition point, wall thickening/ischemia.
  • Contrast Enema: "Bird's beak" tapering at twist site; therapeutic reduction possible but risk of perforation.

Treatment Algorithm

  1. Nonoperative Reduction (if no peritonitis/ischemia): Rigid sigmoidoscopy with decompression/flatus tube placement. Success rate 60–90%. Tube left 24–48 hrs.
  2. Elective Resection (after decompression): Sigmoid colectomy with primary anastomosis (preferred) or Hartmann's procedure (end colostomy) if high risk. Laparoscopic approach is standard when feasible—less pain, faster recovery.
  3. Emergency Surgery (if ischemia, perforation, failed reduction): Resection with anastomosis or stoma. Higher morbidity/mortality.

Surgical Approaches

ApproachIndicationsOutcomes
LaparoscopicElective, stable patient, no dense adhesionsLess pain, shorter LOS, fewer wound complications
OpenEmergency, obesity, adhesions, ischemia, perforationNecessary for exposure/control

Prognosis

  • Recurrence after decompression alone: 40–60% → elective resection recommended.
  • Mortality: <5% elective; 15–30% emergency.
  • Postop: Monitor for anastomotic leak, ileus, stoma complications.

Early recognition and timely intervention are key. Decompression buys time; definitive resection prevents recurrence.

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