Synopsis
Recognise sigmoid and caecal volvulus, detect bowel ischaemia before attempting decompression, and coordinate endoscopic detorsion with definitive surgery to prevent recurrent obstruction.
- Volvulus is axial twisting of a mobile bowel segment and its mesentery, creating obstruction with progressive venous congestion, arterial compromise, necrosis and perforation.
- Sigmoid volvulus is associated with a redundant sigmoid, chronic constipation, neurological or psychiatric disease, immobility, institutional care and previous episodes.
- Caecal volvulus reflects abnormal right-colon mobility and often presents as a more acute obstruction in a younger or postoperative patient than sigmoid disease.
- Abdominal radiography may show a coffee-bean or markedly dilated loop, but contrast CT more reliably identifies the whirl, beak, transition, anatomical type and viability.
- Uncomplicated sigmoid volvulus is initially treated by urgent flexible endoscopic detorsion and decompression, usually leaving a decompression tube according to local practice.
- Successful detorsion is temporary source control rather than cure; recurrence is high, so offer definitive sigmoid resection during the same admission or promptly when fitness allows.
- Do not attempt endoscopic detorsion when perforation, peritonitis or non-viable bowel is suspected; these patients need emergency resection.
- Caecal volvulus is managed surgically because endoscopic decompression is unreliable; resection is generally preferred when fitness and viability permit.
Key red flags
Massive painless or colicky distension, obstipation and a CT twist in sigmoid mesentery without free air, poor enhancement or peritonism supports urgent endoscopic detorsion.
Continuous pain, involuntary guarding, fever, shock, bloody rectal discharge or CT signs of non-enhancement, pneumatosis and free fluid indicates infarction and emergency surgery.
Acute right-sided or central pain, obstruction and a displaced dilated caecum with mesenteric whirl or beak on CT indicates a mobile right-colon twist that normally requires operation.
Anterior folding of a hypermobile caecum can obstruct without the classic axial whirl. CT anatomy and proximal small-bowel dilatation help identify this surgical variant.
An annular lesion with an abrupt transition but no mesenteric twist suggests malignant large-bowel obstruction; cancer can also act as a lead point or coexist and must be excluded after detorsion.
Investigation priorities
Confirm the twist and site, distinguish sigmoid from caecal anatomy, identify a tumour and assess bowel viability or perforation.
Management branches
Acute distension, pain and obstipation suggest colonic volvulus.
- Keep fasting, obtain venous access, correct fluid and electrolyte deficits, provide analgesia and antiemetic care, and decompress the stomach when vomiting or small-bowel dilatation warrants it.
- Examine for peritonism and rectal findings, send urgent bloods and lactate, and obtain CT with direct radiology discussion about site, direction, viability and perforation.
- Call senior colorectal surgery at diagnosis and alert endoscopy or theatre according to viability; begin local antibiotics when ischaemia, perforation or sepsis is suspected.
- Do not allow temporary symptomatic improvement or a normal lactate to defer definitive anatomical management.