Volvulus

Carol K. Le; Phillip Nahirniak; Sachit Anand; Wantzy Cooper.

Author Information

Last Update: December 7, 2020.

Introduction
Volvulus occurs when a loop of intestine twists around itself and the mesentery that supplies it,
causing a bowel obstruction. Symptoms include abdominal distension, pain, vomiting,
constipation, and bloody stools. The onset of symptoms may be insidious or sudden. The
mesentery becomes so tightly twisted that blood supply is cut off, resulting in bowel ischemia.
Pain may be significant and fever may develop. 
Risk factors for volvulus include intestinal malrotation, Hirschsprung disease, an enlarged colon,
pregnancy, and abdominal adhesions. A higher incidence of volvulus is also noticed among
hospitalized patients with neuropsychiatric disorders such as Parkinson's disease, multiple
sclerosis, etc.  High fiber diet, chronic constipation with chronic use of laxatives and/or enema,
and associated myopathy like Duchene muscular dystrophy, etc. are also associated with
an increased risk of sigmoid volvulus. In adults, the sigmoid colon and cecum are the most
commonly affected. On the contrary, splenic flexure is least prone to volvulus. In children, the
small intestine and stomach are more commonly involved. Diagnosis is mainly clinical, however,
characteristic radiological findings on plain radiograph, ultrasound, and upper GI series help in
differentiating from other differentials. [1] The present article will cover volvulus in adults with
specific differences from midgut volvulus in children. However, a detailed discussion of
malrotation and midgut volvulus is beyond the scope of this article.
Sigmoidoscopy or a barium enema can be attempted as an initial treatment for sigmoid volvulus.
However, due to the high risk of recurrence, bowel resection with anastomosis within two days is
generally recommended. If the bowel is severely twisted or the blood supply is cut off, emergent
surgery is required. In a cecal volvulus, part of the bowel is usually removed. If the cecum is still
healthy, it may be returned and sutured in place. However, conservative treatment in both cases
is associated with high rates of recurrence.

Etiology
Volvulus is associated with intestinal malrotation, an enlarged colon, a long mesentery,
Hirschsprung disease, pregnancy, abdominal adhesions, and chronic constipation. In adults, the
sigmoid colon is the most commonly affected part of the gut followed by the cecum. In children,
the small intestine is more commonly involved. [2] In most cases, sigmoid volvulus is an
acquired disorder. Cecal volvulus, on the other hand, may occur due to incomplete dorsal
mesenteric fixation of the right colon or cecum or an elongated mesentery. Sigmoid volvulus is
more common in individuals with neuropsychiatric disorders, multiple sclerosis, and Parkinson's
disease. Neuroleptic drugs can also interfere with colonic motility and may trigger volvulus.
Nursing home patients who are bedridden and have chronic constipation have a greater risk of
developing sigmoid volvulus. A higher incidence of volvulus is also noticed among patients with
associated myopathy like Duchene muscular dystrophy, visceral myopathy, etc. In developing
countries, consumption of high fiber diet leads to overloading of the sigmoid colon, causing it to
twist around the mesentery. Similarly, Chagas disease or megacolon can also predispose to
sigmoid volvulus. Rarely, appendicitis or surgery may lead to excessive adhesions leading to
volvulus

Epidemiology
Colonic volvulus constituted nearly 2% of all the cases of bowel obstructions admitted in the
United States between 2002-2010. [3] Sigmoid volvulus, accounting for 8% of all intestinal
obstructions, occurs between the third and the seventh decades of life. It is more frequent in
elderly males, African Americans, adults with chronic constipation, and associated
neuropsychiatric disorders. On the other hand, cecal volvulus is more common in younger
females. [3] The age group of midgut volvulus is strikingly different from colonic volvulus. It is
typically seen in babies with rotation anomalies of the intestine. Segmental volvulus of other
portions of the gut can occur in people of any age, usually because of abnormal intestinal
contents or adhesions. 

Pathophysiology
Sigmoid volvulus is typically caused by two mechanisms i.e. chronic constipation and a high-
fiber diet. In both instances, the sigmoid colon becomes dilated and loaded with stools, making it
susceptible to torsion. The direction of the volvulus is counterclockwise. With repeated attacks
of torsion, there is a shortening of mesentery due to chronic inflammation. Subsequently, there is
the development of adhesions which then entrap the sigmoid colon into a fixed twisted
position. Cecal volvulus can be either organoaxial (cecocolic or true cecal volvulus) or
mesentericoaxial (cecal bascule). In the organoaxial variety, the ascending colon and distal ileum
twist around each other in a clockwise manner. However, in the mesentericoaxial sub-type, the
caecum is not completely fixed and is located anteriorly over the ascending colon at a right angle
to the mesentery. Since there is no twisting of the vascular pedicle, vascular compromise is
rarely associated with cecal volvulus. [4] In contrast to colonic volvulus, midgut volvulus in
children is invariably due to rotation anomalies of the intestine. [5] 

History and Physical

Patients with sigmoid volvulus are usually elderly males with a history of chronic constipation.
Although the majority of patients have an acute onset of symptoms, nearly one-third may have
an insidious presentation. Signs and symptoms of volvulus include abdominal pain, distension,
vomiting, constipation, obstipation, hematochezia, fever, etc. [6] Patients presenting to the
hospital after a significant delay may have features such as diffuse tenderness, guarding, and
rigidity suggesting perforation peritonitis. In the presence of severe abdominal distension,
patients often develop hemodynamic instability and respiratory compromise. In
contrast, newborns with midgut volvulus have sudden onset bilious emesis, upper abdominal
distension, hematochezia, inconsolable cry, etc. Older children with midgut volvulus may also
present with features including episodic abdominal pain, diarrhea, and failure to thrive. [5] 

Evaluation
Diagnosis of colonic volvulus is clinical, however, radiological investigations are often required
for diagnostic confirmation due to an overlap of clinical features with other diseases. The first
investigation to be performed is a plain radiograph of the abdomen. Specific signs including
"bent inner tube" or a "coffee bean" sign are characteristic for sigmoid volvulus. These refer to
the appearance of the air-filled closed loop of the colon which forms the volvulus revealing a
thick inner and a thin outer wall. Similarly, plain radiographs of patients with cecal volvulus
reveal distended small bowel and large bowel. Contrast enema should be performed only after
perforation peritonitis is ruled out. Demonstration of a "bird's beak" at the point where
the colon rotates to form the volvulus is characteristic of sigmoid volvulus. Computed
tomography (CT) of the abdomen and pelvis is generally not indicated in patients with colonic
volvulus, however, when performed an upward displacement of the appendix with large and
small bowel obstruction is suggestive for cecal volvulus. [7] Similar to colonic volvulus, in
children with midgut volvulus, radiological features include paucity of gas throughout the
intestine with few scattered air-fluid levels on plain radiograph, and an abnormally placed
duodenojejunal junction (DJ) with the small bowel looping entirely on the right side of the
abdomen on upper GI series. [5] Laboratory studies including complete blood count
(CBC) and serum biochemistry may show a left shift with leucocytosis and electrolyte
abnormalities respectively, however, these are non-specific. 

Treatment / Management
In all the cases of volvulus, patients need to be resuscitated prior to surgery. Broad-spectrum
antibiotics should also be administered in these patients preoperatively. Vitals monitoring
including measurement of the urine output should be done periodically. Some clinicians also
advocate nursing the patient in a left lateral position to avoid compression over the vena cava.
The initial treatment for sigmoid volvulus is sigmoidoscopy. Sigmoidoscopy can also help in
establishing a diagnosis of sigmoid volvulus. Spiralling of the mucosa and difficulty to negotiate
the scope beyond the site of obstruction are classical features of sigmoid volvulus on
sigmoidoscopy. [8] For endoscopic treatment, gentle insertion of the endoscope just below the
site of torsion and air insufflation is attempted. If unsuccessful, the tip of the endoscope can be
used to follow the twisted mucosa and reach the apex. Alternatively, a soft flatus tube or red
rubber tube can be inserted. This leads to detorsion and decompression. The success rate of
sigmoidoscopic reduction lies between 50-100%.[8] To prevent an early recurrence, a flatus tube
is kept in-situ after the endoscopic reduction. Due to a high recurrence rate, a bowel resection
within two days is recommended. Contraindications to endoscopic reduction include suspicion of
bowel gangrene manifesting as fever, persistent hematochezia and features of sepsis; and
perforation peritonitis. Immediate resuscitation and surgery are recommended in these cases. 
Surgical options for sigmoid volvulus include bowel resection and bowel conservative surgery.
Bowel resection is recommended over conservative surgery (sigmoidopexy or mesenteric
plication) as recurrence rates are higher with the later. If there is no faecal peritonitis, a primary
resection can be done. While if there is bowel perforation, then a Hartmann procedure can be
performed. Minimally invasive approach for sigmoid volvulus can be considered depending on
the surgeon's preference and experience. Elderly patients may benefit from minimally invasive
procedures.
Endoscopic decompression for cecal volvulus has low success rates (nearly 20%) and is also
associated with high recurrence rates. In a cecal volvulus, the cecum can be detorsed and
cecopexy can be performed. However, a part of cecum often needs to be removed. The ideal
procedure for cecal volvulus right hemicolectomy. If the bowel is obviously necrotic, then
resection with an ileostomy or a colostomy is necessary. If the patient is critically ill and is not fit
for general anaesthesia, a percutaneous tube cecostomy can be performed as an interim
procedure. A definite procedure can be attempted when the patient is declared fit by the
anaesthesia team. 

Differential Diagnosis
 Abdominal hernia
 Appendicitis
 Acute mesenteric ischemia
 Colon cancer
 Constipation
 Colonic polyps
 Diverticulitis
 Intestinal perforation
 Intestinal pseudo-obstruction
 Intussusception
 Megacolon, chronic
 Megacolon, toxic
 Mesenteric artery ischemia
 Ogilvie syndrome
 Pseudomembranous colitis
 Rectal cancer

Prognosis
Any delay in the diagnosis of cecal or sigmoid volvulus can be associated with high morbidity
and mortality. Mortality rates appear to be much higher for cecal volvulus compared to sigmoid
volvulus. When volvulus is treated non-surgically rates of recurrence are very high approaching
40-60%. When surgery is done in unstable patients, mortality rates of 12-25% have been
reported.

Complications
If untreated, volvulus can cause bowel strangulation, gangrene, perforation, and peritonitis.
Complications of surgery include the following:
 Recurrence (if conservative surgery is performed)
 Anastomotic leak
 Wound infection
 Pelvic abscess
 Sepsis
  Fecal fistula
 Complications of colostomy and/or ileostomy

Postoperative and Rehabilitation Care

Resumption of the enteral feeds may be delayed in some patients, especially those having
perforation peritonitis or those who had undergone resection of the necrotic
bowel with anastomosis. In these conditions, a nasogastric tube provides optimal bowel
decompression. Total parenteral nutrition (TPN) can be considered in patients who require
prolonged fasting due to resection of a major proportion of the small bowel. Colostomy and/or
ileostomy care must be taught to the patients and their relatives.

Deterrence and Patient Education

The elderly population must be explained about the risk factors associated with colonic volvulus.
These include chronic constipation, high-fiber diet, chronic dependence on enemas or
laxatives, association with neuropsychiatric disorders and myopathies, the use of neuroleptic
drugs, etc. Similarly, Chagas disease or megacolon can also predispose to sigmoid volvulus.
Rarely, appendicitis or surgery may lead to excessive adhesions leading to volvulus. Patients
must also be informed about the available treatment options including conservative strategies and
their complications. A need for enterostomy (colostomy and /or ileostomy) must always be
explained to the patients before the surgery for volvulus.

Enhancing Healthcare Team Outcomes

Patients with volvulus often present to the emergency department. While the diagnosis is not
difficult, the management is not always straight forward. Thus, it is important to involve an
interprofessional team that includes the emergency department physician, intensivist, nurse
practitioner, general surgeon, gastroenterologist, and internist. It is also vital to involve the
radiologist right from the beginning so that a diagnosis can be made urgently. The monitoring of
the patient, before and after the surgery, is exceedingly important and must be done in ICU or
HDU under the care of an intensivist. Immediate consultation with a surgeon is necessary to plan
for surgery. The role of a gastroenterologist is also vital, as immediate treatment of sigmoid
volvulus is detorsion utilizing the sigmoidoscopic reduction technique. In the postoperative
period, nurses should provide prophylaxis against DVT, pressure ulcers, and gastritis. Nurses
also play a critical role in educating the patients and their relatives about stoma care. Open
communication between the team is vital in order to achieve good outcomes. 

Volvulus

Syed Mahmood
I. What every physician needs to know.
Volvulus refers to torsion of a segment of the alimentary tract, which often leads to bowel
obstruction.The most common sites of volvulus are the sigmoid colon and the cecum.Volvulus of
other portions of the alimentary tract, such as the stomach, gallbladder, small bowel, splenic
flexure, and transverse colon, are rare.

Midgutvolvulus is a well-recognized surgical emergency in children, but it is rarely found in

adults. It usually manifests as congenital midgut malrotation but may also be acquired from
postoperative adhesion bands, tumors, persistent omphalomesenteric duct, and mesenteric cysts.
Volvulus has also been reported in the setting of Crohn’s disease, pregnancy, post-colonoscopy,
Hirschsprung’s disease, mobile cecum syndrome, and Chagas disease. It may also be a delayed
complication of blunt trauma to the abdomen resulting from post-traumatic cyst development.
The causes of sigmoid volvulus are primarily acquired so it is usually seen in elderly,
institutionalized, or chronically constipated persons.

Anatomical risk factors for volvulus are rotation abnormalities (intestinal malrotation and non-
rotation). Although these conditions usually cause volvulus at a much earlier age, they are
sometimes seen in adults. Rotation abnormalities are conditions that develop as a result of an
arrest of normal rotation of the embryonic gut. These abnormalities occur in 1/200 to 1/500 live
births. Non-rotation is not as dangerous as malrotation since risk of volvulus is lower in non-
rotation.
In malrotation, the cecum is abnormally fixated by bands of peritoneum known asLadd
bands,which can cause extrinsic compression of the intestine. Additionally, in malrotation the
narrow mesenteric base of the small bowel further predisposes the gut to volvulus. Volvulus as a
result of non-rotation and malrotation usually occurs after birth (with up to 40% of patients
presenting within the first week of life and up to 75% to 85% having been diagnosed by age one
year)and is rare in older children and adults. The literature is not clear concerning whether the
risk for volvulus(among those with malrotation), decreases with advancing age.

II. Diagnostic Confirmation: Are you sure your patient has volvulus?
Patients with volvulus usually present with nonspecific complaints. Abdominal imaging
(discussed in detail below) usually confirms the diagnosis. Plain abdominal X-ray picks up
volvulus in about 60 percent of cases.

A. History Part I: Pattern Recognition:

Clinical symptoms of volvulus are non-specific but most commonly includecolicky abdominal
painand vomiting. Accompanying signs may also includeabdominal distension andbloody stool.
Blood in the stool is a worrisome sign since it usually implies bowel ischemia and necrosis.

Fever, hypotension,and signs ofperitonitis usually indicate bowel gangrene.

Gastric volvulus, which is uncommon, is characterized by theBorchardt triad,which consists of

sudden epigastric pain, intractable retching, and inability to pass a nasogastric tube in to the
stomach.

B. History Part 2: Prevalence:

Volvulus in adults accounts for only 2 percent of all cases of mechanical intestinal
obstruction(Ballantyne et al.). Adult sigmoid volvulus usually occurs in the debilitated elderly
patient.

Rotation abnormalities significantly increase risk for volvulus; however, their incidence in the
population is difficult to estimate since most patients go through life without any
symptoms.Kapfer et al.noted that, according to barium enema series and autopsy results, 0.2-1
percent of the population may harbor such abnormalities.

C. History Part 3: Competing diagnoses that can mimic volvulus.

The majority of patients present with features of small bowel obstruction, which can mimic
almost any other cause of obstruction. It is important to identify volvulus as the underlying
etiological mechanism for obstruction, which can be achieved by means of abdominal imaging
(as detailed below).

D. Physical Examination Findings.

Patients with volvulus may initially present with nonspecific physicalabdominal pain, nausea,
vomiting,andtachycardia. In some cases, amass can be palpated. As necrosis sets in, patients may
developperitoneal signs, fevers,andhematochezia.

E. What diagnostic tests should be performed?

The diagnosis of volvulus can be established onby imaging (discussed below).

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How
should the results be interpreted?
There are no diagnostic laboratory tests for volvulus; however, some commonly found
nonspecific laboratory abnormalities are leukocytosis, lactate elevation, and metabolic acidosis.
2. What imaging studies (if any) should be ordered to help establish the diagnosis? How
should the results be interpreted?
Abdominal plain film has about 60 percent sensitivity and may pick up dilated loops of bowel in
midgut volvulus. It offers the advantage of a rapid test without the need for contrast and is the
test of first choice. In sigmoid volvulus, a “coffee bean” sign may be seen, which is formed by
closely apposed, dilated loops of bowel.

CT of the abdomen has high sensitivity and specificity for this diagnosis. A “whirlpool” sign,
which refers to SMA wrapped by coils of intestine, may be seen. Some authors believe that this
sign is diagnostic of midgut volvulus.

Upper gastrointestinal series with small bowel follow-through is the most specific radiological
exam for the diagnosis of midgut volvulus; however, it is time-consuming and poorly tolerated
by patients with acute abdominal pain. In midgut volvulus, a “corkscrew” appearance and “beak-
like” stenosis may be seen.

Angiography may reveal the “barber pole” sign in midgut volvulus, which represents rotation of
the small intestine around the root of the mesentery. However, this test is invasive and not the
test of choice.

Ultrasonography: The “whirlpool: sign (noted under CT) may be seen on ultrasound, which has a
similar high specificity for diagnosing volvulus.

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

None notable.

III. Default Management.

Once volvulus is diagnosed, it is important to keep in mind that a volvulated gut is at risk for
ischemia and should undergo emergent surgical intervention.

If the patient is found to have underlying malrotation, the Ladd surgical procedure is performed.
This procedure involves division of the Ladd bands, widening of the base of the mesentery,
placing viable bowel in a position of nonrotation, and appendectomy.

If sigmoid volvulus is found, a flexible or rigid sigmoidoscope may be advanced to untwist the
segment. However, if mucosa is found to be gangrenous, this procedure should be stopped
immediately, and the patient should undergo surgery. Because of high recurrence rates (55-90%)
and high mortality rates (40%), some authors advise that non-operative measures be used only to
move the patient from emergent surgery status to elective surgery status.

A. Immediate management.
Volvulus is a surgical emergency. Once diagnosis is suspected, a surgical consult while
obtaining appropriate imaging is the next step.

Preoperatively, the goals of treatment include cardiopulmonary and circulatory resuscitation.

Doing so involves obtaining appropriate intravenous access (may need a central line if the patient
is at risk for hypotension), generous intravenous fluids, placement of a nasogastric
decompression tube, and broad-spectrum antibiotics.

B. Physical examination tips to guide management.

Signs of peritonitis and blood in the stool usually indicate onset of gangrene and acute decline in
the patient’s status so they should prompt an immediate surgical evaluation and appropriate
abdominal imaging. If surgical services are already involved, these signs may indicate that
patient should go to the operating room sooner than later.

C. Laboratory tests to monitor response to and adjustments in management.

Worsening lactic acidemia and leukocytosis usually indicate worsening disease.
D. Long-term management.
The definitive management of volvulus is surgical correction. In some cases of sigmoid volvulus,
endoscopic correction may be considered; however, because of the high rate of recurrence,
endoscopic correction should be only a temporary measure. Surgery should still be considered
electively at some point.

E. Common pitfalls and side effects of management

Outcome in the management of this condition is dependent on early diagnosis. Unfortunately,
these patients usually present with signs of acute bowel obstruction and need quick intervention
to avoid bowel necrosis. Delay in making the diagnosis or getting surgical service involved may
have lethal complications.

V. Transitions of Care
A. Sign-out considerations while hospitalized.
Volvulus frequently presents with acute abdominal pain and is often a surgical emergency.
Ideally, a plan for surgical evaluation should be in place prior to sign-out. In addition, sign-out
should include detailed instructions to follow up on surgical consult recommendations and
frequent bedside visits to ensure that the patient is stable. If the patient is unstable in any way,
sign-out should include a discussion about the threshold for transfer to the intensive care unit.

B. Anticipated length of stay.

Length of stay is variable and determined by surgical outcome and perioperative complications.

C. When is the patient ready for discharge?

Discharge readiness is determined by operative outcome and complications. The surgical service
will weigh in on discharge readiness.

D. Arranging for clinic follow-up

Patients should follow up with surgical services and primary care.

1. When should clinic follow-up be arranged and with whom?

Follow-up should be arranged with surgical service and primary care. Timing of follow up is
varaible and will be determined by surgical outcome and perioperative complications.

2. What tests should be conducted prior to discharge to enable best clinic first visit?
None notable.

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit?
None notable.

E. Placement considerations
No diagnosis specific placement considerations.

F. Prognosis and patient counseling

This condition is rare in adults, hence prognosis will be determined by surgical outcome and
complications.
VI. Patient Safety and Quality Measures
A. Core indicator standards and documentation
Surgical care improvement measures will apply. The hospitalist should work with surgical teams
to ensure appropriate peri-operative antibiotics (if indicated) along with foley catheter
management post surgery.

B. Appropriate prophylaxis and other measures to prevent readmission

Appropriate wound care as advised by the surgical team and surgical follow up (as discussed
above). If discharged home, patient will likely benefit from ‘visiting nurse’ care.

An algorithm for the management of sigmoid colon volvulus and the safety of primary
resection: experience with 827 cases

Durkaya Oren 1, S Selçuk Atamanalp, Bülent Aydinli, M Ilhan Yildirgan, Mahmut Başoğlu, K

Yalçin Polat, Omer Onbaş
Affiliations expand

Abstract

Purpose: This study was designed to review the outcomes of emergent treatment of sigmoid
colon volvulus.

Methods: The records of 827 patients were reviewed retrospectively.

Results: The mean age was 57.9 years (range, 10 weeks to 98 years), and 688 patients (83.2
percent) were male. Nonoperative reduction was applied in 575 patients (barium enema in 13,
rigid sigmoidoscopy in 351, and flexible sigmoidoscopy in 211, with rectal tube placement in all
patients). The results were as follows: success of 78.1 percent, mortality of 0.9 percent,
complication of 3 percent, and early recurrence of 3.3 percent. Surgical treatment was performed
on 393 patients (detorsion in 46, mesosigmoidopexy in 56, exteriorization in 4, resection with
Hartmann's procedure in 146, resection with Mikulicz procedure in 14, resection with primary
anastomosis in 51, tube cecostomy and colonic cleansing with resection in 75, and laparotomy in
1). The results were as follows: mortality of 15.8 percent, complication of 37.2 percent, early
recurrence of 0.8 percent, and late recurrence of 6.7 percent.

Conclusions: Nonoperative reduction is the initial treatment of sigmoid colon volvulus, and

flexible sigmoidoscopy with rectal tube placement can be used successfully. Patients in whom
bowel gangrene or peritonitis is present or nonoperative treatment is unsuccessful need
emergency surgery. In surgical treatment, resection and primary anastomosis is the first choice,
and it can be performed with acceptable mortality and morbidity rates if the patient is stable and
a tension-free anastomosis is possible. Nondefinitive procedures have high recurrence rates; thus,
definitive surgical techniques must be preferred.

SIGMOID VOLVULUS

Background
The term volvulus is derived from the Latin word volvere (“to twist”). A colonic volvulus occurs
when a part of the colon twists on its mesentery, resulting in acute, subacute, or chronic colonic
obstruction. The main types of colonic volvulus are sigmoid volvulus and cecal volvulus. [1, 2]
See Can't-Miss Gastrointestinal Diagnoses, a Critical Images slideshow, to help diagnose the
potentially life-threatening conditions that present with gastrointestinal symptoms.
Before the 19th century, management of patients with volvulus was largely expectant. Gradually,
as nonintervention became associated with a high mortality, early surgical treatment became a
widely accepted practice.
By 1920, three surgical approaches (ie, open detorsion and mesenteric plication, resection with
colostomy, and resection with anastomosis) were widely used for the surgical treatment of
patients with sigmoid volvulus. Emergency resection carried a mortality of well over 50%. The
Mikulicz operation, the Hartmann procedure, and sigmoidopexy combined with partial resections
were also attempted, with variable results.
In 1947, the technique of transanal deflation of the volvulus using sigmoidoscopy was described.
This method of treatment was supported by subsequent studies, [3] but nonoperative detorsion as
the only treatment was found to be associated with a high recurrence rate. Consequently, elective
resection after a few days of decompression of the colon was adopted, and this approach remains
the current surgical treatment of patients with sigmoid volvulus.
Surgical treatment of cecal volvulus paralleled that of sigmoid volvulus. Before the early 19th
century, expectant management was widely practiced; as experience accrued, surgical treatment
became accepted. Detorsion and cecopexy were commonly performed, as was placement of
cecostomy tubes. The high recurrence and complication rates led to the adoption of right
hemicolectomy for the treatment of cecal volvulus, which remains the accepted approach.
Cecostomy is reserved for patients who are too debilitated to withstand resection.

Anatomy
The embryonic right colon typically has a mesentery that eventually fuses to the parietal
peritoneum; this fusion results in adherence to the posterior abdominal wall. Developmental
variations in the degree of fusion lead to differences in the mobility of the ascending colon and
the cecum (see the image below). Hendrick, in a review of cadaver studies, found that 10-25% of
the general population had a propensity for cecal volvulus on the basis of the length of the
colonic mesentery. [4] The long mesentery of the ascending colon results in a mobile cecum.

Variable degrees of attachment of ascending

colon to abdominal wall by reflection of overlying parietal peritoneum. (A) Normal attachment.
(B) Reflection of peritoneum to create paracolic gutter. (C) Mobile colon with reflection of
peritoneum to create colonic mesentery.
View Media Gallery
Two conditions must be present for the development of a cecal volvulus: (1) an abnormally
mobile segment of cecum and colon and (2) a fixed point around which the mobile segment can
twist. The second condition is created through normal ileocolic attachments, as well as through
abnormal adhesions after surgery or appendicitis.
The Jackson veil is an abnormal membrane that passes anterior to the ascending colon and
permits the cecum to be mobile around the lower point of the fixation permitted by the
membrane (see the image below).
 Jackson veil over ascending colon
contains numerous small blood vessels from renal and lumbar arteries.
View Media Gallery
At the level of the iliac crest, the descending colon becomes the sigmoid colon. The
mesosigmoid has variable attachments to the posterior body wall; most often, it is attached
diagonally downward toward the right. Cadaver studies in the United States found the average
length and breadth of the sigmoid mesentery to be 7.9 cm and 5.6 cm, respectively (see the
image below). [5] Cadaver studies from the Middle East reported a mesenteric breadth of 15.2 cm.
This difference may be developmental or may reflect differences in diet.

Average measurements of sigmoid

mesocolon.
View Media Gallery
Resection of the colon is based on the arterial supply to its various anatomic divisions (see the
image below). The ascending colon and cecum are supplied by the superior mesenteric artery via
the ileocolic and right colic arteries. Adjacent to the colonic wall, these arteries form arcades that
give off the vasa recta. The vasa recta divide into short and long branches that supply the medial
and lateral aspects of the colon, respectively.
 Arterial blood supply to colon.
View Media Gallery
The middle colic artery forms an arcade with the left colic artery, which is a branch of the
inferior mesenteric artery. This arcade, termed the marginal artery of Drummond, lies in the
mesenteric border adjacent to the colonic wall. The marginal artery gives off vasa recta to the
transverse colon, the splenic flexure, and the descending colon. The sigmoid colon is supplied by
branches of the left colic artery, as well as by two to four sigmoidal arteries, which are branches
of the inferior mesenteric artery.
In 3-5% of the population, the right colic and ileocolic arteries do not anastomose, creating an
area of poor blood supply. Similarly, the point of Griffith is an area of poor blood supply in the
region of the splenic flexure.
The critical point of Sudeck was previously considered to be a similar watershed area of poor
blood supply at the junction of the rectum with the sigmoid colon. Because of the extensive and
intramural submucosal plexus of arteries formed by the branches of the superior, middle, and
inferior rectal arteries, the rectum and distal sigmoid colon are well vascularized. In contrast, the
vasa recta (the end arteries in the colon wall) are not well vascularized. For this reason, the
clinical implications of the critical point of Sudeck are not as important.
To avoid injuring the ureters, the surgeon must always be aware of the location of these
structures in the retroperitoneum. The ureter is easily identified at the pelvic brim where it
crosses over the external iliac artery. It is visible as a white structure that, on gentle compression,
demonstrates characteristic propulsive movement.

Pathophysiology
Chronic constipation in Western society and a high-fiber diet in developing nations lead to an
overloaded sigmoid colonic loop. The weight of this loaded sigmoid colon makes it susceptible
to torsion along the axis of the elongated mesentery. The presence of a gravid uterus or a large
pelvic mass alters the relative positions of the intra-abdominal organs, also predisposing to
formation of volvulus.
As a result of repeated subacute attacks of torsion, the base of the sigmoid mesocolon becomes
foreshortened. The associated mild, chronic inflammation at the base of the mesentery and the
two limbs of the sigmoid colon loop leads to the formation of adhesive tissue. This causes the
sigmoid loop to become chronically fixed into a paddlelike configuration, which, in turn,
predisposes to recurrence of the torsion (see the image below).
 Sigmoid volvulus. (A) Counterclockwise torsion at base of
mesentery. (B) Adhesions at base of sigmoid mesocolon leading to formation of fixed omega
loop that is susceptible to repeat torsion.
View Media Gallery
Cecal volvulus may be organoaxial (true cecal or cecocolic volvulus) or mesentericoaxial (cecal
bascule). The former involves the distal ileum and ascending colon twisting around each other, in
much the same way as a sigmoid volvulus. Compared with sigmoid volvulus, in which the
torsion is in a counterclockwise direction, cecal volvulus usually occurs in a clockwise direction.
Incomplete cecal and ascending colonic fixation occurs because of a lack of embryologic
development of the dorsal mesentery. The lack of development predisposes the patient to
clockwise torsion of the cecum, terminal ileum, and ascending colon (see the images below).
Vascular compromise is common because of mesenteric torsion.

Cecal volvulus. (A) Clockwise torsion of mesentery of

cecum, ascending colon, and terminal ileum. (B) Absence of dorsal mesenteric attachments of
cecum and proximal ascending colon, leading to lack of fixation to retroperitoneum.
View Media Gallery
 Cecal volvulus with ischemic
changes of distended cecum and terminal ileum. Remainder of small bowel involved in volvulus
appears distended but not ischemic. No obvious peritoneal contamination is observed.
View Media Gallery
In contrast, a cecal bascule occurs when the malfixed cecum folds anteriorly over the ascending
colon (see the image below) in an axis at right angles to the mesentery. Because no torsion of the
ileocolic mesentery is present, vascular compromise of the cecum rarely occurs. Vascular
compromise occurs more commonly in cases in which significant distention is present, which
prevents the cecum from unfolding into its normal position.

Cecal bascule. (A) Anterior folding of cecum. (B) Lack of

dorsal mesenteric fixation of cecum to retroperitoneum.
View Media Gallery
A complete volvulus leads to the development of a closed-loop obstruction of the affected
colonic segment. Increased dilation of the bowel loop compromises the vascular supply of the
bowel, eventually leading to ischemic gangrene and bowel wall perforation.

Etiology
The presence of a long mesentery with a narrow base of fixation to the retroperitoneum and
elongated, redundant bowel predisposes to the formation of volvulus. Volvulus can develop in
any portion of the large bowel. However, it is most common in the sigmoid colon because of the
mesenteric anatomy. Less commonly, volvulus develops in the right colon and terminal ileum
(cecal or cecocolic volvulus) or the cecum alone (termed a cecal bascule). In rare cases, volvulus
may develop in the transverse colon or the splenic flexure.
Sigmoid volvulus may occur because of sigmoid elongation, resulting in a redundant loop. Most
commonly, this is the result of chronic constipation and the progressive dilatation and
lengthening of the sigmoid colon and its mesentery.
Institutionalized patients with neuropsychiatric disorders often develop sigmoid volvulus. A
higher incidence of the condition is observed in patients with Parkinson disease, multiple
sclerosis, or spinal cord injury. Psychotropic drugs interfere with colonic motility and are
etiologically implicated in the high incidence observed in patients in psychiatric institutes.
Patients in nursing homes also commonly develop sigmoid volvulus. This association may be a
manifestation of the prolonged recumbency and chronic constipation that patients in chronic care
facilities experience. Not surprisingly, the excessive use of laxatives, cathartics, and enemas is
highly associated with the development of sigmoid volvulus.
In developing countries, a high-fiber diet leads to overloading of the sigmoid colon, which twists
around its mesentery and results in volvulus. Megacolon, either congenital or acquired
through Chagas disease, predisposes to the development of sigmoid volvulus. In areas of South
America where Chagas disease is endemic, the development of sigmoid volvulus in affected
patients is reported to be as high as 30%.
The presence of a pelvic mass also increases the risk of developing sigmoid volvulus. The mass
displaces the sigmoid colon sufficiently to result in torsion of the mesentery and subsequent
volvulus. The association of pregnancy and large ovarian tumors with sigmoid volvulus is well
known. In Western societies, as many as 45% of pregnant patients with intestinal obstruction
have sigmoid volvulus.
Less common conditions resulting in sigmoid volvulus include postoperative adhesions, internal
herniations, intussusceptions, omphalomesenteric abnormalities, intestinal malrotations, and
carcinoma. A rare condition in patients with abnormally long mesenteries of the stomach, splenic
flexure, and sigmoid colon has been described as traveling volvulus. The abnormal mesenteric
fixation of intraperitoneal organs predisposes these patients to recurrent spontaneous torsion and
detorsion.
Whereas sigmoid volvulus is usually an acquired condition, cecal volvulus is due to congenital
incomplete dorsal mesenteric fixation of the cecum or ascending colon associated with an
abnormally elongated mesentery distal to this area of absent mesentery. In autopsy studies,
marked mobility of the right colon occurs in an estimated 15-20% of the population.
Other anomalies that predispose to cecal volvulus include undescended right colon and previous
surgical mobilization of the cecum, both permitting sufficient mobility for
volvulus. Appendicitis, with resultant formation of adhesions, predisposes to cecal volvulus as
well.
As in sigmoid volvulus, a pelvic space-occupying lesion (eg, a gravid uterus or an ovarian
tumor) may precipitate an episode of cecal volvulus by altering the relative positions of the intra-
abdominal organs. Gaseous dilation of the sigmoid colon and cecum after colonoscopy has also
been described as a cause of volvulus.

Epidemiology
United States statistics
Colonic volvulus ranks after cancer and diverticulitis as a cause of large-bowel obstruction in the
United States; it is responsible for approximately 5% of all cases of intestinal obstruction and 10-
15% of all cases of large-bowel obstruction. In these populations, the most common site of large-
bowel torsion is the sigmoid colon (80%), followed by the cecum (15%), the transverse colon
(3%), and the splenic flexure (2%). [6]
In Western societies, the average age of patients with sigmoid volvulus is in the eighth decade,
and the two sexes are equally affected. Various series have reported that of all patients diagnosed
with volvulus, 25-35% are admitted to an acute care facility from a neuropsychiatric care
institution, and 10-15% are admitted from a long-term nursing care facility.
International statistics
Worldwide geographic variations in the incidence of sigmoid volvulus are well described. Much
higher frequencies are reported in African, Asian, Middle Eastern, Eastern European, and South
American countries. In all of these regions, the inhabitants consume a high-fiber diet, which is
considered a predisposing factor for the development of sigmoid colon volvulus. In these
endemic areas, patients are younger and predominantly male.
In the “volvulus belt” of Africa and the Middle East, nearly 50% of large-bowel obstructions are
a result of volvulus, almost exclusively of the sigmoid colon. Cecal volvulus is much less
common than sigmoid volvulus, accounting for 10-15% of all cases of volvulus and
predominately affecting women in the sixth decade of life.

Prognosis
Delay in diagnosis and treatment of sigmoid and cecal volvulus is associated with substantial
morbidity and mortality. Studies report a mortality of 30-40% in patients in whom diagnosis and
treatment of cecal volvulus are delayed.
The suggested interval between endoscopic decompression and definitive surgical intervention is
48-72 hours. This is adequate time for resuscitation, investigation, and intervention to further
reduce surgical risk.
Even when volvulus is adequately treated with endoscopic decompression and surgical resection,
mortality is in the range of 12-15%, according to various studies. In part, these figures reflect the
poor general health of this patient population. A retrospective review of patients in Veterans
Affairs (VA) hospitals with sigmoid volvulus quoted a mortality of 24% for emergency
procedures and a mortality of 6% for elective procedures (after decompression). [7]
As many of 50% of patients who undergo endoscopic decompression alone experience
recurrence. Endoscopic decompression alone for sigmoid volvulus carried a recurrence rate of
40-50%, with a mortality of 25-30% after surgical treatment of the recurrent volvulus.

History
Patients with volvulus are commonly elderly, debilitated, and bedridden. Often, the patient has a
history of dementia or neuropsychiatric impairment. As a result, only a limited history is
available.
More than 60-70% of patients present with acute symptoms; the remainder present with subacute
or chronic symptoms. A history of chronic constipation is common. The patient may describe
previous episodes of abdominal pain, distention, and obstipation, which suggest repeated
subclinical episodes of volvulus.
Physical Examination
The presentation of volvulus is much the same, regardless of its anatomic site. Cramping
abdominal pain, distention, obstipation, and constipation are present. With progressive
obstruction, nausea and vomiting occur. The development of constant abdominal pain is ominous
and indicates the development of a closed-loop obstruction with significant intraluminal
pressure. This, in turn, portends the development of ischemic gangrene and bowel wall
perforation.
Abdominal distention is commonly massive and characteristically tympanitic over the gas-filled,
thin-walled colon loop. Overlying or rebound tenderness raises the concern of peritonitis due to
ischemic or perforated bowel. The patient may have a history of episodes of acute volvulus that
spontaneously resolved; in such circumstances, marked abdominal distention with minimal
tenderness may occur.
Depending on the extent of bowel ischemia or fecal peritonitis, signs of systemic toxicity may be
apparent. Because of the massive abdominal distention, the patient may have respiratory and
cardiovascular compromise.

Diagnostic Considerations
The differential diagnosis of colonic volvulus includes a rare condition known as an ileosigmoid
knot. An ileosigmoid knot occurs when the ileum and sigmoid colon become entangled, creating
a knot that results in vascular compromise of the bowel. The patient presents with acute onset of
abdominal pain and rapidly developing shock. Ileosigmoid knot is a life-threatening condition
that requires urgent surgical treatment.

Laboratory Studies
Laboratory tests include a complete blood count (CBC) with differential and a comprehensive
metabolic profile. An elevated white blood cell (WBC) count and left shift indicate bowel
ischemia, peritoneal infection, or systemic sepsis. Bowel obstruction may cause significant
changes in electrolyte levels.
Other diagnostic studies include plain abdominal radiography, computed tomography (CT),
barium enema, and sigmoidoscopy or colonoscopy (see below).

Plain Abdominal Radiography

Massive dilation of the sigmoid colon loop arising from the pelvis and extending to the
diaphragm is a typical finding of sigmoid volvulus. The walls of the loop are evident as three
bright lines converging in the pelvis to create a beaklike appearance (see the image below).
 Plain abdominal radiograph demonstrating
massively dilated sigmoid colon loop and convergence of walls of colon into beaklike formation.
View Media Gallery
Cecal volvulus produces large- and small-bowel obstruction. Radiographic findings reveal a
markedly distended loop of bowel extending from the right lower quadrant upward to the left
upper quadrant. The small bowel is distended, whereas the distal colon is decompressed (see the
image below).

Cecal volvulus with associated small bowel

obstruction.
View Media Gallery
Detailed overviews of the radiologic findings of colonic volvulus are available elsewhere
(see Sigmoid Volvulus and Cecal Volvulus).
CT of Abdomen and Pelvis
Computed tomography (CT) is not often needed, because the plain radiographic findings
typically suffice for diagnosis of sigmoid volvulus. However, the radiographic findings for cecal
volvulus may be less diagnostic. In such cases, CT can delineate the exact site of the torsion and
reveal evidence of ischemia.
Upward displacement of the appendix with large-bowel obstruction is a definitive sign of cecal
volvulus. Additionally, decompressed transverse and descending colon are apparent.
Barium Enema
A contrast enema should be performed in patients who show no evidence of peritonitis and in
whom plain abdominal radiographs are not diagnostic. The contrast study typically demonstrates
a beaklike termination at the point of the sigmoid volvulus (see the image below). Similarly, a
foldlike termination may be observed at the point of obstruction in the ascending colon in
patients with cecal volvulus.

Barium enema of sigmoid volvulus revealing

termination of contrast in bird's-beak formation at base of volvulus.

Approach Considerations
Surgery is the definitive treatment of sigmoid and cecal volvulus. The decisions regarding timing
of surgery and choice of procedure depend on the clinical presentation (see the image below).

Algorithm for treatment of patients

with sigmoid and cecal volvulus.
View Media Gallery
In patients with no evidence of peritonitis or ischemic bowel, treatment starts with resuscitation
and detorsion of the sigmoid volvulus. This is accomplished by means of sigmoidoscopy or
colonoscopy and concomitant rectal tube placement. The bowel is then prepared, and surgery is
undertaken electively during the same hospitalization. Inability to detorse the sigmoid volvulus
endoscopically is an indication for immediate surgical intervention.
If the patient has evidence of peritonitis or ischemic bowel, emergency surgery is indicated, and
the operative procedure is chosen on the basis of intraoperative findings.
Radiologic diagnoses of cecal volvulus or cecal bascule are also generally considered indications
for surgical intervention because the obstruction in these conditions cannot be reliably reduced
with colonoscopy. However, there is some controversy on this point; the increasing number of
reports citing successful detorsion of cecal volvulus suggest that in stable patients, a single
attempt at colonoscopic decompression is reasonable.
For sigmoid volvulus, the currently accepted surgical procedures include sigmoid resection with
primary anastomosis and resection and the Hartmann procedure. Primary anastomosis is
performed if the divided bowel ends are viable, peritoneal contamination is not evident, and the
patient is hemodynamically stable. If evidence of ischemic bowel or gross peritoneal
contamination is observed or if the patient is hemodynamically unstable, a Hartmann procedure
is safer.
Various surgical techniques for sigmoidopexy and mesenteric plication have been described.
These are associated with high volvulus recurrence rates and are not commonly performed.
For cecal volvulus, the success rate of endoscopic decompression is only 15-20%, and
emergency surgical intervention is therefore mandated. The choice of procedure depends on the
patient’s clinical condition. In severely debilitated patients, cecostomy is a valid option;
however, it is associated with a wound infection rate of 40-50% and a recurrence rate of
approximately 2-5%. If the patient can withstand surgery, a right hemicolectomy with primary
ileocolic anastomosis is the procedure of choice. Rarely, an end ileostomy is performed.
Cecopexy is associated with volvulus recurrence in 20-30% of patients. An extensive form of
fixation of the right colon and cecum, which reportedly carries a lower recurrence rate, has been
described. The time required for this procedure is as long as, if not longer than, that required for
colectomy, which is the definitive procedure. Hence, most fixation procedures for volvulus are
not recommended.
Elective laparoscopic sigmoid resection and right hemicolectomy after endoscopic
decompression is increasingly being described and performed to treat patients with volvulus. In
these patients, who are often elderly and chronically ill, minimally invasive surgery may provide
significant benefit. Further studies comparing the outcomes of laparotomy versus laparoscopy for
colectomy for volvulus are required.
Initial Measures
The patient is resuscitated with intravenous isotonic crystalloid solution to correct fluid deficits
and hypovolemia. This is performed while the patient is being examined and arrangements are
being made to attempt endoscopic reduction of volvulus. Laboratory tests and plain radiographs
of the abdomen are obtained in the emergency department.
Broad-spectrum antibiotics with anaerobic coverage are given to patients in whom peritonitis,
ischemic bowel, or sepsis is evident. A Foley catheter is inserted to assess fluid balance, and a
nasogastric tube is placed if the patient has been vomiting. Because pressure on the inferior vena
cava may compromise venous return, the patient is placed in the left lateral position to improve
venous return.
Endoscopic Detorsion and Decompression
Recognition of the typical radiologic findings of a sigmoid volvulus on plain abdominal
radiography is followed by emergency sigmoidoscopy or colonoscopy for detorsion and
decompression of the volvulus.
The sigmoidoscope or colonoscope is advanced into the rectum under direct vision. The rectum
is insufflated to provide good visibility and facilitate identification of the apex of the volvulus.
Occasionally, the pressure of the air causes detorsion, reducing the volvulus.
If detorsion does not occur, the spiraling rectal mucosa is followed upward to the apex, and a soft
rectal tube is passed up through this under direct vision. The tip of the endoscope can also be
used to apply constant pressure at the apex, which can lead to detorsion and decompression.
Placement of a soft rectal tube allows continued decompression and bowel preparation before the
planned surgical procedure. Placement of a rectal tube without endoscopic visualization is not
advised, because of the risk of perforation. Decompression is evident through passage of large
amounts of gas and fecal material but should be radiologically confirmed.
Sigmoidoscopic detorsion is successful in more than 90% of patients with sigmoid volvulus, but
colonoscopic detorsion is successful in only 10-15% of patients with cecal volvulus. Computed
tomography (CT) of the abdomen and pelvis can be obtained in hemodynamically stable patients.
This can better define a cecal volvulus as the cause of the obstruction.
Volvulus recurs in as many as 60% of patients who are treated solely with decompression.
Elective surgery should be undertaken during the same admission. The patient can be further
stabilized and mechanical bowel preparation given. Clinical evidence of peritonitis, unsuccessful
endoscopic detorsion, or a radiologically evident cecal volvulus necessitates emergency surgical
intervention.
Sigmoid Colectomy for Sigmoid Volvulus
After successful endoscopic decompression of sigmoid volvulus, the surgical approach that is
simplest and has the lowest rate of recurrence is sigmoid colectomy with primary anastomosis.
The patient is placed in a dorsal lithotomy position with Lloyd Davis stirrups. This allows for the
possibility that an unexpectedly low anastomosis may be required, which can be accomplished
through transanal passage of an end-to-end anastomosis (EEA) stapler. The abdomen and
perineum are prepared and draped separately. The perineum remains draped until it is time to
pass the stapling device.
A low midline incision is made. The massively dilated sigmoid colon loop is immediately
encountered. This is exteriorized, and the volvulus is detorsed by rotating it clockwise (because a
sigmoid volvulus is usually the result of counterclockwise torsion). The colon proximal and
distal to the site of torsion is circumferentially isolated and clamped. The inferior mesenteric
artery is divided where it is easily accessible.
Often, detorsion is not possible, because of adhesions at the base of the mesentery. In these
instances, the omega loop is resected by clamping and dividing the bowel proximal and distal to
the loop. The sites of transection are chosen to allow a well-perfused, tension-free anastomosis
(see the first image below). The anastomosis can be completed in a hand-sewn fashion or with a
gastrointestinal (GI) stapling device (see the second image below).

Extent of resection required for

sigmoid volvulus is limited to resection of omega loop of sigmoid volvulus and resection of
sigmoid mesentery.
View Media Gallery

Divided descending colon and rectum

are reanastomosed in hand-sewn manner or with GI stapling device.
View Media Gallery
In the event of a failed sigmoidoscopic reduction or a suspected ischemic bowel, the divided
bowel is carefully inspected to ensure good supply.
Hartmann Procedure for Sigmoid Volvulus
If fecal peritonitis is present or the patient is hypotensive, a Hartmann procedure (rapid resection
of the volvulus with an end colostomy) is preferred.
The patient is placed in a supine position, and a low midline incision is made. The omega loop of
the sigmoid colon is resected. The proximal divided end of the colon is mobilized sufficiently to
create a tension-free end colostomy. The distal stapled end of the bowel remains in the pelvis
(see the image below). A Hartmann procedure is also a good option in a severely debilitated,
bedridden patient who requires long-term care.
 Hartmann procedure for sigmoid
volvulus.
View Media Gallery
Patients who undergo a Hartmann procedure may be candidates for colostomy reversal in 3-6
months. This decision whether to proceed with reversal is based on the patient’s overall clinical
condition and ability to withstand another major surgical procedure. Debilitated patients who
require long-term institutional care may not benefit from colostomy reversal.
Other Procedures for Sigmoid Volvulus
The Mikulicz resection is of historic interest only and is rarely performed today. It involves
exteriorization of the volvulus via a lateral oblique incision. The sigmoid loop is amputated, and
a double-barrel colostomy is created.
Sigmoidopexy is never a surgical option, because it is associated with a recurrence rate of 40-
50%. Mesenteric plication procedures have been described but are not recommended, because of
the associated high recurrence rates.
Right Hemicolectomy for Cecal Volvulus
The preferred surgical procedure for the treatment of patients with cecal volvulus is right
hemicolectomy.
The patient is placed in a supine position, and the abdomen is prepared and draped. A low
midline incision is made. The area of the volvulus and the terminal ileum are exteriorized. The
volvulus is reduced through counterclockwise detorsion, because the torsion occurs in a
clockwise direction.
The terminal ileum is clamped and divided. The transverse colon immediately proximal to the
middle colic artery is circumferentially isolated and divided between clamps. The colon is
mobilized by dividing the mesentery and the peritoneal reflections (see the first image below).
The divided bowel ends are approximated in a tension-free manner by using a hand-sewn
technique or a GI stapler (see the second image below).
 Extent of resection for cecal volvulus is
similar to that in right hemicolectomy for benign disease.
View Media Gallery

Terminal ileum is anastomosed to transverse

colon in reconstruction after right hemicolectomy.
View Media Gallery
Other Procedures for Cecal Volvulus
In extremely debilitated patients who are unable to tolerate a surgical procedure, a percutaneous
cecostomy may be attempted. This procedure has a low recurrence rate (only 1-3%) but is
associated with a high incidence of wound infection and persistent fecal fistula.
Cecopexy is mentioned only to be condemned. The recurrence rate associated with cecopexy is
15-20%, the same as that for detorsion alone.
Complications
Postoperative care includes continued fluid resuscitation and antibiotic therapy as guided by the
patient’s clinical condition. Possible postoperative complications include the following:
 Surgical wound infection (8-12%)
 Anastomotic leakage (3-7%)
 Colocutaneous fistula (2-3%)
 Abdominal or pelvic abscess (1-7%)
 Sepsis (2%)

Medication Summary
To correct fluid deficits and hypovolemia, the patient is initially resuscitated with intravenous
isotonic crystalloid solution.
Isotonic Crystalloids
Class Summary
Isotonic sodium chloride (normal saline [NS]) and lactated Ringer (LR) are isotonic crystalloids,
the standard intravenous (IV) fluids used for initial volume resuscitation. They expand the
intravascular and interstitial fluid spaces. Typically, about 30% of administered isotonic fluid
stays intravascular; therefore, large quantities may be required to maintain adequate circulating
volume.
Both fluids are isotonic and have equivalent volume restorative properties. While some
differences exist between metabolic changes observed with the administration of large quantities
of either fluid, for practical purposes and in most situations, the differences are clinically
irrelevant. No demonstrable difference in hemodynamic effect, morbidity, or mortality exists
between resuscitation with either NS or LR.
Normal saline (NS, 0.9% NaCl)
NS restores interstitial and intravascular volume. It is used in initial volume resuscitation.
Lactated Ringer
LR restores interstitial and intravascular volume. It is used in initial volume resuscitation.
Colloids
Class Summary
Colloids are used to provide oncotic expansion of plasma volume. They expand plasma volume
to a greater degree than isotonic crystalloids and reduce the tendency of pulmonary and cerebral
edema. About 50% of the administered colloid stays intravascular.

Albumin (Buminate, Albuminar)

 View full drug information

Albumin is used for certain types of shock or impending shock. It is useful for plasma volume
expansion and maintenance of cardiac output. A solution of NS and 5% albumin is available for
volume resuscitation. Five percent solutions are indicated to expand plasma volume, whereas
25% solutions are indicated to raise oncotic pressure.