INTESTINAL SURGERY II
Sigmoid volvulus, acquired
megacolon and pseudo-
obstruction
Ramana R Kallam
Dibyendu Bandyopadhyay
Abstract
This article is aimed at describing three common colorectal surgical emer-
gencies that present as large bowel obstruction. Emphasis is given to sig-
moid volvulus, acquired megacolon/megarectum and colonic pseudo-
obstruction with respect to their clinical presentation and management
including emergency treatment and any further elective treatment options
once the emergency situation is resolved. In western society, these con-
ditions are commonly associated with elderly and institutionalized pa-
tients posing significant management challenges. With increasing
emphasis on emergency sub-speciality care provision, thorough under-
standing of these clinical conditions is essential to appropriately tailor
the management to individual patient needs.
Keywords Acquired megacolon/megarectum; colonic obstruction; large
bowel obstruction; Ogilvie’s syndrome; pseudo-obstruction; sigmoid
volvulus
Sigmoid volvulus
Definition
In general, volvulus describes the condition in which the bowel
becomes twisted on its mesenteric axis resulting in partial or
complete obstruction of the bowel lumen and a variable degree of
impairment of its blood supply. Volvulus commonly affects: a
redundant sigmoid colon (61%) due to its anatomy of long sig-
moid mesentery with a narrow base, the right colon (34.5%)
described as caecal volvulus (a misnomer), the transverse colon
(3.5%) and very rarely the splenic flexure (1%).1,2
Epidemiology
Accounting for 5e7% of emergency hospital admissions with
colonic obstruction, sigmoid volvulus is relatively rare in North
America and Europe. In Russia, sigmoid volvulus accounts for
50% of emergency admissions with a large bowel obstruction. In
Iran, India and Africa, sigmoid volvulus is the most common
cause for a large bowel obstruction. A typical European or North
American patient with sigmoid volvulus is usually elderly,
institutionalized and with multiple medical co-morbidities like
dementia, Parkinson’s disease, Alzheimer’s and longstanding
electrolyte imbalances and frailty. Sigmoid volvulus is more
prevalent in males.
Ramana R Kallam FRCS is a Specialist Registrar in Surgery in Yorkshire
Deanery, UK. Conflicts of interest: none declared.
Dibyendu Bandyopadhyay MS FRCS FRCS (Gen Surg) is a Consultant
Colorectal Surgeon at York Teaching Hospital, UK. Conflicts of interest:
none declared.
SURGERY 32:8
Aetio-pathology
Sigmoid volvulus is permitted by an elongated segment of bowel
accompanied by a lengthy mesentery with a narrow retroperi-
toneal attachment. This allows the two ends of the mobile colon
to come together and twist around the narrow mesenteric base
(Figure 1). Chronic constipation and treatment with psychotropic
drugs may predispose to volvulus by affecting intestinal motility.
High dietary fibre intake has been attributed to volvulus in
developing nations. A twist of greater than 180 in the sigmoid
mesentery can result in closed loop colonic obstruction if the
patient has competent ileo-caecal valve. Volvulus impairs blood
supply to the affected bowel leading to ischaemia. Bacterial
fermentation of colonic contents in the closed loop results in
further gas production and worsening colonic distension thus
setting in a cascade of progressive ischaemia, bacterial trans-
location, systemic sepsis, segmental infarction, gangrene and
perforation leading to generalized peritonitis and death.
Clinical presentation
Patients with sigmoid volvulus may present as acute or sub-acute
intestinal obstruction. There is usually sudden onset of severe
abdominal pain, obstipation and abdominal distension more
dramatic than would be associated with other causes of colonic
obstruction. Vomiting is usually a late feature. In the majority of
patients, there may be a history suggestive of similar episodes
which have spontaneously resolved with the passage of large
quantities of flatus and faeces or hospitalization and various
interventions to resolve the volvulus. The abdomen is usually
markedly distended and tympanic. Severe abdominal pain,
rebound tenderness and tachycardia are ominous signs as they
are usually associated with either mural ischaemia from
increased tension in excessively distended bowel wall or arterial
occlusion caused by torsion of the mesenteric arterial supply.
Plain radiographic findings often enable prompt diagnosis in at
least 75% of cases. Radiographs reveal a markedly distended air-
filled sigmoid colon with its apex in the right upper quadrant e
classically described as the ‘coffee bean’ sign (Figure 2). Proximal
colon is usually dilated and if the ileo-caecal valve is incompetent
there will be associated small bowel dilatation. Gas is usually ab-
sent in the rectum. An erect chest X-ray helps to exclude perforation
if there is no pneumoperitoneum. In the case of any diagnostic
uncertainty based on plain radiographs, a CT scan is recommended
for a more certain diagnosis. CT scans reveal a characteristic
mesenteric whirl. Even though not routinely used, a contrast enema
typically demonstrates the point of obstruction with the patho-
gnomonic ‘bird’s beak’ deformity. Flexible endoscopy will help to
confirm the diagnosis, treat the condition and more importantly, it
will help to rule out other causes of large bowel obstruction.
Management
Once the diagnosis of sigmoid volvulus is established, initial
management is aimed at resuscitation with correction of hypo-
volaemia and electrolyte imbalance. In almost all the patients in
absence of perforation initial treatment is non-surgical intervention
with a view to resolve the twist.3 This can be attempted either with
a rigid or a flexible sigmoidoscope with controlled insufflation and
advancement of scope beyond the point of obstruction to decom-
press the obstructed sigmoid colon. Sigmoidoscopic decompres-
sion is successful in 70e80% of cases in conventional practice.1,3
427 Ó 2014 Elsevier Ltd. All rights reserved.
 INTESTINAL SURGERY II
Figure 1 Sigmoid volvulus.
Once decompressed it is advisable to leave a flatus tube to maintain
continuous drainage for 24e48 hours; this will also help to prevent
immediate recurrence. It is strongly advised for the operator to
wear protective clothing whilst attempting endoscopic decom-
pression as de-rotation is associated with rapid egress of flatus and
liquid stool. In patients with clinical, radiological or biochemical
signs of peritonitis from perforation or gangrene of the colon if the
patient is fit enough to withstand the surgical stress, treatment
should be emergency surgery with simultaneous resuscitation.
Emergency operative interventions in this group of patients are
associated with higher morbidity and mortality. In one of the larger
case series from Veterans’ Affairs Hospitals, emergency surgery
was associated with 24% mortality when compared to 6% in
elective setting after emergency decompression of volvulus.1
Surgical options
Recurrent sigmoid volvulus is common and can recur in 90%1 of
patients after first successful conservative de-rotation and
decompression. Due to this high rate of recurrence, once the
emergency is over surgical treatment should be considered in the
Figure 2 The ‘coffee bean’ sign.
SURGERY 32:8
semi-elective or elective setting for suitable patients. The oper-
ation could be conducted through a small left lower quadrant
incision or laparoscopic approach. As the elongated colon and
mesentery require virtually no mobilisation, sigmoid resection
with primary anastomosis is easily accomplished. However, the
authors feel that it is important to excise the sigmoid loop and
anastomose at the upper rectum to prevent recurrent volvulus
following surgery. Colonoscopy should be considered before
elective resection if there is any suspicion of an associated
neoplasm. In fit patients it is feasible to proceed to surgery at the
index admission once endoscopic decompression is successful.
When there is clinical peritonitis, endoscopic decompression
is contra indicated and main stay of treatment is surgical inter-
vention. Options in the emergency setting depend on the viability
of the bowel, the patient’s general and nutritional status and
local expertise. Surgical options include the following.
 A primary sigmoid resection with anastomosis is the best
option. A sigmoid resection with end colostomy and
closure of rectal stump (Hartmann’s resection), if condi-
tions for a safe primary anastomosis are unfavourable.
 A double-barrel stoma as in Paul-Mikulicz’s procedure.
 A subtotal colectomy with end ileostomy or ileo-rectal
anastomosis, in case of non-viable colon (closed loop
obstruction).
If the patient’s general condition does not permit resection sur-
gery or general anaesthesia, percutaneous endoscopic sigmoi-
dopexy is a preferred option once sigmoid volvulus is
decompressed. Elongated loop of sigmoid is triangulated and
fixed using three-point endoscopic fixation using percutaneous
endoscopic gastrostomy (PEG) tubes or button devices.
Idiopathic megabowel/acquired megacolon/megarectum
Definition
A subgroup of patients with intractable constipation has persis-
tent dilatation of the bowel. In the absence of an organic cause
this is termed idiopathic megabowel (IMB). This is associated
with chronic abnormal dilatation of colon and rectum down to
the level of anal sphincters. Dilatation may affect various parts of
colon. If dilatation is confined to colon it is described as mega-
colon, if dilatation is confined to rectum it is described as meg-
arectum and if dilation involves both colon and rectum the
condition is described as idiopathic megabowel.
428 Ó 2014 Elsevier Ltd. All rights reserved.
 INTESTINAL SURGERY II
Incidence and aetiology
True incidence of IMB is unknown as majority of these patients
are asymptomatic. Males and females are equally affected.4 This
condition is characterized by recurrent faecal impaction usually
beginning in childhood or early adult life.5 Despite the aetiology
being unknown, evaluation of anorectal function has revealed
that patients with IMB have excessive laxity (increased compli-
ance), hypomotility, and sensory dysfunction of the rectum.5
Furthermore, patients also have impaired rectal evacuatory
function, often with secondary delay in colonic transit.5
Clinical presentation
Commonly presents with features suggestive of large bowel
obstruction with abdominal distension and obstipation; this may or
may not be associated with pain. Often no significant previous
history of bowel disturbance is reported although a history of reg-
ular laxative use for constipation can be elicited. Progressive prox-
imal colonic distension and faecal loading of rectum predisposes to
acute presentation as sigmoid volvulus.5 On clinical examination
one can observe gross abdominal distension with tympanic reso-
nance on percussion. Digital rectal examination provides adequate
clues to differentiate from volvulus as in IMB, rectum is usually
voluminous and empty or faecally impacted.5 Plain radiographs will
reveal a grossly distended colon and rectum. Formal diagnosis is
made on contrast enema when the rectal diameter is greater than 6.5
cm at the level of pelvic brim.5 Histology of megacolon confirms the
presence of ganglion cells in contrast to the absence of ganglions as
seen in Hirschsprung’s disease.5
Management
The majority of patients with IMB are managed conservatively to
control symptoms. Basic measures include appropriate hydration
and correction of electrolyte disturbances. Regular rectal evacu-
ation should be encouraged with the help of stimulant laxatives,
suppositories, enemas and rectal irrigation. Even though it has
been claimed that the majority of these patients can be managed
conservatively, 50e70% of patients may not tolerate medical
treatment and represent with recurrent symptoms.5 Those who
respond will require lifelong treatment. Medical therapy fails to
achieve restoration of rectal calibre to normal even after pro-
longed treatment.5 More recently, the role of behavioural
retraining incorporated with biofeedback has been explored.5
Surgical options
Primary treatment for IMB is medical. However, when medical
therapy fails surgical options should be carefully considered in
selected patients with intractable symptoms impinging on quality
of life. This should preferably be performed in a specialist surgical
unit with multi disciplinary team approach. Patients should be
carefully counselled, as surgery may only partially improve
symptoms and may not provide a cure. In patients with mega-
colon and normally functioning normal capacity rectum, the
operation of choice would be subtotal colectomy with ileo-rectal
anastomosis, as segmental resections are associated with higher
failure rates of up to 50%.5 In patients with IMB procedure of
choice would be restorative proctocolectomy with ileo-anal pouch
with up to a 73% success5 or total colectomy with end ileostomy.
Vertical resection rectoplasty has been suggested for megarectum
alone with normal colon with successful resolution of symptoms
SURGERY 32:8
in 83% of patients in a small series.5 Pelvic floor procedures
described are internal sphincterotomy or puborectalis division
with limited success. The final option would be creation of a
stoma proximal to non-functioning segment.5
Colonic pseudo-obstruction
Definition
Colonic pseudo-obstruction is a term used to characterize a clin-
ical syndrome with symptoms, signs, and a radiographic appear-
ance of large bowel obstruction without a mechanical cause.6
According to presentation, pseudo-obstruction syndromes can
be subdivided into acute and chronic forms. Acute colonic pseudo-
obstruction (ACPO) is characterized by massive colonic dilatation
in the absence of mechanical obstruction. ACPO is also referred to
as acute colonic ileus or Ogilvie’s syndrome.6
Incidence and aetiology
The exact incidence of colonic pseudo-obstruction is unknown
but may be inferred from the incidence of large bowel obstruc-
tion, where it is responsible for 20% of cases.6 The highest
prevalence of ACPO is observed during the late middle age and
men are more commonly affected than women.6 ACPO occurs in
1% of hospitalized orthopaedic patients undergoing hip, knee
and spinal surgery. Although a few patients without any asso-
ciated disease are affected, most develop ACPO in association
with a wide spectrum of illnesses.6 Common associations are
listed in Box 1.7 The cause of ACPO is thought to be due to an
alteration in the normal autonomic regulation of colonic motor
function. This could be either by excess parasympathetic sup-
pression reducing colonic contractility or excessive sympathetic
stimulation decreasing colonic motility.6 Nitric oxide, an inhibi-
tory neurotransmitter, has also been shown to be overproduced
in experimental models of ACPO.6
Clinical presentation
Acute colonic pseudo-obstruction is characterized by abdominal
distension, pain, nausea and/or vomiting, with a failure to pass
flatus and stool. Symptoms tend to develop gradually over a
period of time. Clinical examination reveals distended tympanitic
Predisposing conditions associated with acute colonic
pseudo-obstruction
C Trauma (long bone, spinal injuries)
C Infection (pneumonia, urinary tract infection, pyrexia of unknown
origin, abdominal sepsis)
C Cardiac (myocardial infarction, cardiac failure)
C Obstetric and gynaecological (lower segment Caesarean section,
child birth, hysterectomy)
C Abdominal or pelvic surgery
C Neurological (stroke, Parkinson’s disease, multiple sclerosis,
Alzheimer’s)
C Electrolyte imbalances (low sodium, potassium, phosphate,
magnesium and calcium)
C Uraemia and renal failure
C Drugs (antidepressants, phenothiazines, opiates and anti-
parkinsonian agents)
Box 1
429 Ó 2014 Elsevier Ltd. All rights reserved.
 INTESTINAL SURGERY II
abdomen with bowel sounds. Massive colonic dilatation may
cause ischaemia and spontaneous perforation in 3% of patients,6
with subsequent findings of peritonitis, tachycardia and raised
C-reactive protein and white blood cell count. Spontaneous
perforation is associated with 40% mortality when compared to
15% in patients with viable non-perforated bowel.6
A plain abdominal radiograph will reveal a dilated large bowel
with or without associated small bowel dilatation (Figure 3). The
differential diagnosis in hospitalised or institutionalised patients
includes mechanical obstruction from rectal lesion and toxic
megacolon due to Clostridium difficile infection. An erect chest X-
ray helps to look for free air under the diaphragm in suspected
perforation. A water-soluble contrast enema or CT should be
performed to differentiate a mechanical obstruction from a
pseudo-obstruction. CT also helps to accurately measure the
caecal diameter as a diameter greater than 12 cm is associated
with risk of perforation.6
Management
Once the diagnosis of acute pseudo-obstruction is suspected,
treatment should accompany the diagnostic evaluation. Initial
treatment is conservative including correction of fluid and elec-
trolyte loss, naso-gastric decompression (in case of incompetent
ileo-caecal valve) and discontinuing all opiates and motility in-
hibitors. Patients should be monitored closely for response with
serial abdominal examinations and plain radiographs. Sponta-
neous resolution can be observed in 77% of patients with con-
servative measures.6 If the situation deteriorates or does not
resolve, colonoscopic decompression, mucosal inspection for
ischaemia and placement of flatus tube for continuous decom-
pression should be considered.6
Medical management
In unresolved cases of ACPO, neostigmine, a para-
sympathomimetic agent has been successfully used to enhance
colonic motility in up to 90% of patients.6 It is imperative that
mechanical obstruction be excluded prior to neostigmine admin-
istration, or the subsequent high pressure generated in the colon
against a distal obstruction could cause colonic perforation.
Neostigmine enhances parasympathetic activity by competing
with acetylcholine for acetylcholinesterase-binding sites.8e10
Neostigmine is administered intravenously at a dose of 2e2.5
mg over 3e5 minutes with close cardiac monitoring.9 The reso-
lution of ACPO is indicated by passage of stool and flatus in less
Figure 3 Small bowel dilatation.
SURGERY 32:8
than 10 minutes. Recurrence rates of ACPO after neostigmine
administration appears to be lower (11%), than after colonoscopic
decompression without flatus tube placement (40%).6 A signifi-
cant side effect of neostigmine is bradycardia. Atropine must be
immediately available. Nevertheless, caution with neostigmine is
needed in patients with a history of myocardial infarction, active
bronchospasm, renal failure and who are receiving b-blockers.
Alternatively neostigmine can be given orally at a dose of 15 mg
twice a day, until a regular bowel habit is established. Other
agents tried with limited success include, erythromycin, cisapride
and ondansetron as prokinetic agents. Administration of poly-
ethylene glycol electrolyte-balanced solution after initial resolu-
tion of ACPO either with neostigmine or colonoscopy is associated
with marked reduction in recurrence of ACPO.11
Surgical management
CT-guided percutaneous caecostomy has been reported in suit-
able high-risk patients who failed to respond to optimal medical
treatment with high success rate.6
Surgery is either reserved for patients with imminent perfo-
ration or inpatients who have not responded to maximum non-
surgical measures. Surgery is associated with high morbidity
(30%)6 and mortality (6%).6 If the colon is viable, a venting
caecostomy or a colostomy is preferred option with. If the colon
is nonviable or perforated, subtotal colectomy or segmental
resection with double barrel stoma should be considered. A
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430 Ó 2014 Elsevier Ltd. All rights reserved.