Radiology of sigmoid volvulus

WSES consensus guidelines on sigmoid volvulus management

Sigmoid volvulus is a common surgical emergency, especially in elderly patients. Patients can present with a wide range of clinical states: from asymptomatic, to frank peritonitis secondary to colonic perforation. These patients generally need urgent treatment, be it endoscopic decompression of the colon or an upfront colectomy. The World Society of Emergency Surgery united a worldwide group of international experts to review the current evidence and propose a consensus guidelines on the management of sigmoid volvulus.

Bowel obstruction and pseudo-obstruction

The gastroenterologist is frequently involved in the care of patients with bowel obstruction and pseudo-obstruction. In the case of obstruction, the central problem is determining which patients should be managed surgically. In both SBO and LBO, evidence of vascular compromise to the gut mandates surgical intervention. Most patients with pseudo-obstruction respond to conservative therapy or neostigmine. Endoscopic decompression is indicated in recalcitrant cases, with surgery reserved as a last resort.

Significant plain film findings in sigmoid volvulus

The aim of this study was to evaluate the plain abdominal radiographs of patients thought clinically to have a sigmoid volvulus. Strict diagnostic criteria based on the findings at barium enema and/or surgery were applied to establish or refute a diagnosis of sigmoid volvulus. The presenting plain abdominal radiographs were assessed for 10 radiological signs considered valuable in the diagnosis of sigmoid volvulus. Of the 17 patients with a volvulus, 88% had 6 or more signs, and in the 5 patients without a volvulus, 80% had 4 signs or less. Five signs achieved significance in differentiating between the groups. Three signs, apex of the loop under the left hemi-diaphragm, inferior convergence on the left and the left flank overlap sign, were 100% specific as well as being highly sensitive. The signs which were least specific were a distended ahaustral sigmoid loop and an air fluid ratio greater than 2:1.

Sigmoid volvulus in a young patient

The case of an 18-year-old man with sigmoid volvulus and recurrent abdominal pain is presented. He was seen in the emergency department three times in a 4-month period, each time complaining of cramping left lower quadrant pain of one to two hours duration without vomiting or diarrhea. Physical examination on each occasion revealed left lower quadrant tenderness without mass, guarding, or rebound. Radiologic evaluation on the first visit revealed sigmoid volvulus, which was reduced by barium enema. Despite identical clinical presentation on two subsequent occasions, radiologic studies showed no evidence of recurrent volvulus. During the ensuing two years, the patient has had no further symptoms.