PassFinals
Gastroenterology & Nutrition

Volvulus

Volvulus is twisting of bowel around its mesentery, causing a closed-loop obstruction and threatening the blood supply; sigmoid volvulus may be detorted endoscopically when uncomplicated, whereas caecal and paediatric midgut volvulus generally require urgent surgical management.

In a nutshell

Volvulus is a closed-loop obstruction with threatened blood supply. In adults, sigmoid volvulus usually causes massive distension and may be urgently detorted by flexible sigmoidoscopy if there is no ischaemia or perforation; then definitive sigmoid surgery should be planned because recurrence is common. Caecal volvulus needs surgery. Bilious vomiting in an infant is an emergency possible midgut volvulus and needs immediate paediatric surgical referral.

Classic presentation

An older frail patient with chronic constipation has massive tympanitic abdominal distension, colicky pain and absolute constipation. CT shows a twisted mesentery. If there is no peritonism or ischaemia, urgent flexible-sigmoidoscopic decompression is the first step, with colorectal surgery involved from the outset.

Key points

  • Volvulus causes a closed-loop obstruction and can strangulate the mesenteric blood supply.
  • Contrast-enhanced CT is the preferred index-admission test when diagnosis is uncertain or bowel viability must be assessed; a coffee-bean sign may suggest sigmoid volvulus on plain film.
  • Uncomplicated sigmoid volvulus may be urgently detorted and decompressed endoscopically, with surgical backup.
  • Peritonitis, ischaemia, perforation, shock or failed detorsion means urgent operation.
  • A successful sigmoid detorsion is not definitive: plan index-admission sigmoid resection when appropriate.
  • Caecal volvulus is managed surgically; do not copy the sigmoid endoscopic pathway.
  • Green or bilious vomiting in a neonate or infant is possible midgut volvulus until proven otherwise.

First-line investigation

Urgent senior surgical assessment, blood gas with lactate and emergency bloods, followed by contrast-enhanced CT when needed to confirm the twist and assess viability; plain radiography can suggest sigmoid volvulus in a stable patient.

Management

Resuscitate and identify strangulation

  • Keep nil by mouth, resuscitate, correct electrolyte disturbance, involve senior surgery and urgently assess for peritonitis, ischaemia, perforation or shock.1

Detorse uncomplicated sigmoid volvulus

  • If no ischaemia or perforation is suspected, use urgent flexible or rigid sigmoidoscopic detorsion and decompression with surgical backup; proceed to surgery if it fails.1,5

Prevent recurrence and treat caecal volvulus surgically

  • Plan sigmoid resection after successful detorsion where physiology and goals permit; caecal volvulus needs specialist surgery rather than routine endoscopic decompression.1

Recognise paediatric midgut volvulus

  • Treat bilious vomiting in a neonate or infant as possible malrotation with volvulus: urgent paediatric surgical transfer, resuscitation, gastric decompression and no delay to emergency operation when clinically unstable.2,3

Monitor for recurrence and postoperative complications

  • Review bowel function, stoma or anastomosis, nutrition, frailty and precipitating constipation or neurological factors, and give urgent return advice for recurrent distension, pain, vomiting or absolute constipation.1,3

Exam traps

  • Do not attempt repeated endoscopic decompression when ischaemia or perforation is suspected.
  • A normal lactate does not exclude early bowel ischaemia.
  • Caecal volvulus is not managed like uncomplicated sigmoid volvulus.
  • Detorsion alone leaves a high recurrence risk; arrange a definitive plan during the index admission.
  • Bilious vomiting in a young infant is a surgical emergency, not simple gastroenteritis.

Illustrations

Intraoperative appearance of bowel volvulusMarkedly distended, congested loops of bowel with a twisted mesenteric pedicle at laparotomy, illustrating closed-loop obstruction and threatened or established ischaemia.Kalumet (de:Benutzer:Kalumet), selbst erstellt, Wikimedia Commons · CC-BY-SA-3.0
Twisted loop and mesentery (whirl sign)A diagram of a bowel loop twisted around its mesenteric axis, occluding both the lumen and mesenteric vessels, with the CT whirl sign labelled.Hellerhoff, Wikimedia Commons · CC-BY-SA-4.0

Key sources

  1. ACPGBI: Consensus guidelines in emergency colorectal surgery (Colorectal Disease 2021;23:476–547; DOI 10.1111/codi.15503)Published 20 Jan 2021
  2. Cambridge University Hospitals: Intestinal malrotation and volvulus in children (Current specialist paediatric patient pathway information)
  3. Great Ormond Street Hospital: Malrotation and volvulus (Current specialist paediatric diagnosis and emergency-treatment information)Updated 1 Oct 2019
  4. WSES consensus guidelines on sigmoid volvulus management (World Journal of Emergency Surgery 2023;18:34; DOI 10.1186/s13017-023-00502-x)Published 15 May 2023
  5. NICE HTG105: Percutaneous endoscopic colostomy (Recommendations for selected recurrent sigmoid volvulus and colonic motility problems)Published 22 Mar 2006

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.