589 d iseases of the c olon & r eCtum V olume 59: 7 (2016) key words

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589

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KEY WORDS: 

acute colonic pseudo-obstruction; Colon 

volvulus.

t

he american society of Colon and Rectal surgeons 

is dedicated to ensuring high-quality patient care 

by advancing the science, prevention, and man-

agement of disorders and diseases of the colon, rectum, 

and anus. this Clinical Practice Guidelines Committee 

is charged with leading international efforts in defining 

quality care for conditions related to the colon, rectum, 

and anus by developing Clinical Practice Guidelines 

based on the best available evidence. these guidelines are 

inclusive, not prescriptive, and are intended for the use 

of all practitioners, healthcare workers, and patients who 

desire information about the management of the condi-

tions addressed by the topics covered in these guidelines. 

their purpose is to provide information on which deci-

sions can be made rather than to dictate a specific form 

of treatment.

it should be recognized that these guidelines should 

not be deemed inclusive of all proper methods of care or 

exclusive of methods of care reasonably directed toward 

obtaining the same results. the ultimate judgment regard-

ing the propriety of any specific procedure must be made 

by the physician in light of all of the circumstances pre-

sented by the individual patient.

STATEMENT OF THE PROBLEM

large-bowel obstruction in adults is most often caused 

by colon or rectal cancer, diverticular disease, or volvu-

lus of the colon.

2,3

 obstruction from colonic volvulus 

results from twisting of a redundant segment of colon 

on its mesentery.

4–6

 the worldwide incidence of colonic 

volvulus is variable, with historical evidence indicating 

higher rates in parts of india, africa, and middle eastern 

countries, and a relatively lower incidence in the united 

states, australia, new Zealand, and Western european 

countries.

5,7–11

  Volvulus occurs in the sigmoid colon or 

cecum in >95% of cases, with the remainder involving 

either the transverse colon or the splenic flexure of the 

colon.

7,9,12,13

 in the united states and other Westernized 

countries, patients with volvulus typically present in 

their 6

th

 to 8

th

 decade of life and frequently experience 

chronic medical conditions, neuropsychological impair-

ment, or constipation.

4,5,7,10,12,14

 in general, sigmoid vol-

vulus affects patients who are older, with more comorbid 

medical and neuropsychological conditions, compared 

with those with cecal volvulus.

4,5,9–12,14–19

 earlier reports, 

along with recent evidence from 2 large studies from the 

united states, 1 from france, and 1 from new Zealand, 

indicate an ≈2:1 predominance of sigmoid volvulus in 

men and 3:1 predominance of cecal volvulus in wom-

en.

4,10,11,14,15,17,20,21

 the evaluation and management of 

colon volvulus include endoscopic and/or operative as-

sessment of the viability of the volvulized colon segment, 

relief of the colon obstruction, and measures aimed at 

preventing recurrence of the problem. Without defini-

tive operative treatment, colonic volvulus tends to re-

cur, with each episode presenting a risk of ischemia and 

perforation.

7,10,18,22,23

acute colonic pseudo-obstruction (aCPo), or ogil-

vie syndrome, is hypothesized to result from dysregula-

tion of autonomic impulses in the enteric nervous system 

of the colon, creating a clinical picture consistent with 

large-bowel obstruction, although no mechanical block-

age is present.

24–29

 aCPo typically occurs in patients of 

advanced age who are hospitalized for medical conditions, 

traumatic injury, or a surgical procedure.

28,30–34

 untreated 

aCPo may progress to ischemic perforation of the colon, 

and, thus, timely recognition and therapeutic intervention 

are essential.

30,35,36

 therapeutic interventions in aCPo 

are focused on decompression of the colon and include 

supportive measures, pharmacologic therapy with neo-

stigmine, colonoscopic decompression, and, occasionally, 

operative intervention. this parameter will focus on the 

evaluation and treatment of cecal and sigmoid volvulus 

and aCPo.

Clinical Practice Guidelines for Colon Volvulus  

and Acute Colonic Pseudo-Obstruction

Jon D. Vogel, M.D. • Daniel L. Feingold, M.D. • David B. Stewart, M.D.  

Jacquelyn S. Turner, M.D. • Marylise Boutros, M.D. • Jonathan Chun, M.D.  

scott R. steele, m.D.

Dis Colon Rectum 2016; 59: 589–600

Doi: 10.1097/DCR.0000000000000602

© the asCRs 2016

CLINICAL PRACTICE GUIDELINES

Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.

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METHODOLOGY

an organized search of relevant literature was performed 

using the following databases from inception: ovid meD-

LINE (1946 to current), EMBASE (1980 to May 2015), the 

Cochrane Database of systematic Reviews (Wiley inter-

face), the Cochrane Central Register of Controlled trials 

(Wiley interface), and the national Guidelines Clearing-

house (www.guideline.gov). Retrieved literature was limit-

ed to the english language, but no year limits were applied. 

the searches are complete through may 2015. the search 

strategies were based on the concepts of volvulus, pseudo-

obstruction, and various surgical and diagnostic procedures 

using multiple subject headings and text word terms to de-

scribe each concept. for example, the concept of volvulus 

is described by terms such as malrotation, torsion, bascule, 

and  intestinal volvulus, whereas surgical and diagnostic 

concepts are described by terms like decompression,  col-

ectomy, resection, imaging, and radiography, among many 

others. Directed searches of the embedded references from 

the primary articles were also performed in selected cir-

cumstances. although not exclusionary, primary authors 

focused on all english language articles and studies of 

adults. Prospective, randomized controlled trials and meta-

analyses were given preference in developing these guide-

lines. Recommendations were formulated by the primary 

authors and reviewed by the entire Clinical Practice Guide-

lines Committee. the final grade of recommendation was 

performed using the Grades of Recommendation, assess-

ment, Development, and evaluation system.

1

 (table 1)

Colon Volvulus

1. Initial evaluation should include a focused history and 

physical examination, complete blood cell count, serum 

electrolytes, and renal function assessment. Grade of 

Recommendation: Strong recommendation, based on 

low- or very-low-quality evidence, 1C.

Common presentation of symptoms of both sigmoid and 

cecal volvulus includes abdominal cramping, pain, nausea, 

vomiting, and obstipation.

5,7–9,17,37,38

 on physical examina-

tion, there is typically abdominal distension, varying de-

grees of tenderness, diminished or increased bowel sounds, 

and often an empty rectum on digital examination.

7,9,16,17,38

 

the duration of symptoms before presentation ranges 

from a few hours to several days, with acute presentations 

more common with cecal volvulus and indolent presen-

tations more common with sigmoid volvulus.

5,9,10,14,15,17,20

 

the frequent presence of comorbid conditions in patients 

with colon volvulus, along with the possibility of electro-

lyte derangement and acute renal insufficiency secondary 

to vomiting and dehydration, warrants the inclusion of 

routine blood testing during the initial evaluation of pa-

tients with suspected colonic volvulus. emergency presen-

tations, with clinical signs of peritonitis or shock related to 

colon ischemia or perforation, have been noted to occur 

in <25% and 35% of patients with sigmoid and cecal vol-

vulus.

9,15,37,38

 in general, the history and physical examina-

tion, laboratory blood work, and radiological evaluation 

are occurring in parallel to avoid delays.

2. Diagnostic imaging for colonic volvulus is initially 

based on plain abdominal radiographs and often in-

cludes confirmatory imaging with a contrast enema or CT 

imaging. Grade of recommendation: Strong recommen-

dation, based on low- or very-low-quality evidence, 1C.

Plain abdominal radiographs are often useful in the ini-

tial diagnostic evaluation of patients with suspected co-

lon volvulus. as above, imaging should occur early in the 

course of suspected volvulus because they may rapidly 

lead to a diagnosis. Radiographic images typically reveal 

a distended loop of colon that may resemble a coffee bean 

or bent inner tube projecting toward the upper abdomen, 

sometimes above the transverse colon, which has been 

described as the “northern exposure sign.”

5,16,39–43

 Plain 

abdominal radiographs may also show distention of the 

small bowel with air-fluid levels and decompressed co-

lon distal to the point of volvulus. in a recently published 

study, abdominal radiographs were considered suggestive 

of diagnosis or diagnostic of cecal volvulus in 27% and 

15% of patients and in 31% and 51% of those with sig-

moid volvulus.

10

 in another recent review, lau et al

16

 re-

ported that plain abdominal radiographs were diagnostic 

of sigmoid and cecal and sigmoid volvulus in 26% and 

66% patients. Plain abdominal radiographs may also re-

veal other conditions that are included in the differential 

diagnosis of colon volvulus, as well as complicating fac-

tors, such as pneumoperitoneum or pneumatosis.

in cases in which clinical assessment and plain ad-

nominal radiographs are insufficient to confirm the di-

agnosis of colon volvulus, contrast enema or Ct imaging 

may be helpful. a water-soluble contrast enema may help 

confirm the diagnosis of cecal or sigmoid volvulus by dem-

onstrating a smooth, tapered point of obstruction known 

as a “bird’s beak” at the point of colon torsion.

5,17,23,39,43,44

 

in the recent report by swenson et al,

10

 contrast enema was 

suggestive of diagnosis or diagnostic for cecal volvulus in 

44% and 33% of patients and for sigmoid volvulus in 13% 

and 78% of patients. in the review by lau et al,

16

 the com-

bination of plain abdominal radiographs and contrast en-

ema images was diagnostic for sigmoid and cecal volvulus 

in 90% and 42% of patients. older studies also supported 

the use of a contrast enema in cases of suspected cecal or 

sigmoid volvulus and have shown that the point of co-

lonic torsion could be identified in ≈70% of cases.

17,43,44

 

in general, water-soluble contrast medium is preferable to 

barium contrast, because the latter could cause a chemical 

peritonitis in the setting of a perforated colon.

Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.

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Contrast-enhanced Ct imaging is currently the pre-

ferred confirmatory diagnostic study for both cecal and 

sigmoid volvulus because it is noninvasive, easily obtain-

able, accurate for both cecal and sigmoid volvulus, and has 

the advantage of identification of incidental pathology 

that may be missed with plain radiographs or fluoroscopic 

contrast studies. in addition, abdominal Ct has proven 

useful to distinguish organoaxial cecal volvulus from cecal 

bascule and may facilitate the diagnosis of colonic isch-

emia.

41,42,45–47

 in the study by swenson et al,

10

 the positive 

diagnostic yield of Ct for cecal and sigmoid volvulus was 

71% and 89%. other diagnoses that can mimic the pre-

sentation of colonic volvulus, such as obstruction because 

of a neoplasm or pseudo-obstruction, can also be evalu-

ated with the above modalities.

Sigmoid Volvulus

1. Rigid or flexible endoscopy should be performed to as-

sess sigmoid colon viability and to allow initial detorsion 

and decompression of the colon. Grade of Recommen-

dation: Strong recommendation, based on low- or very-

low-quality evidence, 1C.

in the absence of colonic ischemia or perforation, the 

initial treatment of sigmoid volvulus is endoscopic de-

torsion, which is effective in 60% to 95% of patien

ts.

7,9,14,18,33,48,49

 Detorsion may be performed by rigid or 

flexible sigmoidoscopy or colonoscopy in unusual cases in 

which the transition point is beyond the reach of a short-

er scope.

7,18,50–52

 after successful detorsion of the sigmoid 

colon, a decompression tube should, in general, be left in 

place for a period of 1 to 3 days to maintain the reduction, 

allow for continued colonic decompression, and facilitate 

mechanical bowel preparation, as needed.

7,11,14,18,48–50,53–57

 

in patients with sigmoid volvulus who undergo success-

ful endoscopic detorsion without subsequent interven-

tion, index admission and long-term recurrent volvulus 

have been observed in 3% to 5% and 43% to 75% of  

patients.

10,11,14,18,50,57,58

 With this high risk of recurrent 

volvulus and the attendant risks associated with each epi-

sode, operative intervention should be strongly consid-

ered in appropriate patients during the index admission 

or soon thereafter.

10,14,18,50,57,59

in a recent study by Yassaie et al,

11

 31 patients with sig-

moid volvulus who underwent successful endoscopic de-

torsion and no further interventions before discharge were 

evaluated. Recurrent sigmoid volvulus was diagnosed in 19 

(61%) of these patients at a median of 31 days. of these 19 

patients, 7 underwent colectomy and 12 had repeat endo-

scopic detorsion alone, of whom 5 (48%) were diagnosed 

with a third episode of volvulus at a median interval of 5 

months and 3 (25%) required emergent sigmoid colectomy.

11

 

in the study by swenson et al,

10

 10 (48%) of 21 of patients 

with sigmoid volvulus treated nonoperatively returned with 

TABLE 1.    The GRADE system: grading recommendations

Grade

Description

Benefit vs risk and burdens

Methodologic quality  

of supporting evidence

Implications

1A

Strong recommendation; 

high-quality evidence

Benefits clearly outweigh risk 

and burdens or vice versa

RCTs without important limitations 

or overwhelming evidence from 

observational studies

Strong recommendation, can 

apply to most patients in 

most circumstances without 

reservation

1B

Strong recommendation; 

moderate-quality 

evidence

Benefits clearly outweigh risk 

and burdens or vice versa

RCTs with important limitations 

(inconsistent results, methodologic 

flaws, indirect, or imprecise) or 

exceptionally strong evidence 

from observational studies

Strong recommendation, can 

apply to most patients in 

most circumstances without 

reservation

1C

Strong recommendation; 

low- or very-low-quality 

evidence

Benefits clearly outweigh risk 

and burdens or vice versa

Observational studies or case series

Strong recommendation but may 

change when higher-quality 

evidence becomes available

2A

Weak recommendation; 

high-quality evidence

Benefits closely balanced with 

risks and burdens

RCTs without important limitations 

or overwhelming evidence from 

observational studies

Weak recommendation, best 

action may differ depending 

on circumstances or patient or 

societal values

2B

Weak recommendation; 

moderate-quality 

evidence

Benefits closely balanced with 

risks and burdens

RCTs with important limitations 

(inconsistent results, methodologic 

flaws, indirect, or imprecise) or 

exceptionally strong evidence 

from observational studies

Weak recommendation, best 

action may differ depending 

on circumstances or patient or 

societal values

2C

Weak recommendation; 

low- or very-low-quality 

evidence

Uncertainty in the estimates of 

benefits, risks, and burden; 

benefits, risk and burden 

may be closely balanced

Observational studies or case series

Very weak recommendations; 

other alternatives may be 

equally reasonable

Table was adapted and reprinted with permission from Chest. 2006;129:174–181. 

GRADE = Grades of Recommendation, Assessment, Development, and Evaluation; RCT = randomized controlled trial.

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recurrent volvulus at a median of 106 days (range, 8–374 

days) after discharge. similarly, tan et al

54

 observed recurrent 

sigmoid volvulus in 28 (61%) of 46 patients who were dis-

charged after endoscopic reduction alone.

Care should be taken in the selection of patients for en-

doscopic detorsion, and those with signs and symptoms of 

bowel ischemia or perforation should not be considered for 

endoscopic intervention. in cases in which advanced muco-

sal ischemia, peroration, or impending perforation of the 

colon is discovered during endoscopy, the procedure should 

be aborted in favor of emergent operative intervention.

2. Urgent sigmoid resection is generally indicated when 

endoscopic detorsion of the sigmoid colon is not possible 

and in cases of nonviable or perforated colon. Strong 

recommendation, based on low- or very-low-quality 

 evidence,  1C.

urgent operative intervention for sigmoid volvulus is 

required in the 5% to 22% of patients in whom endo-

scopic detorsion is not possible and in the 5% to 25% 

of patients in whom colonic ischemia, perforation, peri-

tonitis, or septic shock complicate the initial presenta-

tion.

7,9,10,14,18,33,50,54,60–65

 in general, resection of infarcted 

bowel should be performed without detorsion and with 

minimal manipulation to prevent release of endotoxin, 

potassium, and bacteria into the general circulation and 

to avoid perforation of the colon.

23,56,66–68

 once the vol-

vulized segment of colon has been removed, the decision 

to perform primary colorectal anastomosis, defunc-

tioned colorectal anastomosis, or end-descending co-

lostomy should be individualized, with consideration of 

both the overall condition of the patient and the colon. 

this approach was exemplified in a consecutive series of 

patients reported by Kuzu et al in 2002.

64

 in their ret-

rospective study of 106 sigmoid volvulus cases accumu-

lated over 8 years, sigmoid resection with end colostomy 

(hartmann procedure, n = 49) or sigmoid resection 

with colorectal anastomosis without diverting ostomy  

(n = 57) was performed at the discretion of the oper-

ating surgeon. a hartmann procedure was used more 

often in patients with a nonviable colon or peritonitis 

and resulted in increased postoperative complications 

and mortality (8% vs 5%), whereas anastomotic leak oc-

curred in 7% of patients in the anastomosis group.

64

 in 

the largest reported series of patients with sigmoid vol-

vulus, a hartmann procedure was the most commonly 

performed emergency operation, with overall morbid-

ity of 42% and mortality of 20%.

50

 although this study 

included 952 patients accumulated over 4 decades, the 

most recent 10-year period was notable for more selec-

tive use of the hartmann procedure in the setting of a 

nonviable colon (mortality = 7%) and resection with 

anastomosis when the colon was viable (mortality = 1%). 

another nonrandomized study of sigmoid resection with 

nondiverted or diverted (blow-hole colostomy) colorec-

tal anastomosis was  notable for 12% and 0% anastomotic 

leaks and mortality in 8% and 10%.

63

 although there are 

insufficient data to support one technique over anoth-

er in emergent cases for sigmoid volvulus, more robust 

studies performed in patients with sigmoid diverticular 

disease have compared urgent hartmann procedure with 

colorectal anastomosis, both with and without proximal 

diversion. these studies demonstrated no difference in 

mortality or overall surgical postoperative complications 

among the various approaches.

60,62,63,69,70

 notwithstand-

ing this limited evidence, end colostomy creation is of-

ten the most appropriate choice for hemodynamically 

unstable patients or when concomitant factors, such as 

increased asa or acute Physiology and Chronic health 

evaluation ii score, hemodynamic instability, coagulopa-

thy, acidosis, or hypothermia, add prohibitive risk to the 

integrity of a colorectal anastomosis.

18,62,64,71–73

the role of laparoscopic surgery for emergent colorec-

tal operations is still being defined, and there is a paucity of 

data specific to emergent laparoscopic sigmoid volvulus sur-

gery. one recent comparison of open and laparoscopic cases 

demonstrated a 2-fold increase in anastomotic leak in the 

latter group and similar overall postoperative morbidity.

74

 

additional published results indicate that the laparoscopic 

approach is a suitable alternative to laparotomy in select cas-

es by surgeons who are competent with this technique.

50,74–76