OBSTRUCTION & ISCHEMIA • SENIOR RESIDENT / SURGEON

Sigmoid Volvulus

Sigmoid volvulus differs from cecal volvulus because a viable, nonperforated sigmoid can often be endoscopically decompressed first, followed by definitive resection during the same admission.

PROTOTYPE REVIEW REQUIRED

The Call

Elderly institutionalized patient with progressive distention and obstipation

Marked abdominal distention with a classic massively dilated sigmoid configuration on plain film and no initial peritonitis.

Stable initially

The decision hinges on viability: uncomplicated volvulus can be decompressed; ischemia or perforation requires surgery.

Read the Image • Clinical Data

Abdominal Radiograph / CT Recognize the classic dilated twisted sigmoid pattern and look for signs of ischemia or perforation. Clinical image slot reserved for this case.

Make the Decision • Commit to a Plan

Sigmoid Volvulus

Elderly institutionalized patient with progressive distention and obstipation

A stable patient has sigmoid volvulus without peritonitis, ischemia or perforation. Best initial treatment?

A second patient has sigmoid volvulus with free air, shock and peritonitis. Best next step?

After successful endoscopic detorsion the patient refuses definitive resection and returns two weeks later with recurrent volvulus. Best principle?

Resect when viability is threatened or decompression fails.

Recurrence prevention is part of the treatment.

Surgical Pearls

Pitfalls

A patient with presumed sigmoid volvulus now has fever, guarding and free air. What changes?