He sigmoid colon is the most frequently re ported site of intestinal tract volvulation



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he sigmoid colon is the most frequently re-

ported site of intestinal tract volvulation.

1 – 4

The symptom triad of constipation, severe



abdominal pain, and a distended abdomen is

common in patients with sigmoid volvulus. Sigmoid

volvulus is responsible for 5% to 7% of all intestinal

obstructions

1

and is the third leading cause of large



bowel obstruction.

5

In the United States, sigmoid volvu-



lus is classically described as an illness in elderly persons,

persons with psychiatric disorders, or persons residing in

nursing homes or mental institutions.

6

However, some



reports suggest that sigmoid volvulus occurs in younger

age-groups more frequently than has been reported.

7–10

This report reviews the case of a 46-year-old previously



healthy man with sigmoid volvulus. 

CASE PRESENTATION

A 46-year-old African-American man with a history

of untreated hypertension presented to the emergency

department for evaluation of constipation that had

been present for 6 days and severe left lower quadrant

abdominal pain that had been present for 6 hours. He

was normotensive, nontachycardic, and in moderate

acute distress. He had no surgical history or significant

medical history. Physical examination revealed a distend-

ed abdomen with tympanic percussion tones in the

upper quadrants. Rectal examination revealed normal

mucosa and guaiac-negative stools. The patient devel-

oped nausea 4 hours prior to examination and began to

vomit in the emergency department. 

Intravenous lines were placed and resuscitation was

started with normal saline. Results of a complete blood

count, serum electrolyte panel, assessment of amylase

and lipase values, liver function studies, and coagula-

tion profile were within normal limits. A nasogastric

tube and Foley catheter were placed. Surgical consulta-

tion was requested. Abdominal radiography demon-

strated a dilated sigmoid colon projecting into the

upper quadrants of the abdomen (Figure).

After the surgical team examined the patient and

reviewed the abdominal radiographs, sigmoidoscopy

and rectal tube placement were scheduled for reduc-

tion of a sigmoid volvulus. The patient also consented

to laparotomy in the event that nonviable mucosa was

encountered on sigmoidoscopy. Sigmoidoscopy dem-

onstrated pink viable mucosa with a contracted seg-

ment of colon suggestive of torsion. A rectal tube was

left in place for 48 hours, and the patient underwent

sigmoid resection 2 days after reduction of the volvu-

lus. The patient’s course following surgery was un-

eventful, and he was discharged 3 days after surgery.

DISCUSSION

Epidemiology

The worldwide incidence of sigmoid volvulus is un-

known. In the United States patients with sigmoid

volvulus are typically older than age 50 years. These

patients are often elderly, have neurologic or psychi-

atric conditions, or are residents of nursing homes or

mental health care facilities. Chronic constipation is a

common symptom of sigmoid volvulus in these pa-

tients. However, there are reports of younger individu-

als presenting with a medical history of intermittent

abdominal pain as a sign of sigmoid volvulus.

7 – 10


Inter-

nationally, the pediatric age-group is the second most

affected population in areas of roundworm infestation,

such as Africa, Southeast Asia, and the South Pacific. In

a review by Ballantyne,

11

sigmoid volvulus was more com-



mon in men (64%) and in African Americans (67%).

Women are thought to have a lower incidence because

of a wider pelvis. Sigmoid volvulus causes 5% to 7% of

all intestinal bowel obstructions, with a mortality rate as

high as 20% to 25% depending on the time interval

from symptom onset to treatment.

5

Etiology

In the United States, a long, redundant sigmoid

colon—commonly seen in patients with illnesses such

as Parkinson’s disease, multiple sclerosis, spinal cord

injuries, and psychiatric disorders—is the major cause

of sigmoid volvulus. Inhibition of colonic motility by



T

Dr. Williams is chief administrative surgery resident, and Dr. Steffes is

an associate professor of surgery; both are at the Department of Surgery,

Wayne State University/Detroit Medical Center, Detroit, MI.

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Hospital Physician  January 2006

33

C a s e   R e p o r t

Sigmoid Volvulus in a 46-Year-Old Man

Mallory Williams, MD

Christopher P. Steffes, MD

psychotropic medications as well as the possible inher-

ent colonic dysmotility properties of the primary disease

lead to sigmoid elongation. This redundant, enlarged

bowel causes the approximation of 2 limbs of sigmoid

colon and predisposes the limbs to twist around the

mesenteric axis. Similarly, the patient with congenitally

narrow sigmoid mesentery is predisposed to sigmoid

volvulus due to increased mobility of the colon. Hirsch-

sprung’s disease affects the myenteric plexus of the

colon and also predisposes the patient to sigmoid vol-

vulus.

Chronic constipation, most often resulting from the



low physical activity levels seen in residents of nursing

care facilities, is also a cause of sigmoid volvulus sec-

ondary to sigmoid enlargement. Another important

etiologic factor is the repetitive use of laxatives, cathar-

tic agents, and enemas. The etiology of sigmoid volvulus

in younger patients has been thought to be a congenital

megasigmoid with additional stimuli, such as purgation,

diet, fecal loading, active peristalsis, or pregnancy.

7

Outside the United States, sigmoid volvulus may be



caused by diet or infectious etiologies. Patients in non-

industrialized countries often have high-residue diets

that may result in overloading and enlargement of the

sigmoid colon, prompting rotation around the root of

the mesentery. The myenteric plexus of the bowel is

affected by Chagas’ disease, resulting in megacolon

and predisposing the patient to sigmoid volvulus.

Roundworm infestation is prevalent in more than 

1 million persons worldwide and causes sigmoid en-

largement secondary to constipation.



Clinical Presentation

Because patients with sigmoid volvulus often pre-

sent with debilitated physical status resulting from neu-

rologic or psychiatric illness, it may not be possible to

obtain a coherent and complete medical history from

the patient. A patient history should be obtained from

family or caregivers. A history of recent weight loss may

signal a coexisting condition. Patients with dehydration

from vomiting and/or third-spacing of fluid caused by

bowel obstruction may present with hypovolemic

shock. Prompt resuscitation with crystalloid should

begin immediately. Because of underlying illness, resus-

citation may not improve the patient’s mental status.

The abdomen should be examined for surgical scars. A

gastrostomy tube that is vented without significant

improvement of the abdominal distention may signal a

distal or complete obstruction. Leukocytosis and 

guaiac-positive stools may be an indicator of bowel

ischemia. A distended and painful abdomen with 

guaiac-positive stools may indicate a need for laparoto-

my after resuscitation. 

Diagnosis

The diagnosis of sigmoid volvulus is made by physi-

cal examination and radiographic studies. Abdominal

radiographs demonstrate a markedly distended sig-

moid colon with a convex superior margin projecting

into the right upper quadrant of the abdomen. This

section of sigmoid colon is often devoid of haustral

markings (Figure). A “coffee bean” or “omega loop”

sign has been described on abdominal radiograph.

These terms refer to the 2 large compartments of dis-

tended sigmoid colon with central double walls of

colon and a single outer wall, which assume the shape

of a coffee bean or omega loop. Computed tomogra-

phy scan has been used to rule out other etiologies of

obstruction and colonic ischemia in patients with sig-

moid volvulus.

Contrast enema can be used as a diagnostic study as

well as a therapeutic radiographic study that can

reduce the sigmoid volvulus and provide immediate

relief of the patient’s symptoms. On radiography, a

“bird’s beak” sign can be demonstrated at the torsion

point of the sigmoid. A limited enema using water-

soluble contrast material can be performed in patients

for whom perforation is suspected. Contrast enema



34

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Figure. Upright abdominal radiograph demonstrating a distend-

ed colon with an “omega loop” projecting into the right upper

quadrant. The right colon is distended with signs of fecal stasis.


successfully reduces 5% of cases of sigmoid volvulus.

12

Although the patient experiences dramatic relief of



symptoms, contrast enema is not definitive treatment.

Recurrence rates of sigmoid volvulus after contrast

enema are 80% to 90%, and sigmoid resection is rec-

ommended as definitive treatment. Although air ene-

mas have been described in the reduction of intestinal

intussusception, no data are available to support their

use in sigmoid volvulus.

Sigmoidoscopy with insertion of a rectal tube be-

yond the obstruction point is a safe and fast method

for diagnosis that allows thorough assessment of the

bowel mucosa and that has therapeutic value as well.

Sigmoidoscopy for reduction of sigmoid volvulus was

first described by Bruusgaard.

13

It can be performed in



the operating room by the surgeon. Like contrast

enema, sigmoidoscopy with rectal tube placement is an

acute management strategy.

Treatment

The 3 goals of the therapy for the patient with 

sigmoid volvulus are (1) resuscitation of the patient,

(2) acute reduction of the volvulus and relief of the

colonic obstruction, and (3) prevention of recurrence

of the volvulus. It is essential that patients be fluid

resuscitated on presentation to the hospital. Electrolyte

abnormalities and fluid deficits may be present. The

patient’s ability to survive invasive procedures, includ-

ing surgery, may depend on appropriate resuscitation.

Fluid resuscitation may be accomplished with lactated

Ringer’s solution or normal saline. Premorbid heart

conditions may require invasive monitoring of filling

pressures. A Foley catheter, at the very least, should be

placed to monitor urine output. 

Acute reduction of the volvulus by either detorsion

or resection is the second goal of therapy. The manage-

ment approach is contingent on the hemodynamic sta-

bility of the patient and the presence or absence of

necrotic bowel. Patients with viable mucosa may under-

go delayed resection after sigmoidoscopy or contrast

studies with rectal tube placement beyond the torsion

point. It is important that this rectal tube be secured in

place. Patients who have necrotic colon mucosa should

undergo detorsion and immediate resection. 

Prevention of recurrence of the volvulus involves

surgical resection. Patients who are hemodynamically

stable with viable bowel are candidates for laparoscopic

resection. After bowel preparation, resection of the sig-

moid without diversion is the procedure of choice. For

patients with compromised bowel or hemodynamic

instability, we recommend laparotomy.

Arnold and Nance

14

reported a 15% mortality rate



for patients who undergo resection after the first epi-

sode of sigmoid volvulus and a 9% mortality rate for

those who undergo resection after recurrence of sig-

moid volvulus; the data demonstrated higher mortality

rates for patients older than age 70 years. If these older

patients are hemodynamically stable with viable bowel,

some surgeons advocate acute management by detor-

sion without surgery for a first episode of sigmoid

volvulus. Patients younger than age 70 years who are

hemodynamically stable with viable bowel should

undergo detorsion with resection. These data are

rather old, however, and we propose that the patient’s

overall physiologic and functional status should be

evaluated before recommending surgery. We also ex-

pect that, with appropriate perioperative care, some

octogenarian patients with sigmoid volvulus will have a

good outcome after resection. Clinicians should recog-

nize that some patients and their families will refuse oper-

ative management because of the overall prognosis and

will instead opt for palliative decompression or analgesia.

Grossmann et al

5

reported on 228 patients with sig-



moid volvulus. The average age of this cohort was 

70 years, and higher mortality was associated with

emergency surgery and the presence of necrotic

bowel. The mortality rate in this series was 6% for elec-

tive operations versus 24% for emergency surgeries.

Kuzu et al

15

reviewed 106 patients with sigmoid volvu-



lus and showed a 6.6% overall mortality that increased

to 11% when necrotic bowel was present. Bhatnagar et

al

16

demonstrated that when necrotic bowel is present,



it often extends beyond the area of constriction into

the rectum and descending colon. This finding predis-

poses to failure of the anastomoses constructed during

primary repair operations. 

Percutaneous endoscopic sigmoidopexy has been

described as a treatment for sigmoid volvulus but is not

the standard of care.

17

Mesosigmoidoplasty has been



advocated as a successful operative option for nongan-

grenous sigmoid volvulus but is not first-line therapy.

18

Martinez et al



19

demonstrated that endoscopic reduc-

tion of sigmoid volvulus can be performed with high

efficacy, but recurrence rates are high. Although all of

these authors have reported small series of creative

management strategies for sigmoid volvulus, the defini-

tive therapy remains sigmoid resection.

CONCLUSION

Sigmoid volvulus is a surgical emergency that com-

monly occurs in patients older than age 50 years but

can occur in younger age-groups. An accurate patient

history and physical examination followed by prompt

resuscitation is essential. Detorsion of the bowel and



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Hospital Physician  January 2006

35

assessment of the bowel mucosa must be performed. A

rectal tube is placed to maintain the reduction in the

preoperative evaluation and stabilization period. A sig-

moid colectomy is then performed. Findings of is-

chemic colonic mucosa mandate immediate operative

intervention.



HP

REFERENCES

1. Drelichman ER, Nelson H. Colonic volvulus. In:

Cameron JL, editor. Current surgical therapy. 8th ed. St.

Louis (MO): C.V. Mosby; 2004.

2. Turan M, Sen M, Karadayi K, et al. Our sigmoid volvulus

experience and benefits of colonoscope in detortion

process. Rev Esp Enferm Dig 2004;96:32–5.

3. Echenique Elizondo M, Amondarain Arratibel JA.

Colonic volvulus. Rev Esp Enferm Dig 2002;94:201–10.

4. Renzulli P, Maurer CA, Netzer P, Buchler MW. Preop-

erative colonoscopic derotation is beneficial in acute

colonic volvulus. Dig Surg 2002;19:223–9.

5. Grossmann EM, Longo WE, Stratton MD, et al. Sigmoid

volvulus in Department of Veterans Affairs Medical

Centers. Dis Colon Rectum 2000;43:414–8.

6. Connolly S, Brannigan AE, Heffeman E, Hyland JM.

Sigmoid volvulus: a 10-year-audit. Ir J Med Sci 2002;

171:216–7.

7. Northeast AD, Dennison AR, Lee EG. Sigmoid volvulus:

new thoughts on the epidemiology. Dis Colon Rectum

1984;27:260–1.

8. Sturzaker HG, Lawrie RS, Joiner CL. Recurrent sigmoid

volvulus in young people: a missed diagnosis. Br Med J

1975;4:338–9.

9. Mokoena TR, Madiba TE. Sigmoid volvulus among

Africans in Durban. Trop Geogr Med 1995;47:216–7.

10. Atamanalp SS, Yildirgan MI, Basoglu M, et al. Sigmoid

colon volvulus in children: review of 19 cases. Pediatr

Surg Int 2004;20:492–5.

11. Ballantyne GH. Review of sigmoid volvulus: history and

results of treatment. Dis Colon Rectum 1982;25:494–501.

12. Theuer C, Cheadle WG. Volvulus of the colon. Am Surg

1991;57:145–50.

13. Bruusgaard C. Volvulus of the sigmoid colon and its

treatment. Surgery 1947;22:466–78. 

14. Arnold GJ, Nance FC. Volvulus of the sigmoid colon.

Ann Surg 1973;177:527–37.

15. Kuzu MA, Aslar AK, Soran A, et al. Emergent resection

for acute sigmoid volvulus: results of 106 consecutive

cases. Dis Colon Rectum 2002;45:1085–90.

16. Bhatnagar BN, Sharma CL, Gautam A, et al. Gan-

grenous sigmoid volvulus: a clinical study of 76 patients.

Int J Colorectal Dis 2004;19:134–42.

17. Pinedo G, Kirberg A. Percutaneous endoscopic sig-

moidopexy in sigmoid volvulus with T-fasteners: report

of two cases. Dis Colon Rectum 2001;44:1867–70. 

18. Bach O, Rudloff U, Post S. Modification of mesosig-

moidoplasty for nongangrenous sigmoid volvulus. World

J Surg 2003;27:1329–32.

19. Martinez Ares D, Yanez Lopez J, Souto Ruzo J, et al. Indi-

cation and results of endoscopic management of sigmoid

volvulus. Rev Esp Enferm Dig 2003;95:544–8, 539–43.



36

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