Overview

Volvulus occurs when a portion of the intestine twists on itself, creating a closed-loop obstruction that prevents the normal passage of intestinal contents and compromises blood flow to the affected segment. This twisting can occur in various parts of the digestive tract, with the sigmoid colon (sigmoid volvulus) being the most common site in adults, followed by the cecum (cecal volvulus) and small intestine (midgut volvulus).

The condition represents approximately 10-15% of all large bowel obstructions in Western countries, but accounts for up to 50% in regions where high-fiber diets are common, particularly in Africa and South America. Without prompt treatment, volvulus can lead to intestinal ischemia (lack of blood flow), necrosis (tissue death), perforation, and potentially fatal peritonitis. The mortality rate can exceed 30% if bowel necrosis occurs.

Volvulus can affect people of all ages but shows distinct patterns: midgut volvulus primarily affects infants with intestinal malrotation, while sigmoid volvulus typically occurs in elderly adults with chronic constipation. The condition requires a high index of suspicion for early diagnosis, as delayed treatment significantly increases morbidity and mortality rates.

Symptoms of Volvulus

The symptoms of volvulus can vary depending on the location of the twist, degree of obstruction, and whether blood supply is compromised. Symptoms typically develop rapidly and progressively worsen without treatment.

Common Symptoms

  • Sharp abdominal pain - Sudden onset of severe, colicky pain that may be intermittent initially but becomes constant
  • Vomiting - Initially of stomach contents, progressing to bilious (green) or feculent (fecal-smelling) material
  • Abdominal distension - Marked swelling of the abdomen, often asymmetric
  • Constipation - Complete inability to pass stool or gas (obstipation)
  • Nausea - Persistent feeling of sickness accompanying the pain

Symptoms by Type

Sigmoid Volvulus:

  • Gradual onset of abdominal pain and distension
  • History of chronic constipation
  • Massive abdominal distension
  • Tympanic (drum-like) abdomen on examination

Cecal Volvulus:

  • Acute onset of severe pain
  • Pain often localized to right lower quadrant initially
  • Less dramatic distension than sigmoid volvulus
  • May have palpable mass in mid-abdomen

Midgut Volvulus (primarily in infants):

Signs of Complications

  • Fever - Indicates possible perforation or peritonitis
  • Tachycardia - Rapid heart rate suggesting shock
  • Hypotension - Low blood pressure indicating severe illness
  • Altered mental status - Confusion due to severe dehydration or sepsis
  • Peritoneal signs - Rigid abdomen with rebound tenderness

Causes of Volvulus

Volvulus occurs when anatomical and physiological factors combine to allow a segment of bowel to rotate around its mesenteric axis. The specific causes vary by the type and location of volvulus.

Anatomical Factors

Redundant Colon: An abnormally long sigmoid colon or cecum with increased mobility predisposes to twisting. This redundancy may be congenital or acquired through chronic constipation and straining.

Narrow Mesenteric Attachment: A narrow base of mesenteric attachment allows the bowel segment to rotate more easily. This is particularly relevant in sigmoid volvulus where the mesocolon may have a narrow pedicle.

Intestinal Malrotation: Congenital abnormality where the intestines don't rotate properly during fetal development, leading to abnormal fixation. This is the primary cause of midgut volvulus in infants.

Precipitating Factors

  • Chronic constipation: Creates a heavy, dilated sigmoid colon prone to twisting
  • High-fiber diet: In certain populations, produces bulky stools and gas that distend the colon
  • Adhesions: From previous abdominal surgery can create fixed points around which bowel rotates
  • Pregnancy: Enlarged uterus can displace intestines, increasing volvulus risk
  • Psychiatric medications: Anticholinergic effects can cause constipation and bowel dysmotility
  • Neurological conditions: Parkinson's disease, multiple sclerosis affect bowel motility

Types and Their Specific Causes

Sigmoid Volvulus:

  • Chronic constipation leading to elongated, redundant sigmoid
  • Institutionalized or bedridden patients with poor bowel habits
  • Chagas disease in endemic areas (damages intestinal nerves)
  • High altitude living (possibly due to atmospheric pressure changes)

Cecal Volvulus:

  • Congenital lack of cecal fixation to posterior peritoneum
  • Previous abdominal surgery causing adhesions
  • Pregnancy or pelvic masses displacing the cecum
  • Colonoscopy (rare complication)

Small Bowel Volvulus:

  • Intestinal malrotation (most common in neonates)
  • Post-surgical adhesions
  • Internal hernias
  • Meckel's diverticulum acting as a lead point

Risk Factors

Understanding risk factors for volvulus helps identify high-risk individuals who may benefit from preventive measures or closer monitoring.

Demographic Risk Factors

  • Age: Sigmoid volvulus peaks in the 7th-8th decade; cecal volvulus affects younger adults (40-60 years)
  • Gender: Sigmoid volvulus more common in men (4:1 ratio); cecal volvulus slightly more common in women
  • Geographic location: Higher incidence in Africa, South America, Eastern Europe, and India
  • Institutionalization: Nursing home residents have increased risk due to immobility and medications

Medical Conditions

  • Chronic constipation: Most significant modifiable risk factor
  • Neurological disorders: Parkinson's disease, dementia, spinal cord injuries
  • Psychiatric conditions: Often associated with medication side effects and altered bowel habits
  • Connective tissue disorders: Ehlers-Danlos syndrome, Marfan syndrome
  • Diabetes: Autonomic neuropathy affects bowel motility
  • Hypothyroidism: Causes decreased bowel motility
  • Chagas disease: In endemic areas, damages intestinal nerve plexuses

Lifestyle and Dietary Factors

  • High-fiber diet: Paradoxically increases risk in certain populations
  • Laxative dependence: Chronic use may alter normal bowel function
  • Sedentary lifestyle: Reduced physical activity affects bowel motility
  • Dehydration: Contributes to constipation

Iatrogenic Factors

  • Previous abdominal surgery: Creates adhesions and altered anatomy
  • Medications: Anticholinergics, opioids, antipsychotics, antiparkinson drugs
  • Colonoscopy: Rare but recognized risk for cecal volvulus
  • Barium enema: Historical risk factor, less relevant with modern imaging

Diagnosis

Early diagnosis of volvulus is crucial to prevent intestinal ischemia and perforation. Diagnosis combines clinical assessment with imaging studies, with plain radiographs often providing the initial clue.

Clinical Assessment

History: Focus on:

  • Onset and character of abdominal pain
  • Previous episodes of similar pain (recurrent volvulus)
  • Bowel habits and history of constipation
  • Prior abdominal surgeries
  • Medications affecting bowel motility

Physical Examination:

  • Vital signs: Tachycardia, hypotension suggest complicated volvulus
  • Abdominal inspection: Asymmetric distension characteristic
  • Palpation: Tympanic abdomen, may feel twisted loop
  • Peritoneal signs: Indicate perforation or ischemia
  • Rectal examination: Empty rectum, may have blood if ischemia present

Imaging Studies

Plain Abdominal X-rays: First-line imaging showing characteristic signs:

  • Sigmoid volvulus: "Coffee bean sign" or "bent inner tube sign" - dilated loop pointing to right upper quadrant
  • Cecal volvulus: Dilated cecum in left upper quadrant, "comma sign"
  • Small bowel volvulus: Multiple dilated loops with air-fluid levels
  • Loss of haustral markings in affected segment

CT Scan: Gold standard for diagnosis with high sensitivity and specificity:

  • "Whirl sign" - swirling of mesenteric vessels around the twist point
  • "Bird beak sign" - tapered appearance at the point of obstruction
  • Assesses bowel wall viability (enhancement patterns)
  • Identifies complications (perforation, pneumatosis)
  • Rules out other causes of obstruction

Contrast Studies: Limited use in modern practice:

  • Water-soluble contrast enema may show "bird's beak" at obstruction site
  • Avoided if perforation suspected
  • Can be therapeutic in sigmoid volvulus (reduction)

Laboratory Tests

  • Complete blood count: Leukocytosis suggests inflammation or ischemia
  • Electrolytes: Dehydration, metabolic abnormalities from vomiting
  • Lactate: Elevated with intestinal ischemia
  • Blood gas: Metabolic acidosis in severe cases
  • Amylase/Lipase: May be elevated with intestinal ischemia

Differential Diagnosis

Consider other causes of intestinal obstruction:

Treatment Options

Treatment of volvulus requires urgent intervention to relieve obstruction and restore blood flow. The approach depends on the type of volvulus, presence of complications, and the patient's overall condition.

Initial Stabilization

All patients require immediate supportive care:

  • Fluid resuscitation: Aggressive IV hydration to correct dehydration and electrolyte imbalances
  • Nasogastric decompression: Relieves proximal distension and prevents aspiration
  • Pain management: Careful use of analgesics avoiding those that decrease bowel motility
  • Antibiotics: Broad-spectrum coverage if ischemia or perforation suspected
  • Monitoring: Continuous vital signs, urine output, serial abdominal exams

Non-Operative Management

Endoscopic Decompression (Sigmoid Volvulus):

  • First-line treatment for uncomplicated sigmoid volvulus
  • Success rate 70-90% for initial decompression
  • Flexible sigmoidoscopy or colonoscopy to untwist bowel
  • Placement of rectal tube to maintain decompression
  • Contraindicated if signs of ischemia or perforation
  • High recurrence rate (40-70%) without definitive surgery

Barium Enema Reduction:

  • Historical treatment, largely replaced by endoscopy
  • May be attempted for cecal volvulus in select cases
  • Risk of perforation limits use

Surgical Management

Emergency Surgery Indications:

  • Failed endoscopic decompression
  • Signs of intestinal ischemia or necrosis
  • Perforation or peritonitis
  • Cecal or small bowel volvulus (rarely amenable to endoscopic treatment)

Surgical Options for Sigmoid Volvulus:

  • Detorsion alone: High recurrence rate, reserved for unstable patients
  • Sigmoid resection with primary anastomosis: Preferred for viable bowel
  • Hartmann's procedure: Resection with end colostomy for compromised bowel
  • Sigmoidopexy: Fixation without resection, high recurrence rate
  • Mesosigmoidoplasty: Widening the mesocolon base, limited use

Surgical Options for Cecal Volvulus:

  • Right hemicolectomy: Most definitive treatment with low recurrence
  • Cecopexy: Fixation of cecum, higher recurrence than resection
  • Cecostomy: Tube decompression, high complication rate
  • Detorsion alone: Unacceptably high recurrence rate

Postoperative Care

  • ICU monitoring: For complicated cases or elderly patients
  • Bowel rest: NPO until bowel function returns
  • Nutritional support: TPN if prolonged ileus
  • DVT prophylaxis: Early mobilization and anticoagulation
  • Stoma care: If colostomy performed
  • Bowel regimen: Prevent constipation to reduce recurrence risk

Elective Surgery

After successful endoscopic decompression of sigmoid volvulus:

  • Elective sigmoid resection recommended due to high recurrence
  • Lower morbidity and mortality than emergency surgery
  • Typically performed within same admission or within 2-4 weeks
  • Laparoscopic approach feasible in selected patients

Prevention

While not all cases of volvulus can be prevented, especially those due to congenital abnormalities, several strategies can reduce risk in susceptible individuals.

Managing Constipation

  • Dietary fiber: Gradual increase to 25-35 grams daily with adequate fluids
  • Hydration: Minimum 8 glasses of water daily
  • Regular bowel habits: Respond promptly to urge to defecate
  • Avoid straining: Use footstool for proper positioning
  • Laxatives: Judicious use under medical supervision, avoid dependence
  • Probiotics: May help maintain healthy bowel function

Lifestyle Modifications

  • Physical activity: Regular exercise promotes bowel motility
  • Medication review: Minimize constipating medications when possible
  • Treat underlying conditions: Manage hypothyroidism, diabetes
  • Avoid rapid dietary changes: Gradual transitions prevent bowel disturbance

Medical Surveillance

  • High-risk patients: Regular monitoring of bowel habits
  • Previous volvulus: Consider elective surgery to prevent recurrence
  • Nursing home residents: Bowel management protocols
  • Neurological patients: Proactive bowel regimens

Surgical Prevention

For patients with recurrent volvulus or high risk:

  • Prophylactic sigmoid resection: After first episode in good surgical candidates
  • Elective surgery: Lower risk than emergency procedures
  • Laparoscopic options: Reduced recovery time

When to See a Doctor

Volvulus is a medical emergency requiring immediate attention. Delayed treatment significantly increases the risk of complications and death.

Seek Emergency Care Immediately For:

  • Sudden, severe abdominal pain that doesn't improve
  • Inability to pass gas or have bowel movements
  • Progressive abdominal distension
  • Vomiting, especially if bilious (green) or fecal-smelling
  • Signs of shock: rapid pulse, dizziness, cold sweats
  • Fever with abdominal pain and distension
  • Previous volvulus with return of symptoms

Schedule Urgent Appointment For:

  • Chronic constipation not responding to treatment
  • Recurrent episodes of abdominal pain and distension
  • Changes in bowel habits with abdominal discomfort
  • Family history of volvulus with concerning symptoms

Risk Assessment Consultation:

Consider evaluation if you have:

  • Multiple risk factors for volvulus
  • Neurological conditions affecting bowel function
  • Long-term use of constipating medications
  • Previous abdominal surgery with new symptoms

Important: Never attempt to "wait out" severe abdominal pain with inability to pass gas or stool. Early intervention can mean the difference between simple decompression and major surgery with bowel resection.

Frequently Asked Questions

What is the difference between volvulus and other types of bowel obstruction?

Volvulus specifically involves twisting of the bowel around its mesenteric axis, cutting off blood supply. Other obstructions may be caused by tumors, adhesions, or hernias that compress or block the bowel without twisting. Volvulus typically causes more severe symptoms and requires urgent treatment to prevent bowel death.

Can volvulus recur after treatment?

Yes, recurrence is common, especially after non-surgical treatment. Endoscopic decompression of sigmoid volvulus has a 40-70% recurrence rate without definitive surgery. This is why elective surgical resection is often recommended after successful initial decompression to prevent future episodes.

How quickly does volvulus need to be treated?

Volvulus is a surgical emergency requiring treatment within hours. The twisted bowel loses blood supply, and tissue death can begin within 6-12 hours. Delayed treatment increases the risk of bowel perforation, sepsis, and death. Mortality rates increase significantly after 24-36 hours without treatment.

Are there warning signs before volvulus occurs?

Some patients experience prodromal symptoms including chronic constipation, intermittent abdominal pain, bloating, and previous episodes of partial twisting that resolved spontaneously. However, volvulus can also occur suddenly without warning, especially in patients with anatomical predispositions.

What is the prognosis after volvulus surgery?

Prognosis depends on several factors including the patient's age, presence of bowel necrosis, and timing of treatment. With prompt treatment and viable bowel, mortality is less than 5%. However, if bowel necrosis has occurred, mortality can exceed 30-40%. Long-term outcomes are generally good after definitive surgical treatment.

Medical Disclaimer: This information is for educational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or qualified health provider with any questions you may have regarding a medical condition. If you suspect you have volvulus, seek emergency medical attention immediately.