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Sigmoid Volvulus

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Sigmoid Volvulus

Sigmoid volvulus is a twisting of the sigmoid colon around its mesenteric attachment, producing a closed-loop large-bowel obstruction. Continued twisting may compromise blood flow and cause bowel ischemia, necrosis, perforation, and peritonitis.

Also called

Volvulus of the sigmoid colo

ICD-10

K22.7

Specialty

Gastroenterology

Onset

Acute

Reviewed

July 2026

On This Page

Overview

Sigmoid volvulus occurs when a long, mobile sigmoid colon twists around the base of its mesentery. This obstructs the bowel lumen and may also compress the mesenteric blood vessels. Patients commonly present with marked abdominal distension, colicky abdominal pain, constipation or obstipation, nausea, and vomiting. Diagnosis is usually made by abdominal radiography or CT. In patients without ischemia or perforation, urgent endoscopic detorsion is the initial treatment, followed by definitive sigmoid colectomy because recurrence is common

Etiology & Risk Factors

Etiology

Sigmoid volvulus develops when an elongated and redundant sigmoid colon with a narrow mesenteric base rotates around its mesenteric axis.

Risk Factors

  • Advanced age

  • Chronic constipation

  • Redundant or elongated sigmoid colon

  • Institutionalization

  • Reduced mobility or prolonged bed rest

  • Neurological disease

  • Parkinson disease

  • Previous stroke

  • Dementia

  • Psychiatric illness

  • Use of medications that reduce bowel motility

  • High-fiber bulky diet in some populations

  • Previous abdominal surgery

  • Chagas disease

  • Megacolon

  • Pregnancy, rarely

Pathophysiology

A long, mobile sigmoid colon twists around its narrow mesenteric base, causing obstruction at both ends of the affected segment. Gas and fecal material accumulate within the closed loop, producing progressive colonic distension. Increasing pressure compresses venous drainage first, causing congestion and bowel-wall edema, followed by reduced arterial blood flow. Untreated volvulus can therefore progress to ischemia, gangrene, perforation, fecal peritonitis, sepsis, and shock

Clinical Presentation

Symptoms

  • Progressive abdominal distension

  • Colicky or constant abdominal pain

  • Absolute constipation or obstipation

  • Inability to pass flatus

  • Nausea

  • Vomiting, often occurring late

  • Reduced appetite

Signs

    • Markedly distended abdomen

    • Tympanic percussion note

    • Abdominal tenderness

    • Increased bowel sounds early

    • Reduced or absent bowel sounds late

    • Empty rectum on digital rectal examination

    • Tachycardia

    • Fever

    • Guarding or rebound tenderness in complicated disease

History Taking

Ask about:

    • Onset and progression of abdominal distension
    • Abdominal pain
    • Last bowel movement
    • Ability to pass flatus
    • Nausea or vomiting
    • Previous similar episodes
    • Chronic constipation
    • Neurological or psychiatric disease
    • Reduced mobility or institutionalization
    • Previous abdominal surgery
    • Medications that reduce bowel motility
    • Fever or rectal bleeding

Physical Examination

General Examination

Assess for:

  • Fever

  • Tachycardia

  • Hypotension

  • Dehydration

  • Confusion

  • Signs of sepsis or shock

Abdominal Examination

Look for:

  • Marked generalized distension

  • Visible bowel loops

  • Surgical scars

Assess for:

  • Tympany

  • Tenderness

  • Guarding

  • Rebound tenderness

  • Bowel sounds

  • Features of peritonitis

Digital Rectal Examination

May show:

  • Empty rectum

  • Absence of stool

  • Blood, which may suggest mucosal ischemia

Investigations

Laboratory Tests

  • Complete blood count

  • C-reactive protein

  • Renal function and electrolytes

  • Serum lactate

  • Arterial or venous blood gas

  • Liver function tests

  • Coagulation profile

  • Blood group and crossmatch

  • Blood cultures if sepsis is suspected

Abdominal Radiograph

Typical findings include:

  • Coffee-bean sign

  • Large dilated sigmoid loop

  • Bent inner-tube appearance

  • Apex of the dilated loop directed toward the upper abdomen

  • Absence of rectal gas

CT Abdomen and Pelvis

CT can demonstrate:

  • Twisted sigmoid colon

  • Whirl sign of the twisted mesentery

  • Bird-beak tapering at the point of torsion

  • Proximal bowel dilatation

  • Bowel-wall ischemia

  • Pneumatosis

  • Free air or perforation

  • Alternative causes of obstruction

Flexible Sigmoidoscopy

Flexible sigmoidoscopy can:

    • Confirm the diagnosis

    • Assess mucosal viability

    • Detorse and decompress the colon

    • Allow placement of a rectal decompression tube

Diagnosis

Diagnosis is based on:

    • Typical symptoms of large-bowel obstruction
    • Marked abdominal distension
    • Characteristic abdominal radiograph or CT findings
    • Endoscopic confirmation in suitable patients
    • Assessment for bowel ischemia, necrosis, or perforation
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Management

Initial Management

  • Keep the patient nil by mouth

  • Establish intravenous access

  • Give intravenous fluids

  • Correct electrolyte abnormalities

  • Provide analgesia and antiemetics

  • Insert a nasogastric tube if significant vomiting is present

  • Give venous thromboembolism prophylaxis when appropriate

  • Administer broad-spectrum antibiotics if ischemia, perforation, or sepsis is suspected

  • Arrange urgent surgical review

Stable Patient Without Ischemia or Perforation

Urgent flexible sigmoidoscopy or colonoscopy should be performed for:

  • Endoscopic detorsion

  • Colonic decompression

  • Assessment of mucosal viability

  • Placement of a decompression tube

Successful endoscopic decompression should usually be followed by sigmoid colectomy during the same admission or soon afterward, because recurrence after decompression alone is common.

Emergency Surgery

Immediate surgery is indicated for:

  • Peritonitis

  • Perforation

  • Bowel ischemia or gangrene

  • Hemodynamic instability

  • Failed endoscopic detorsion

  • Recurrent volvulus when endoscopic treatment is unsuitable

Surgical options include:

    • Sigmoid colectomy with primary anastomosis in selected stable patients

    • Sigmoid colectomy with end colostomy, such as a Hartmann procedure, in unstable patients or when the bowel is gangrenous or perforated

Complications

  • Recurrent sigmoid volvulus
  • Bowel ischemia
  • Colonic gangrene
  • Perforation
  • Fecal peritonitis
  • Sepsis
  • Septic shock
  • Electrolyte abnormalities
  • Acute kidney injury
  • Death

Prognosis

  • The prognosis is generally good when sigmoid volvulus is diagnosed early and successfully treated before ischemia develops. Delayed presentation, bowel gangrene, perforation, advanced age, and severe comorbidities significantly increase morbidity and mortality. Recurrence is common after endoscopic decompression without definitive surgery.

Key Points / Clinical Pearls

  • Sigmoid volvulus is twisting of the sigmoid colon around its mesentery.
  • It causes closed-loop large-bowel obstruction.
  • Abdominal distension, pain, and obstipation are typical.
  • The coffee-bean sign may be visible on abdominal radiography.
  • CT may show a whirl sign or bird-beak appearance.
  • Endoscopic detorsion is first-line when there is no ischemia or perforation.
  • Peritonitis, gangrene, perforation, or failed decompression requires emergency surgery.
  • Definitive sigmoid colectomy is recommended because recurrence after decompression alone is common.
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  • Fu CG. Appropriate Treatment of Acute Sigmoid Volvulus in the Emergency Setting. World J Gastroenterol. 2013;19:4979-4983.
  • MedlinePlus, National Library of Medicine (NIH). Intestinal Obstruction: Medical Encyclopedia.