This document provides an overview of sigmoid volvulus, a condition characterized by twisting of a segment of the colon, leading to obstruction. It discusses its epidemiology, risk factors primarily affecting the elderly, clinical features, differential diagnosis, and investigative techniques. Treatment approaches vary based on patient age and ischemia signs, including endoscopic and surgical options, emphasizing the need for resuscitation and careful management to prevent complications.

1. SIGMOID VOLVULUS
GENERALISED ABDOMINAL PAIN
AN OVRVIEWDr.B.Selvaraj MS;Mch;FICS;
“Surgical Educator”
Malaysia

2. SIGMOID VOLVULUS
 Different causes for generalized abdominal pain
 Epidemiology
 Etiology- Risk Factors
 Pathology
 Clinical features- Symptoms & Signs
 Differential diagnosis
 Investigations
 Treatment
 Mindmap
 Diagnostic Algorithm
 Treatment Algorithm

3. SIGMOID VOLVULUS
D/D for Generalised Abdominal Pain

4. SIGMOID VOLVULUS
Epidemiology
 Volvulus occurs when a segment of colon
undergoes twisting along its own mesentery
(mesenterio-axial) resulting in obstruction.
 Twisting of 180 degrees results in clinical
obstruction, and further twisting to 360
degrees causes strangulation with venous
gangrene, ischemia, and eventual perforation.
 It is a closed loop obstruction
 Common in elderly and those who are taking
neuro-psychiatric drugs
 Sigmoid volvulus accounts for 5% of large
bowel obstruction in developed countries. and
10% to 50% in developing countries
 This is because of intake of high-fibre diet in
these countries
 Patients are often institutionalized and
debilitated due to underlying neurologic or
psychiatric disease and have a history of
constipation

5. SIGMOID VOLVULUS
ETIOLOGY-Risk Factors
 Higher incidence in developing countries (attributed
to high fiber diets)
 Seen mostly in elderly, institutionalized male with
chronic neuropsychiatric conditions
 Long pelvic mesocolon
 Narrow attachment of pelvic meso-colon
 Overloaded pelvic colon- constipation
 A loop of bowel fixed at its apex by adhesions.

6. SIGMOID VOLVULUS
PATHOLOGY
 The loop of sigmoid colon usually
undergoes twisting in an
anticlockwise direction from one
half to three turns.
 As the volvulized segment
enlarges, it becomes trapped in the
confines of the abdominal wall and
is unable to spontaneously detorse.

7. SIGMOID VOLVULUS
Clinical Features- Symptoms & Signs
SYMPTOMS
 Abdominal pain (initially
left-sided, later diffuse)
 Enormous abdominal
distension (left iliac fossa
and then whole of abdomen)
 Obstipation
 Hiccough, retching
 Vomiting- late feature
SIGNS
 Tympanic abdomen
 Tyre-like consistency of abdomen
is diagnostic
 Empty rectal vault (on digital
rectal exam)
 Just distension of abdomen
without tendernessViable
bowel
 Generalised tenderness with
rebound tenderness
Gangrenous bowel
 Rigid abdomen Bowel
perforation

8. SIGMOID VOLVULUS
Clinical Features- Symptoms & Signs

9. SIGMOID VOLVULUS
DIFFERENTIAL DIAGNOSIS
 Colorectal carcinoma causing
obstruction
 Toxic megacolon
 Colorectal strictures
 Hirschsprung's disease
 Caecal volvulus
 Paralytic ileus
 Ileosigmoid knotting
 Ogilvie's disease (colonic pseudo-
obstruction)- Dysfunction of Sacral
para-sympathetic nerves
 Acquired megacolon
 Giant colonic diverticulum

10. SIGMOID VOLVULUS
INVESTIGATIONS
 Blood tests : FBC, Serum
Electrolytes
 RFT: Blood urea&Creatinine
 AXR- Erect is diagnostic
- Coffee-bean appearance
- Bent-inner tube sign
-Omega sign
- Frimann-Dhal sign

11. SIGMOID VOLVULUS
INVESTIGATIONS
 Barium Enema:
- Bird’s beak appearance
- Ace of spade sign
 Upper end of Barium
column tapers into spirally-
twisted distal sigmoid colon

12. SIGMOID VOLVULUS
INVESTIGATIONS
 CT Abdomen:
- whirl sign, which represents
tension on the tightly twisted
mesocolon by the afferent and
efferent limbs of the dilated colon.

13. SIGMOID VOLVULUS
TREATMENT
Indication: Young patients without
signs of Ischemia
 Rigid/Flexible Sigmoidoscopy-
negotiate obstruction and
decompress proximal bowel
 Risk of recurrence >50%
 To prevent recurrence
-Percutaneous endoscopic
sigmoidopexy (Non-resectional)
- Mesosigmoidoplasty
-Sigmoid colectomy( Resectional)
Indication: Old patients with signs of
Ischemia
Exploratory laparotomy
 If bowel is viable
- Sigmoidopexy/Sigmoidectomy
 If bowel non-viable
- Paul-Mickulicz double barrel
colostomy
- Hartman’s procedure
 Never do primary anastomosis in an
emergency scenario for fear of
anastomotic leakage
CONSERVATIVE OPERATIVERESUSCITATION
-I.V.Fluids
-Antibiotics
-Bladder
Catheteris
ation

14. SIGMOID VOLVULUS
TREATMENT
Paul-Mickulicz Double
barrel Colostomy
Hartman’s temporary End-
Colostomy

15. SIGMOID VOLVULUS
MINDMAP

16. SIGMOID VOLVULUS
DIAGNOSTIC ALGORITHM

17. SIGMOID VOLVULS
TREATMENT ALGORITHM

18. Peripheral Arterial Diseases(PAD)