An 82-Year-Old Woman With Abdominal Pain

James J. McCombie, MB ChB

Disclosures

March 13, 2017

Historically, immediate treatment of sigmoid volvulus has been mainly surgical. This approach should still be used if complications are believed to be present. In simple cases, derotation and decompression are the mainstay of acute therapy.

Selection of the immediately applied therapy depends on local institutional resources, practitioner availability, and physician preference. Both radiologic and endoscopic therapies are used in treating the patient with nonperforated, nongangrenous sigmoid volvulus. A radiologist may pass a 30- to 36-Fr, 50-cm long, large-bore, flexible tube through the anus and rectum to the point of obstruction under fluoroscopic guidance. Contrast medium is then introduced into the tube, generally using either gravity or gentle hand injection. In successful cases, hydrostatic pressure alone opens the lumen of the twisted segment, thereby decompressing it; a flush of stool and flatus is often explosively obtained. At that point, the transanal, large-bore catheter may be advanced into the proximal bowel to serve as a stent to prevent rerotation and reobstruction.

This same effect can be achieved with rigid sigmoidoscopy. The scope is passed along the lumen of the bowel under direct vision until the site of the volvulus is identified. The volvulated segment often derotates around the rigid scope; again, relief is identified by a sudden gush of feces and flatus, of which the operator should be aware. A well-lubricated tube may then be passed through the scope and manipulated gently into the sigmoid.

A flexible sigmoidoscope can also be placed under vision into the obstructed sigmoid to achieve the same effect, although it is more difficult to enable derotation around the flexible scope; therefore, this is a distant third choice for bedside decompression.

Failure to decompress the volvulated sigmoid should prompt surgical consultation for another attempt in the operating room with the aid of general anesthesia or deep sedation; surgical therapy may be directly undertaken if ischemia is found on the previous endoscopy or if a repeat attempt leads to iatrogenic perforation or identifies existing perforation after decompression (often found at the point of volvulus). A surgeon may be involved in the decision-making process upfront, rather than waiting until a potential complication occurs.

If successfully decompressed without the need for surgical therapy, patients can often be discharged home with dietary and medication regimen modification. However, the clinician should know that sigmoid volvulus is often a recurrent problem. One study demonstrated that of 48 patients discharged after one episode of volvulus, 61% were subsequently readmitted with recurrence.[12] With this in mind, many surgeons advocate an elective procedure after the second episode of volvulus, if the patient's condition allows this. This can be in the form of the procedures described later under emergency surgery or percutaneous endoscopic colostomy.

Percutaneous endoscopic colostomy has emerged as a possible treatment option for frail patients unfit to undergo surgery and general anesthesia.[13] A colostomy tube is inserted under endoscopic guidance, forming a decompressant or irrigant channel between the colonic lumen and the skin. In a series of 33 patients, fecal peritonitis (the most feared complication) developed in 8%, and minor complications developed in 30%, with an overall mortality of 3%.[14]

Clinicians should note that although percutaneous endoscopic colostomy is a novel therapy, percutaneous colonic intubation may be limited by tube clogging; tube dislodgement; tube-related mucosal hemorrhage; and the fact that the volvulated segment often demonstrates impaired motility, leading to failure of the distal colonic cleansing event with irrigation. Alternatively, sigmoid colostomy may be performed under local anesthesia in selected patients.

Emergency surgical treatment is generally reserved for patients with evidence of complications—that is, ischemia, necrosis, or perforation—or when conservative treatment has failed. One series reported conservative management to be successful in 74.6% of cases.[12] If surgery is indicated, one should be mindful that most patients are elderly and have comorbidities, often with a grade 4 American Society of Anesthesiologists classification.[15]

Once entry has been made into the abdomen, sigmoid derotation aids in determining therapy. Three management strategies are available: (1) sigmoid resection with primary anastomosis, (2) sigmoid resection and proximal end-colostomy with the creation of a distal stump (Hartmann procedure), and (3) sigmoidopexy. Sigmoidopexy (namely, fixing the sigmoid to the abdominal wall) may be considered in a frail patient with a viable colon after derotation who is suspected not to tolerate resection. Any suggestion of nonviable colon should prompt resection.

Although classically performed as an open procedure, laparoscopic techniques may be equally well applied, but these should be undertaken with care to abrogate abdominal insufflation-associated hypovolemia because this patient population is at risk for cardiovascular collapse from hypovolemia.

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