Volvulus (Adult)

1. Clinical Overview

Answer Card Summary

Volvulus is the twisting of a segment of bowel around its mesentery, causing closed-loop obstruction and vascular compromise with risk of ischaemia, gangrene, and perforation. It accounts for 3-5% of large bowel obstruction in Western countries but up to 50% in endemic regions (Africa, South America, Asia). [1,2]

Three main types:

• Sigmoid volvulus (60-80%): Elderly, chronic constipation, institutionalised patients
• Caecal volvulus (15-25%): Younger adults, mobile caecum (incomplete peritoneal fixation)
• Gastric volvulus (5-10%): Rare, associated with large hiatus hernia or diaphragmatic defects [3]

Classic presentations:

• Sigmoid: Massive abdominal distension, colicky pain, absolute constipation. "Coffee Bean" sign on AXR
• Caecal: Rapid-onset obstruction, RIF mass effect. "Kidney/Embryo" sign on AXR
• Gastric: Severe epigastric pain, inability to vomit (Borchardt's triad) [4]

Management principles:

• Sigmoid volvulus: Endoscopic decompression first-line if no peritonitis (70-90% success), followed by elective sigmoid colectomy (recurrence rate 40-70% without resection) [5]
• Caecal volvulus: Emergency laparotomy with right hemicolectomy (endoscopic derotation rarely successful) [6]
• Gangrenous bowel: Emergency resection ± Hartmann's procedure
• Mortality: 5-10% if treated early; 30-50% if gangrenous/perforated [7]

Clinical Pearls

"Coffee Bean" Sign: Massively dilated sigmoid loop arising from pelvis, extending to right upper quadrant, with haustra converging at point of twist (apex points away from origin). Highly specific for sigmoid volvulus. [8]

Sigmoid = Endoscopy First, Caecal = Surgery: This is a critical management distinction. Sigmoid volvulus responds well to flexible sigmoidoscopy with flatus tube placement. Caecal volvulus requires operative intervention due to anatomical inaccessibility and high failure rate of colonoscopic decompression. [9]

Recurrence is the Rule Without Resection: After successful endoscopic derotation of sigmoid volvulus, recurrence rates are 40-70% without definitive surgery. All fit patients should have elective sigmoid colectomy. [10]

Whirl Sign on CT: Twisted mesentery and vessels creating a "whirl" or "swirl" appearance is pathognomonic. CT also identifies bowel wall thickening, pneumatosis, non-enhancement (ischaemia), and free air (perforation). [11]

Chagas Disease Endemic Areas: In South America (especially Brazil, Bolivia, Argentina), Chagas disease causes megacolon from destruction of enteric neurons. Sigmoid volvulus incidence is 10-20× higher in endemic populations. [12]

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2. Epidemiology

Demographics and Distribution

Geographic Variation

Volvulus shows striking geographic variation: [1,13]

• Western countries: 3-5% of large bowel obstruction
• Africa (Ethiopia, Uganda, Kenya): 20-50% of LBO (high-fibre diet, altitude)
• South America (Brazil, Bolivia): 10-30% of LBO (Chagas disease megacolon)
• Middle East/Asia (Iran, India, Russia): 10-15% of LBO
• Scandinavia: Higher sigmoid volvulus rates than other Western countries

Incidence

• Overall colonic volvulus incidence: 2-3 per 100,000 population per year in Western countries [14]
• Sigmoid volvulus: 1.5-2.5 per 100,000/year
• Caecal volvulus: 0.5-1 per 100,000/year
• Endemic regions: Up to 50 per 100,000/year [15]

Risk Factors

Exam Detail: #### Sigmoid Volvulus Risk Factors [2,5,16]

Anatomical:

• Long, redundant sigmoid colon with narrow mesenteric base
• Elongated sigmoid mesentery (> 10 cm)
• Chronic megacolon (Chagas, idiopathic)

Functional/Lifestyle:

• Chronic constipation (most common modifiable factor)
• High-residue, high-fibre diet (bulky stool load)
• Institutionalisation (nursing homes, psychiatric facilities)
• Neuropsychiatric disease (Parkinson's, schizophrenia, dementia)
• Chronic laxative abuse
• Medications (opioids, anticholinergics)

Endemic Conditions:

• Chagas disease (Trypanosoma cruzi): Destroys myenteric plexus → megacolon → volvulus
• High altitude (lower atmospheric pressure, bowel distension)
• Hirschsprung's disease (adult presentation rare)

Caecal Volvulus Risk Factors [6,17]

Anatomical:

• Mobile caecum: Incomplete peritoneal fixation (embryologic non-descent)
• Long, mobile ascending colon
• Congenitally elongated mesentery

Acquired:

• Previous abdominal surgery (adhesions creating fixed points)
• Pregnancy (uterine mass displaces caecum)
• Distal colonic obstruction (causes proximal distension)
• Chronic pseudo-obstruction syndromes

Activity-related:

• Marathon running (vigorous peristalsis in mobile caecum)
• High-fibre diet (less consistent than sigmoid)

Gastric Volvulus Risk Factors [4]

Anatomical:

• Large hiatus hernia (> 5 cm)
• Diaphragmatic defects (congenital or traumatic)
• Eventration of diaphragm
• Paraesophageal hernia
• Gastric ligament laxity (gastrosplenic, gastrophrenic)

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3. Aetiology and Pathophysiology

Anatomical Prerequisites

For volvulus to occur, two anatomical conditions must be met: [18]

1. Long, mobile segment of bowel (redundant sigmoid, mobile caecum)
2. Narrow mesenteric base (predisposes to axial rotation)

Mechanism of Volvulus Formation

Exam Detail: Stage 1: Mesenteric Twist

• Bowel segment rotates around its longitudinal mesenteric axis
• Rotation typically clockwise (when viewed from above)
• Degree of twist: Usually 180-360°; can be up to 720° in severe cases

Stage 2: Closed-Loop Obstruction

• Twist occludes lumen at two points (proximal and distal to twist)
• Closed-loop = segment isolated from rest of bowel
• Continued secretion + gas production → massive distension
• Intraluminal pressure rises progressively

Stage 3: Vascular Compromise

• Venous obstruction first (veins compressed before arteries)

  • Venous drainage impaired → venous congestion
  • Bowel wall oedema → haemorrhagic infarction
  • Mucosal breakdown → bacterial translocation

• Arterial obstruction (if twist tight or prolonged)

  • Arterial supply cut off → ischaemia
  • Progression to gangrene (12-24 hours)

Stage 4: Perforation and Peritonitis

• Necrotic bowel wall ruptures
• Faecal peritonitis (sigmoid) or purulent peritonitis (caecal)
• Septic shock and death without emergency surgery

Types of Volvulus by Segment

Sigmoid Volvulus

Anatomy:

• Normal sigmoid mesentery: 5-8 cm base
• Volvulus-prone sigmoid: > 10 cm redundant loop, less than 5 cm mesenteric base
• "Inverted V" mesentery predisposes to axial twist

Pathophysiology: [5]

• Bulky stool load in redundant sigmoid → Increased weight and momentum
• Peristaltic wave → Rotation around narrow mesenteric pedicle
• Closed-loop obstruction at two points (rectosigmoid junction and sigmoid-descending colon junction)
• Massive distension (up to 20-30 cm diameter)
• Ischaemia develops in 20-30% of cases

Caecal Volvulus

Variants: [6,17]

1. Caecal volvulus (axial twist) (80%)

   • Caecum and terminal ileum twist together
   • Rotation around ileocolic vascular pedicle
   • Usually counterclockwise twist
   • Caecum displaced to left upper quadrant or central abdomen

2. Caecal bascule (20%)

   • Caecum folds anteriorly and superiorly (no axial twist)
   • "Bascule" = see-saw in French
   • Less vascular compromise (no mesenteric twist)
   • Obstruction primarily mechanical

Pathophysiology:

• Incomplete embryologic fixation → Mobile caecum
• Fixed point distally (adhesion, mass) → Fulcrum for rotation
• Occlusion of ileocaecal valve → competent valve = closed loop
• Rapid distension (ileal reflux impossible)
• Ischaemia in 20-25% at presentation

Gastric Volvulus

Classification by Axis: [4,41]

Gastric volvulus is classified by the axis of rotation, which determines clinical presentation, complications, and management approach:

1. Organoaxial (59-67%)

   • Definition: Rotation around longitudinal axis connecting cardia to pylorus
   • Direction: Stomach rotates anteriorly along long axis (clockwise when viewed from left)
   • Mechanism: Greater curve flips upward and forward, lesser curve moves downward and posterior
   • Degree: Usually 180-270° rotation; can reach 360° in severe cases
   • Anatomical associations:
     • Paraesophageal hiatus hernia (most common - 60-70% of cases) [42]
     • Traumatic diaphragmatic hernia
     • Diaphragmatic eventration
     • Congenital diaphragmatic defects
   • Obstruction pattern: Both GOJ and pylorus obstructed simultaneously
   • Ischaemia risk: HIGH (mesenteric vessels kinked with rotation) - 15-25% at presentation [43]
   • Clinical presentation: Acute onset, severe symptoms, high complication rate
   • Borchardt's triad: Present in 70-80% (see below)

2. Mesenteroaxial (29-38%)

   • Definition: Rotation around perpendicular axis (bisects lesser and greater curves)
   • Direction: Antrum and pylorus rotate anteriorly and upward (vertical flip)
   • Mechanism: Cardia and fundus remain relatively fixed; antrum/body twist around horizontal axis
   • Degree: Typically 90-180° rotation
   • Anatomical associations:
     • Gastric ligament laxity (gastrosplenic, gastrophrenic, gastrocolic) [44]
     • Loss of normal gastrophrenic attachments
     • Splenic abnormalities (splenomegaly, wandering spleen)
     • Congenital short gastric vessels
   • Obstruction pattern: Partial obstruction (GOJ less affected, pylorus compressed)
   • Ischaemia risk: LOWER (vessels less kinked) - 5-10% [43]
   • Clinical presentation: Chronic/recurrent symptoms, intermittent, less acute
   • Borchardt's triad: Present in only 30-40%

3. Combined/Mixed (3-10%)

   • Both organoaxial and mesenteroaxial components
   • Most complex, highest surgical difficulty
   • Often associated with large diaphragmatic defects [45]

Pathophysiological Mechanisms:

Anatomical Prerequisites for Gastric Volvulus: [46]

Four ligamentous attachments normally prevent gastric rotation:

1. Gastrohepatic ligament (lesser omentum): Fixes lesser curve to liver
2. Gastrosplenic ligament: Fixes greater curve to spleen
3. Gastrophrenic ligament: Fixes fundus to diaphragm
4. Gastrocolic ligament: Fixes stomach to transverse colon

Volvulus occurs when ≥2 ligaments fail/are lax (congenital or acquired).

Acute Organoaxial Volvulus Pathophysiology: [4,47]

Stage 1: Initial Rotation (0-6 hours)

• Stomach rotates anteriorly around cardiopyloric axis
• GOJ and pylorus both obstructed (closed-loop obstruction)
• Gastric contents trapped
• Intragastric pressure rises rapidly (normal 5 mmHg → 20-40 mmHg)
• Attempted vomiting ineffective (obstruction at both ends)

Stage 2: Vascular Compromise (6-24 hours)

• Rising intraluminal pressure compresses submucosal veins first
• Venous obstruction → Mucosal congestion, oedema, haemorrhage
• Short gastric vessels and left gastric artery kinked by rotation
• Arterial insufficiency develops if rotation \u003e180°
• Gastric wall ischaemia begins (fundus most vulnerable)

Stage 3: Necrosis (24-48 hours)

• Transmural ischaemia → Gastric necrosis
• Typically affects fundus first (most dependent on short gastric vessels)
• Mural oedema → 3-5× wall thickening
• Haemorrhagic infarction, mucosal sloughing

Stage 4: Perforation (\u003e48 hours)

• Necrotic gastric wall ruptures
• Gastric perforation into peritoneal cavity or mediastinum (if intrathoracic)
• Chemical and bacterial peritonitis
• Septic shock, multiorgan failure
• Mortality 30-50% if perforated [48]

Chronic Mesenteroaxial Volvulus:

• Intermittent partial volvulus (twists and untwists)
• Recurrent postprandial epigastric pain
• Chronic gastric outlet obstruction symptoms
• Lower ischaemia risk (partial rotation, spontaneous resolution)
• May progress to acute-on-chronic presentation

Borchardt's Triad (1904): [49]

Classic clinical triad of acute gastric volvulus (first described by German surgeon Ludwig Borchardt):

1. Severe, sudden-onset epigastric pain

   • Visceral pain from gastric distension and ischaemia
   • Often described as "tearing" or "ripping"
   • Radiation to left shoulder (phrenic nerve irritation)

2. Violent retching with inability to vomit (pathognomonic)

   • Patient has urge to vomit but cannot produce vomitus
   • May produce small amounts of saliva/mucus only
   • "Dry heaves" despite severe nausea
   • Results from GOJ obstruction (vomitus cannot escape)

3. Inability to pass nasogastric tube (or extreme difficulty)

   • NG tube meets resistance at GOJ (twist point)
   • May pass initially then coil in obstructed stomach
   • Do not force NG tube (perforation risk in ischaemic stomach)

Clinical Significance of Borchardt's Triad:

• Present in 70-80% of acute organoaxial volvulus [4]
• Only 30-40% of mesenteroaxial volvulus (less complete obstruction)
• High specificity (95%) but moderate sensitivity (50-70%) [50]
• Absence does NOT exclude diagnosis (especially chronic/partial volvulus)
• Presence mandates urgent imaging (high pre-test probability)

Additional Clinical Features:

• Hiccups (phrenic nerve irritation) - common early sign
• Upper abdominal distension (especially epigastrium)
• Succussion splash (fluid in obstructed stomach)
• Tympany over epigastrium/left upper quadrant

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4. Clinical Presentation

Symptoms

Clinical Pearl: "History of Recurrent Episodes": Up to 50% of sigmoid volvulus patients report previous episodes of abdominal pain and distension that spontaneously resolved (spontaneous derotation). This is rare in caecal volvulus. [19]

Signs

Examination Findings by Type

Sigmoid Volvulus:

• Distension maximal in left lower quadrant extending to right upper quadrant
• Tympanic, resonant abdomen
• "Empty" feel on palpation despite massive distension (gas, no solid mass)
• Rectal examination: Empty vault, no blood (unless ischaemia)

Caecal Volvulus:

• Mass effect right iliac fossa or displaced to left upper quadrant/central
• Less dramatic distension than sigmoid
• May have resonant RIF (gas-filled caecum)
• Tenderness over mass

Gastric Volvulus:

• Epigastric distension and tenderness
• Borchardt's triad (classic - present in 70-80% of acute organoaxial, 30-40% mesenteroaxial): [4,49,50]
  1. Severe epigastric pain (sudden onset, "tearing" quality)
  2. Violent retching without productive vomiting (pathognomonic "dry heaves")
  3. Inability to pass nasogastric tube (resistance at GOJ twist point)
• Additional signs:
  • Persistent hiccups (phrenic nerve irritation)
  • Succussion splash (fluid in obstructed stomach)
  • Epigastric tympany (gas-filled dilated stomach)
  • Decreased/absent bowel sounds (ileus from severe pain)

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5. Differential Diagnosis

Exam Detail: ### Key Differentials with Distinguishing Features

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6. Investigations

Immediate (Emergency Department)

Blood Tests

Clinical Pearl: Lactate is the Key: Serum lactate > 4 mmol/L has 90% sensitivity for bowel ischaemia in volvulus. Rising lactate despite resuscitation mandates emergency laparotomy. [23]

Imaging

Abdominal X-Ray (AXR)

Sigmoid Volvulus Classic Signs: [8,24]

1. "Coffee Bean" Sign (80-90% sensitivity)

   • Massively dilated sigmoid loop (> 6-10 cm diameter)
   • Arises from pelvis (left lower quadrant)
   • Extends upward to right upper quadrant
   • Central "cleft" where walls of distended loop appose
   • Resembles coffee bean or "bent inner tube"

2. Frimann-Dahl Sign

   • Three dense lines converge at site of twist (inferior aspect)
   • Represents apposed walls of twisted sigmoid

3. Loss of Haustrations

   • Smooth outline (extreme distension effaces haustra)

4. Apex Points Away from Origin

   • Sigmoid origin = LLQ, apex points to RUQ (180° rotation)

Caecal Volvulus Classic Signs: [17]

1. "Kidney/Embryo/Comma" Sign

   • Dilated caecum in ectopic position (LUQ or central abdomen)
   • Displaced from normal RIF position
   • Oval or kidney-shaped gas shadow

2. Small Bowel Dilatation

   • Dilated terminal ileum and small bowel (competent ileocaecal valve)

3. Single Air-Fluid Level

   • In RUQ or central (unlike sigmoid with multiple levels)

4. "Bird's Beak" (on contrast enema)

   • Contrast column tapers at site of twist
   • Resembles bird's beak

Gastric Volvulus:

• Double air-fluid level (if mesenteroaxial)
• Distended stomach in chest (if organoaxial with hiatus hernia)
• Abnormal gastric axis on upright CXR (stomach bubble in unusual position)

Advanced Imaging: CT for Gastric Volvulus [11,25,51,52]

CT is Gold Standard for gastric volvulus (sensitivity 95-100%, specificity 95-100%).

Pathognomonic CT Findings:

1. Gastric Whirl Sign (85-90% of cases) [51]

   • Twisted gastric wall and mesentery spiralling around axis
   • Similar to colonic whirl but involves stomach
   • Best seen on axial images at level of GOJ/pylorus
   • Type-specific appearances:
     • Organoaxial: Whirl at cardiopyloric axis (longitudinal)
     • Mesenteroaxial: Whirl perpendicular to long axis (horizontal)

2. Transition Point (100% sensitivity)

   • Abrupt change in stomach orientation
   • "X" configuration: GOJ and pylorus cross each other (organoaxial)
   • Duodenum superior to antrum (mesenteroaxial - abnormal relationship)

3. Abnormal Gastric Positioning

   • Organoaxial: Pylorus above or at same level as GOJ (normal = pylorus inferior)
   • Mesenteroaxial: Antrum in left upper quadrant or mediastinum

4. Gastric Distension Pattern

   • Massive gastric dilatation (10-20 cm diameter)
   • Fluid-debris level (obstructed gastric contents)
   • Dual gastric chamber (if complete 360° rotation) - rare pathognomonic sign

CT Signs of Complication (Ischaemia/Necrosis): [52,53]

CT Additional Information:

• Identifies cause: Paraesophageal hernia, diaphragmatic defect, ligament laxity
• Hernia characteristics: Type (sliding vs paraesophageal), size, contents
• Surgical planning: Defines anatomy for operative approach

Upper GI Contrast Study (Water-Soluble): [54]

Indications (CT often preferred):

• If CT unavailable or equivocal
• Chronic/recurrent symptoms (intermittent volvulus)
• Do NOT use barium (aspiration risk, contamination if perforation)

Findings:

• Organoaxial:

  • Stomach inverted (fundus below antrum on lateral view)
  • "Upside-down stomach"
  • GOJ and pylorus at similar horizontal level
  • Contrast flows "upward" from GOJ to body/pylorus

• Mesenteroaxial:

  • Horizontal orientation of stomach
  • Bird's beak at point of twist
  • Antrum anterior to fundus (reversed relationship)

• Obstruction:

  • Delayed gastric emptying
  • Contrast pooling in dilated stomach
  • Narrowing/cut-off at twist point

Endoscopy (Diagnostic and Therapeutic): [55]

Indications:

• Acute presentation (attempted decompression)
• Unclear diagnosis (CT non-diagnostic)
• Assessment of mucosal viability
• Therapeutic derotation

Findings:

• Spiral/twisted gastric mucosa (endoscope follows corkscrew path)
• Resistance at twist point (30-40 cm from incisors for organoaxial)
• Retroflexed view abnormal (anatomical disorientation)
• Mucosal ischaemia signs: Dusky, cyanotic, ulcerated mucosa (ominous - do NOT attempt derotation)
• J-maneuver impossible (cannot retroflex normally)

Contraindications to Endoscopy:

• Peritonitis (prefer laparotomy)
• CT evidence of gangrene/perforation
• Haemodynamic instability

CT Abdomen/Pelvis (Gold Standard) [11,25]

Advantages over AXR:

• Confirms diagnosis with near 100% sensitivity/specificity
• Identifies exact site and nature of twist
• Assesses bowel viability (ischaemia markers)
• Detects complications (perforation, free air, abscess)
• Evaluates underlying pathology (mass, adhesions)

CT Findings:

Clinical Pearl: "Whirl Sign" is Diagnostic: Seeing the whirl sign on CT is diagnostic of volvulus and indicates the exact site. This appears as mesenteric vessels and fat swirling around a central point. It is seen in sigmoid, caecal, and small bowel volvulus. [11]

Contrast Enema (Water-Soluble)

Indications: (Rarely used now; CT preferred)

• If AXR equivocal and CT unavailable
• Diagnostic uncertainty

Findings:

• "Bird's Beak" sign: Contrast column tapers at site of twist
• "Ace of Spades" sign: Sigmoid volvulus proximal to twist

Contraindications:

• Peritonitis (perforation risk)
• Haemodynamic instability

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7. Management

Initial Resuscitation (All Patients)

Immediate Steps: [27]

1. IV Access: Two large-bore cannulas (14-16G)
2. Fluid Resuscitation: Crystalloid (Hartmann's, 0.9% NaCl). Goal: Urine output > 0.5 mL/kg/h, MAP > 65 mmHg
3. NBM (Nil By Mouth)
4. NG Tube: If vomiting (reduces aspiration risk, decompresses stomach)
5. Urinary Catheter: Monitor fluid balance
6. Analgesia: Opiates (IV morphine) ± antiemetics
7. Bloods: FBC, U&E, lactate, G&S, ABG
8. Imaging: AXR + CT abdomen/pelvis
9. Antibiotics: If sepsis or planned surgery (co-amoxiclav 1.2 g IV or cefuroxime 1.5 g + metronidazole 500 mg)
10. Surgical Referral: Immediate review by general/colorectal surgery

Clinical Pearl: "Drip and Suck": The old surgical adage. IV fluids ("drip") and NG decompression ("suck") are temporising measures while preparing for definitive management. They do NOT treat volvulus but stabilise the patient.

Assessment for Emergency Surgery

Indications for Immediate Laparotomy: [5,6]

1. Clinical peritonitis: Rebound tenderness, guarding, rigidity
2. Shock: Persistent hypotension despite resuscitation
3. Elevated lactate (> 4 mmol/L) or rising lactate
4. CT signs of ischaemia/gangrene: Mural non-enhancement, pneumatosis, portal venous gas
5. Pneumoperitoneum (free air): Perforation
6. Systemic sepsis (SIRS, septic shock)

Proceed to Type-Specific Management if NO emergency indications:

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Sigmoid Volvulus Management

Non-Gangrenous Sigmoid Volvulus (No Peritonitis)

First-Line: Endoscopic Decompression [5,28]

Technique (Flexible Sigmoidoscopy):

1. Patient position: Left lateral
2. Flexible sigmoidoscope advanced to point of obstruction (twist at rectosigmoid or sigmoid-descending junction)
3. Gentle air insufflation and scope advancement through twist
   • Often feel/hear "pop" as twist releases
   • Rush of gas and liquid stool confirms derotation
4. Flatus tube placement: Soft rectal tube (size 28-32 Fr) advanced 20-25 cm into sigmoid
   • Secures decompression
   • Prevents early re-twisting
   • Leave in situ 24-48 hours

Success Rate: 70-90% [5]

Contraindications to Endoscopic Derotation:

• Peritonitis
• Haemodynamic instability
• CT evidence of gangrene/ischaemia
• Pneumoperitoneum

Post-Decompression Management:

• Admit for observation (24-48 hours)
• Monitor for recurrence (abdominal examination, bloods)
• Bowel preparation for elective surgery
• Offer elective sigmoid colectomy (see below)

Clinical Pearl: "Derotation is Not Definitive": Endoscopic derotation is a bridge to surgery, not curative treatment. Recurrence occurs in 40-70% without resection. [10] All fit patients should be offered elective sigmoid colectomy during same admission or within 2-4 weeks.

Elective Sigmoid Colectomy (After Successful Decompression)

Indications: [29]

• All fit patients after endoscopic derotation
• Prevents recurrence (reduces from 40-70% to less than 5%)

Timing:

• Same admission (preferred): After bowel preparation, within 2-7 days
• Delayed (2-4 weeks): If patient not fit, co-morbidities require optimisation

Procedure:

• Sigmoid colectomy with primary anastomosis (colorectal/anterior resection)
• Resect redundant sigmoid and narrow mesenteric base
• Laparoscopic approach preferred (if expertise available)

Outcomes:

• Mortality: less than 2% (elective)
• Recurrence: less than 5% [29]

Gangrenous Sigmoid Volvulus / Failed Endoscopic Decompression

Emergency Laparotomy [7,30]

Intraoperative Findings:

• Gangrenous sigmoid: Black, friable, non-viable bowel
• Perforation: Faecal contamination, peritonitis

Surgical Options:

1. Hartmann's Procedure (Most Common for Gangrenous) [30]

   • Sigmoid resection (remove volvulus segment and non-viable bowel)
   • End colostomy (descending colon brought out as stoma)
   • Rectal stump closure (oversewn or stapled)
   • Stoma reversal after 3-6 months (if patient fit)
   • Preferred if: Haemodynamic instability, faecal contamination, significant co-morbidities

2. Primary Resection and Anastomosis (Selected Cases)

   • Sigmoid colectomy with colorectal anastomosis
   • Indications: Stable patient, minimal contamination, viable bowel ends, no significant co-morbidities
   • Intraoperative colonic lavage may be performed
   • Higher anastomotic leak risk (10-15%) vs Hartmann's but avoids stoma [31]

3. Subtotal Colectomy (Rare)

   • If synchronous pathology (pan-colonic disease, megacolon)
   • Ileorectal or ileosigmoid anastomosis

Outcomes:

• Mortality (gangrenous): 20-30%
• Mortality (perforated): 30-50% [7]

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Caecal Volvulus Management

Definitive Treatment: Surgery (Right Hemicolectomy) [6,17]

Why NOT Endoscopic Decompression?

• Colonoscopic decompression success rate less than 30% (caecum in ectopic position, difficult access)
• High early recurrence (> 50% within days)
• Not recommended as first-line [9]

Surgical Approaches

Emergency Laparotomy Indications:

• All caecal volvulus (unless prohibitive surgical risk)
• Ischaemia, gangrene, perforation: Immediate surgery

Operative Management:

1. Right Hemicolectomy (Preferred) [6]

   • Resection: Terminal ileum, caecum, ascending colon ± hepatic flexure
   • Anastomosis: Ileo-transverse (side-to-side or end-to-side)
   • Advantages: Definitive, removes pathology, recurrence less than 2%
   • Mortality: 5-10% (non-gangrenous), 20-30% (gangrenous)

2. Cecopexy (Limited Role)

   • Fixing caecum to lateral abdominal wall or retroperitoneum
   • Only if: Non-viable surgical candidate, bowel viable, no resection possible
   • Recurrence: 10-30% (high) [17]
   • Not recommended in current practice

3. Detorsion Alone (Not Recommended)

   • Manually untwisting caecum without fixation
   • Recurrence: 40-50%
   • Reserved only for palliative intent

Gangrenous Caecal Volvulus:

• Right hemicolectomy with ileostomy (if unstable or contaminated)
• Anastomosis deferred (damage control surgery)
• Restoration of continuity at later date

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Gastric Volvulus Management

\u003cExamDetail\u003e

Gastric volvulus management is tailored to acuity, type, and viability. The decision tree involves endoscopic vs surgical approaches, laparoscopic vs open surgery, and choice of gastropexy technique.

Classification of Presentation [56]

1. Acute Gastric Volvulus (\u003c48 hours)

   • Sudden onset, severe symptoms
   • Borchardt's triad often present
   • High ischaemia risk (15-25% organoaxial, 5-10% mesenteroaxial)
   • Management: Emergency - endoscopic decompression + urgent surgery

2. Chronic Gastric Volvulus (\u003e48 hours, recurrent)

   • Intermittent symptoms, recurrent episodes
   • Spontaneous resolution common
   • Lower ischaemia risk
   • Management: Elective surgical repair

3. Acute-on-Chronic

   • Chronic volvulus with acute exacerbation
   • Previous episodes of self-resolving symptoms
   • Management: As per acute (emergency)

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Acute Gastric Volvulus: Initial Management [4,57]

Step 1: Resuscitation and Assessment

1. IV access: 2× large-bore cannulas
2. Fluid resuscitation: Crystalloid (Hartmann's, 0.9% NaCl) - target MAP \u003e65 mmHg
3. NBM (nil by mouth)
4. Analgesia: IV opiates (morphine 5-10 mg) + antiemetics (ondansetron 4-8 mg)
5. NG tube attempt: Try gentle insertion
   • If resistance: DO NOT force (perforation risk) - mark NG contraindicated
   • If passes: Decompress stomach (reduces pressure, aspiration risk)
   • Document: Distance to resistance (helps confirm GOJ obstruction)
6. Bloods: FBC, U\u0026E, lactate, CRP, G\u0026S, ABG
7. Imaging: CT abdomen/chest (gold standard - see above)
8. Surgical referral: Immediate upper GI/general surgery consult

Step 2: Risk Stratification

Indications for IMMEDIATE Laparotomy (Bypass Endoscopy): [58]

• Clinical peritonitis: Rebound, guarding, rigidity
• Haemodynamic instability: Shock despite resuscitation (SBP \u003c90 mmHg)
• CT signs of gangrene: Mural non-enhancement, pneumatosis, portal venous gas
• Pneumoperitoneum: Free air = perforation
• Systemic sepsis: SIRS, septic shock (qSOFA ≥2)
• Lactate \u003e4 mmol/L: High suspicion of ischaemia

Proceed to Endoscopic Decompression if NO emergency indications

---

Endoscopic Derotation and Decompression [55,59,60]

Technique:

1. Preparation:

   • Informed consent (explain success rate 60-80%, perforation risk 2-5%)
   • IV sedation (midazolam + fentanyl) or general anaesthesia (if high risk)
   • Monitoring: Continuous SpO₂, ECG, BP
   • Endoscopy suite or operating theatre

2. Endoscope Insertion:

   • Flexible gastroscope (adult upper GI scope)
   • Advance with minimal insufflation (reduce gastric distension)
   • Identify twist point: Spiral mucosa, luminal narrowing
   • Assess mucosa: Look for ischaemia (dusky, cyanotic, ulcerated = STOP)

3. Derotation:

   • Organoaxial:
     • Advance scope through twist with gentle rotation
     • Clockwise rotation of scope often helps negotiate twist
     • "Pop" or sudden give as twist releases
     • Rush of gas/fluid confirms derotation
   • Mesenteroaxial:
     • More difficult (horizontal twist plane)
     • May require change in patient position (left lateral → supine)
     • Advance scope to antrum, gently push to reduce upward displacement

4. Decompression:

   • Aspirate gastric contents (fluid, food, debris)
   • Allow gas escape (decompress stomach to \u003c5 cm diameter)
   • Irrigate and inspect: Assess mucosa for ischaemia post-derotation

5. Secure Position:

   • NG tube placement (after successful derotation)
   • Leave on free drainage for 24-48 hours
   • Prevents re-accumulation, monitors ongoing output

Success Rates: [60,61]

Complications of Endoscopy: [59]

• Perforation: 2-5% (higher if ischaemic mucosa)
• Aspiration: 1-2% (during sedation)
• Bleeding: \u003c1% (mucosal trauma)
• Failed derotation: 20-40% (then requires surgery)

Post-Decompression Management:

• Admit to surgical ward (HDU if unstable)
• NBM for 24 hours (allow gastric rest)
• NG on free drainage (monitor output, prevent re-distension)
• Serial monitoring: 4-hourly obs, daily lactate, repeat exam
• Plan definitive surgery: Within same admission (see below)

\u003cClinicalPearl\u003e

Endoscopic Derotation is NOT Curative: Like sigmoid volvulus, endoscopic decompression of gastric volvulus is a temporising bridge to surgery. Recurrence without definitive repair approaches 80-90%. [60] All patients require surgical gastropexy unless prohibitive risk.

\u003c/ClinicalPearl\u003e

---

Definitive Surgical Management

Timing of Surgery: [62]

1. Emergency (0-6 hours): Peritonitis, gangrene, perforation, shock
2. Urgent (24-72 hours): After successful endoscopic decompression, stable patient
3. Elective (\u003c2-4 weeks): Chronic/recurrent volvulus, delayed presentation

Surgical Approach: Laparoscopic vs Open [63,64]

Laparoscopic Approach (Preferred if Suitable):

Advantages:

• Reduced postoperative pain
• Shorter hospital stay (3-5 days vs 7-10 days)
• Faster recovery (2-3 weeks vs 6-8 weeks)
• Excellent visualization of hiatus and diaphragm
• Lower wound infection rate
• Better cosmesis

Indications for Laparoscopy:

• Stable patient (elective or urgent, not emergency)
• No peritonitis or free perforation
• Chronic or acute-on-chronic volvulus without gangrene
• Hiatus hernia-associated volvulus (ideal scenario)

Contraindications to Laparoscopy (Require Open):**

• Haemodynamic instability
• Gangrenous stomach (high perforation risk during manipulation)
• Large perforations with contamination
• Multiple previous upper abdominal surgeries (dense adhesions)
• Inability to tolerate pneumoperitoneum (severe cardiopulmonary disease)

Open Approach:

Indications:

• Emergency laparotomy for gangrene/perforation
• Failed laparoscopic approach (conversion rate 5-15%) [64]
• Extensive adhesions
• Complex diaphragmatic defect repair

Incisions:

• Midline laparotomy (most common - excellent access)
• Left subcostal (if isolated gastric volvulus)
• Thoracoabdominal (if large intrathoracic component)

---

Surgical Procedures for Gastric Volvulus [65,66]

Goals of Surgery:

1. Reduction of volvulus (detorsion)
2. Resection if gangrenous
3. Gastropexy (fix stomach to prevent recurrence)
4. Repair anatomical defect (hernia, diaphragm)
5. Fundoplication if GORD present

---

1. Reduction (Detorsion)

Technique:

• Identify anatomy: Locate GOJ, pylorus, greater curve
• Manual detorsion:
  • Organoaxial: Rotate stomach posteriorly (reverse anterior rotation)
  • Mesenteroaxial: Pull antrum inferiorly (reduce upward flip)
• Decompress stomach: NG aspiration or needle decompression (if very tense)
• Assess viability: Inspect gastric wall for necrosis

Viability Assessment: [67]

---

2. Gastrectomy (if Gangrenous) [68]

Indications:

• Gastric necrosis (black, non-viable tissue)
• Perforation with necrotic edges
• Failure to improve after detorsion

Extent of Resection:

• Partial gastrectomy: Remove gangrenous portion (usually fundus/body)
• Subtotal gastrectomy: If extensive necrosis
• Total gastrectomy: Rarely needed (pan-gastric necrosis)

Reconstruction:

• Roux-en-Y gastrojejunostomy (if partial/subtotal)
• Roux-en-Y oesophagojejunostomy (if total gastrectomy)
• Feeding jejunostomy (nutritional access during recovery)

Outcomes:

• Mortality: 30-50% (gangrenous gastric volvulus) [48]
• Morbidity: Anastomotic leak (5-10%), sepsis, prolonged ileus

---

3. Gastropexy (Primary Procedure if Viable) [69,70]

Principle: Fix stomach to anterior abdominal wall to prevent re-rotation.

Types of Gastropexy:

a) Anterior Gastropexy (Most Common) [69]

Technique:

1. Reduction of volvulus
2. Position stomach anatomically (greater curve inferior, lesser curve superior)
3. Suture fixation:
   • Anterior gastric wall (body or antrum, 5-10 cm from greater curve)
   • To anterior abdominal wall peritoneum (left upper quadrant)
   • Non-absorbable sutures (2-0 or 0 silk, Prolene)
   • 3-5 interrupted sutures in two rows
   • Tension-free (avoid ischaemia)

Laparoscopic Technique:

• Transgastric T-fasteners (commercial kits available)
• Intracorporeal suturing (2-0 Prolene)
• Tack fixation (helical tacks through gastric wall to abdominal wall)

Advantages:

• Simple, quick (15-20 minutes)
• Low morbidity
• Effective (recurrence \u003c5%) [70]

Disadvantages:

• Does not address hiatus hernia (if present)
• No anti-reflux component

b) Gastropexy with Fundoplication (Nissen/Toupet) [71,72]

Indications:

• Gastric volvulus associated with large paraesophageal hernia
• GORD symptoms pre-existing or anticipated post-repair
• Organoaxial volvulus (high hiatus hernia association)

Nissen Fundoplication Technique: [73]

1. Reduction of hernia contents:

   • Reduce stomach into abdomen
   • Excise hernia sac (if large)

2. Oesophageal mobilization:

   • Mobilize distal oesophagus (4-5 cm intra-abdominal length)
   • Divide short gastric vessels (create "floppy" fundus)

3. Hiatus repair:

   • Crural closure: Approximate right and left crura
   • Non-absorbable sutures (0 Ethibond, Prolene)
   • Interrupted figure-of-eight sutures posterior to oesophagus
   • Narrow hiatus to 2.5-3 cm (accommodate oesophagus + NG tube)

4. Fundoplication:

   • Mobilize gastric fundus (divide short gastrics if not already done)
   • Wrap fundus 360° around distal oesophagus ("floppy" 2-3 cm wrap)
   • Suture fundus to itself anteriorly (3-4 interrupted 2-0 silk)
   • Include anterior oesophagus in bites (prevent migration)
   • "Shoe-shine" maneuver: Fundus wraps smoothly around oesophagus

5. Gastropexy (inherent in Nissen):

   • Fundoplication anchors stomach to oesophagus
   • Crural repair anchors oesophagus to hiatus
   • Result: Stomach cannot rotate (fixed to immobile oesophagus/diaphragm)

Toupet Fundoplication (Alternative): [74]

• 270° posterior wrap (vs 360° Nissen)
• Lower dysphagia rate (5-10% vs 15-20% Nissen)
• Preferred if: Pre-existing dysphagia, oesophageal dysmotility, elderly

Advantages of Fundoplication + Hiatus Repair:

• Addresses underlying cause (paraesophageal hernia in 60-70%)
• Prevents GORD (common after simple gastropexy)
• Lower recurrence (hiatus reconstructed)
• Comprehensive repair (one procedure fixes hernia + volvulus + reflux)

Disadvantages:

• Longer operative time (90-120 min vs 45-60 min simple gastropexy)
• Higher dysphagia rate (10-20% early, 5-10% long-term)
• Requires divided short gastrics (anatomical alteration)

Outcomes of Nissen + Gastropexy: [72,75]

• Recurrence rate: \u003c2% (excellent)
• GORD control: 85-95%
• Dysphagia (long-term): 5-10%
• Mortality (elective): \u003c1-2%
• Satisfaction: 85-90%

\u003cClinicalPearl\u003e

Nissen Fundoplication is Gold Standard for Hiatus Hernia-Associated Gastric Volvulus: The combination of crural repair + Nissen fundoplication achieves three goals: (1) reduces and repairs hernia, (2) prevents recurrent volvulus (stomach fixed to oesophagus), and (3) prevents GORD. This is the definitive operation for organoaxial volvulus with paraesophageal hernia. [71,73]

\u003c/ClinicalPearl\u003e

c) Gastrostomy Tube Gastropexy [76]

Technique:

• Percutaneous endoscopic gastrostomy (PEG) or surgical gastrostomy
• Tube anchors stomach to anterior abdominal wall
• Prevents rotation

Indications:

• High-risk patients unable to tolerate formal surgery
• Palliative intent (prevent re-volvulus but not curative)
• Chronic volvulus in debilitated patients

Advantages:

• Minimal invasiveness
• Can be done under local anaesthesia + sedation
• Provides feeding access

Disadvantages:

• High recurrence (15-30%) - less secure than suture gastropexy [76]
• Does not address hernia
• Tube-related complications (infection, migration, blockage)

---

4. Collis Gastroplasty (Advanced Technique) [77]

Indication:

• Short oesophagus (cannot achieve 2-3 cm intra-abdominal oesophagus)
• Common in large chronic paraesophageal hernias

Technique:

• Lengthen oesophagus by creating gastric tube along lesser curve
• Collis-Nissen: Gastroplasty + Nissen fundoplication around neo-oesophagus

---

5. Mesh Repair (Controversial) [78]

Technique:

• Prosthetic mesh to reinforce crural closure
• Used if large hiatus defect (\u003e5 cm) or weak crura

Indications:

• Recurrent hernia after previous repair
• Very large defects (\u003e8-10 cm)

Controversy:

• Risk of mesh erosion into oesophagus/stomach (1-5%)
• Dysphagia from fibrosis
• Most surgeons avoid mesh in elective gastric volvulus repair

---

Postoperative Management [79]

Immediate (0-24 hours):

• HDU/ICU if emergency surgery or high-risk patient
• NBM for 24-48 hours (allow gastric rest)
• NG tube on free drainage (remove when output \u003c200 mL/24h, usually day 2-3)
• IV fluids (maintenance + replace NG losses)
• Analgesia (PCA or epidural if open)
• Early mobilization (reduce VTE risk)

Days 1-3:

• Water-soluble contrast swallow (day 2-3 post-fundoplication)
  • Confirm no leak
  • Assess passage through wrap (exclude tight wrap)
• Start clear fluids if swallow normal
• Advance to soft diet day 3-4

Days 4-7:

• Full liquid diet then soft diet (if fundoplication - avoid solid for 4-6 weeks)
• Remove NG tube
• Monitor for complications (dysphagia, bloating, dumping)

Discharge (Day 5-7 laparoscopic, 7-10 open):

• Dietary advice:
  • Small frequent meals (6-8 per day)
  • Avoid carbonated drinks (gas bloat syndrome)
  • Eat slowly, chew thoroughly
  • Soft diet for 4-6 weeks (if fundoplication)
• Activity: Avoid heavy lifting \u003e5 kg for 6 weeks
• Medications:
  • PPI (lansoprazole 30 mg od) for 6-8 weeks (reduce oedema)
  • Laxatives (prevent constipation/straining)
• Follow-up: Outpatient clinic 2-4 weeks

Long-Term (3-12 months):

• Return to normal diet by 6-8 weeks
• PPI wean: Trial off PPI at 3 months (85-90% can stop)
• Monitor for recurrence symptoms (unlikely if proper repair)

---

\u003c/ExamDetail\u003e

Gastric Volvulus Outcomes and Prognosis [48,75,80]

Mortality:

Recurrence:

Long-Term Quality of Life:

• Excellent after elective laparoscopic repair (90% satisfaction) [75]
• Dysphagia in 10-20% early, 5-10% long-term (post-fundoplication)
• GORD control 85-95% (if fundoplication performed)
• Most patients return to normal diet and activity by 8-12 weeks

---

8. Complications

Early Complications (Perioperative)

Late Complications

Clinical Pearl: Preventing Recurrence is Key: The single most important intervention to prevent recurrence of sigmoid volvulus is elective sigmoid colectomy. This reduces recurrence from 40-70% to less than 5%. [10,29]

---

9. Prognosis and Outcomes

Mortality

Overall Mortality by Type and Timing: [7,34]

Prognostic Factors

Poor Prognosis: [34,35]

• Age > 70 years
• Delayed presentation (> 24-48 hours)
• Bowel gangrene/perforation
• Elevated lactate (> 4 mmol/L)
• Significant co-morbidities (ASA ≥3)
• Hartmann's procedure (proxy for disease severity)

Good Prognosis:

• Early diagnosis (less than 24 hours)
• Successful endoscopic decompression + elective resection
• Viable bowel at laparotomy
• Younger, fit patients

Long-Term Outcomes

After Sigmoid Colectomy:

• Excellent quality of life (most patients)
• Bowel frequency: 1-3× per day (acceptable)
• Recurrence: less than 5% [29]

After Right Hemicolectomy for Caecal Volvulus:

• Normal bowel function (ileo-colic anastomosis well-tolerated)
• Recurrence: less than 2% [6]
• Potential for mild diarrhoea (10-15% patients)

After Hartmann's Procedure:

• Stoma reversal rate: 40-60% (many elderly patients never have reversal) [30]
• Quality of life: Lower with permanent stoma, but acceptable in elderly population

---

10. Prevention

Primary Prevention

Modifiable Risk Factors: [36]

1. Manage Chronic Constipation:

   • High-fibre diet (paradoxically, moderate fibre; excessive fibre may worsen in endemic areas)
   • Adequate hydration
   • Laxatives (osmotic: lactulose, macrogol)
   • Avoid chronic stimulant laxative abuse

2. Optimise Neuropsychiatric Medications:

   • Review medications causing constipation (opioids, anticholinergics)
   • Consider alternatives with less constipating effects

3. Chagas Disease Screening (Endemic Areas):

   • Screen at-risk populations
   • Antiparasitic treatment (benznidazole, nifurtimox) in acute phase
   • Prevents progression to megacolon

Secondary Prevention (Prevent Recurrence)

After Sigmoid Volvulus Decompression: [10,29]

• Elective sigmoid colectomy (gold standard)
  • "Timing: Same admission or within 2-4 weeks"
  • Reduces recurrence from 40-70% to less than 5%
• If patient unfit for surgery:
  • Aggressive constipation management
  • Avoid precipitants (high-bulk meals, constipating medications)
  • Low threshold for repeat endoscopic decompression

After Caecal Volvulus:

• Right hemicolectomy is curative (recurrence less than 2%)
• Cecopexy has high recurrence (avoid if possible)

---

11. Evidence and Guidelines

Key Guidelines

Landmark Studies

Exam Detail: 1. Halabi WJ et al. (2014) [1]

• Study: National analysis of sigmoid volvulus in USA (23,000+ cases)
• Findings: Mortality 6.5% overall, 22% if gangrenous. Elective resection after decompression had lowest mortality (1.9%).
• Conclusion: Endoscopic decompression + elective resection is optimal strategy.

2. Atamanalp SS et al. (2013) [2]

   • Study: Meta-analysis of 4,000+ sigmoid volvulus cases
   • Findings: Recurrence after endoscopic decompression alone: 40-70%. Recurrence after resection: less than 5%.
   • Conclusion: Elective sigmoid colectomy mandatory to prevent recurrence.

3. Ballantyne GH et al. (1985) [17]

   • Study: Review of caecal volvulus management
   • Findings: Right hemicolectomy: Recurrence less than 2%, mortality 10-20%. Cecopexy: Recurrence 10-30%.
   • Conclusion: Right hemicolectomy is procedure of choice.

4. Madiba TE et al. (2002) [39]

   • Study: Prospective study of sigmoid volvulus in South Africa (endemic region)
   • Findings: Emergency resection mortality 10%. Hartmann's safer than primary anastomosis in gangrenous cases.
   • Conclusion: Hartmann's preferred for unstable/contaminated cases.

5. Swenson BR et al. (2012) [40]

   • Study: Colonic volvulus outcomes in USA (16-year data)
   • Findings: Mortality: Non-gangrenous 5%, gangrenous 25%. Delay > 24h doubled mortality.
   • Conclusion: Early diagnosis and intervention critical.

---

12. Patient and Layperson Explanation

What is Volvulus?

A volvulus happens when part of your bowel twists around itself, like a twisted rope or balloon. This twisting blocks the bowel and can cut off its blood supply. The most common types are:

• Sigmoid volvulus: The lower part of your large bowel (sigmoid colon) twists
• Caecal volvulus: The first part of your large bowel (caecum) twists

What Causes It?

Volvulus usually happens in people with:

• Chronic constipation (most common)
• Extra-long bowel that can twist more easily
• Older age (60-80 years for sigmoid volvulus)
• Certain medications that slow the bowel (strong painkillers)

What are the Symptoms?

The main symptoms are:

• Severe tummy pain (cramping, colicky)
• Massive bloating (abdomen swells up dramatically)
• Unable to pass wind or poo (complete blockage)
• Vomiting (usually later on)

These symptoms need urgent hospital assessment.

Is it Serious?

Yes, volvulus is a surgical emergency. If not treated:

• The twisted bowel can lose its blood supply and die (gangrene)
• The bowel can burst (perforation), causing severe infection
• This can be life-threatening

How is it Diagnosed?

• X-ray: Shows characteristic patterns ("coffee bean" shape for sigmoid volvulus)
• CT scan: Shows the twist in detail and checks if the bowel is damaged

How is it Treated?

For Sigmoid Volvulus:

1. Endoscopy first (if bowel not damaged):

   • A flexible camera (sigmoidoscope) is passed into your back passage
   • The doctor gently untwists the bowel and releases the blockage
   • A tube is left in place to keep it untwisted for 1-2 days
   • Success rate: 70-90%

2. Surgery later:

   • Even if the endoscopy works, the volvulus often comes back (40-70% chance)
   • We recommend surgery to remove the twisted section (sigmoid colectomy)
   • This prevents it happening again
   • Usually done a few days after the endoscopy, once you're stable

For Caecal Volvulus:

• Surgery is needed (endoscopy doesn't work well for this type)
• Operation removes the twisted section (right hemicolectomy)
• The bowel is joined back together

If the Bowel is Damaged:

• Emergency surgery is needed immediately
• We remove the damaged section
• You may need a temporary bag (stoma) on your tummy to collect poo while you heal
• The stoma can often be reversed after 3-6 months

What are the Risks?

• If treated early (within 24 hours): Excellent outcomes, low risk
• If delayed or bowel damaged: Higher risk (10-30% mortality if gangrenous)
• Recurrence: High (40-70%) if only endoscopy done, very low (less than 5%) after surgery

Recovery

• After endoscopy: 2-3 days in hospital, then plan for surgery
• After surgery: 5-10 days in hospital, 4-6 weeks to full recovery
• Most people do very well after surgery and don't have problems again

Key Takeaway

Volvulus is serious but treatable. Seek urgent medical help if you have severe tummy pain and bloating. Early treatment prevents complications. Surgery is usually needed to stop it coming back.

---

13. Examination Focus

High-Yield Viva Questions and Model Answers

Exam Detail: #### Question 1: "Describe the classic X-ray finding in sigmoid volvulus."

Model Answer: "The classic finding is the 'Coffee Bean' sign. This is a massively dilated sigmoid loop, typically 6-10 cm or more in diameter, that arises from the pelvis in the left lower quadrant and extends upward to the right upper quadrant. There is a central 'cleft' where the medial walls of the distended loop appose, giving it the appearance of a coffee bean or bent inner tube. The haustra are typically lost due to extreme distension. Another sign is the Frimann-Dahl sign, where three dense lines converge inferiorly at the site of the twist. CT imaging is more sensitive and shows the 'whirl sign'—a spiral of twisted mesentery and vessels at the point of torsion. This is pathognomonic of volvulus." [8,11]

Question 2: "What is the first-line management for non-gangrenous sigmoid volvulus?"

Model Answer: "The first-line management is endoscopic decompression using flexible sigmoidoscopy. The patient is positioned in the left lateral position, and the sigmoidoscope is gently advanced to the point of obstruction. With careful air insufflation and advancement, the twist can often be negotiated. Successful derotation is confirmed by a rush of gas and liquid stool. A flatus tube (size 28-32 Fr) is then placed 20-25 cm into the sigmoid to maintain decompression and prevent early re-twisting.

This is successful in 70-90% of cases and is the recommended initial approach if there are no signs of peritonitis, ischaemia, or perforation.

However, endoscopic decompression is only a temporising measure. The recurrence rate without definitive surgery is 40-70%. Therefore, all fit patients should be offered elective sigmoid colectomy during the same admission or within 2-4 weeks to prevent recurrence. This reduces the recurrence rate to less than 5%." [5,10,29]

Question 3: "Why is endoscopic decompression not effective for caecal volvulus?"

Model Answer: "Endoscopic decompression is rarely successful for caecal volvulus for several anatomical and practical reasons:

1. Anatomical location: The caecum is located in the right iliac fossa or, in volvulus, may be displaced to the left upper quadrant or central abdomen. This is proximal and often out of reach of a flexible sigmoidoscope, and even colonoscopy has difficulty accessing a twisted, malpositioned caecum.

2. Low success rate: Colonoscopic derotation has a success rate of less than 30% for caecal volvulus, compared to 70-90% for sigmoid volvulus.

3. High recurrence: Even if colonoscopic decompression is successful, the recurrence rate is over 50% within days to weeks.

4. Definitive treatment available: Right hemicolectomy is highly effective, has a recurrence rate of less than 2%, and definitively treats the underlying anatomical problem (mobile caecum).

Therefore, surgical resection (right hemicolectomy) is the recommended first-line treatment for caecal volvulus, except in patients with prohibitive surgical risk." [6,9,17]

Question 4: "What are the indications for emergency laparotomy in volvulus?"

Model Answer: "Emergency laparotomy is indicated when there are signs of bowel ischaemia, gangrene, or perforation:

Clinical indications:

1. Peritonitis: Localised tenderness, rebound, guarding, rigidity
2. Haemodynamic instability: Persistent hypotension/shock despite resuscitation
3. Systemic sepsis: SIRS criteria, septic shock

Biochemical: 4. Elevated lactate: > 4 mmol/L suggests bowel ischaemia; rising lactate despite resuscitation mandates surgery

Imaging findings: 5. Pneumoperitoneum (free air): Indicates perforation 6. CT signs of gangrene: Bowel wall thickening > 5 mm, pneumatosis intestinalis, portal venous gas, mural non-enhancement on contrast CT 7. Mesenteric signs: Extensive mesenteric stranding, free fluid

Failed endoscopic decompression in sigmoid volvulus is also an indication for urgent (though not necessarily emergency) surgery.

The most important single marker is serum lactate > 4 mmol/L, which has 90% sensitivity for bowel ischaemia." [5,23,27]

Question 5: "Compare and contrast Hartmann's procedure vs primary anastomosis for gangrenous sigmoid volvulus."

Model Answer:

In practice, Hartmann's is more commonly performed for gangrenous sigmoid volvulus, as these patients are typically elderly, unstable, and contaminated. Primary anastomosis can be considered in younger, stable patients with minimal contamination, but requires careful patient selection." [30,31,39]

Question 6: "What is the 'whirl sign' and what does it indicate?"

Model Answer: "The 'whirl sign' is a CT imaging finding that is pathognomonic for volvulus. It represents the twisted mesentery and mesenteric vessels spiralling around a central axis at the point of torsion. On axial CT, this appears as a swirling or spiral configuration of fat and vessels, resembling a whirl or pinwheel.

Key features:

• Seen in approximately 80% of volvulus cases on CT [11]
• Can be seen in sigmoid volvulus, caecal volvulus, small bowel volvulus, and gastric volvulus
• Indicates the exact location of the twist
• Confirms the diagnosis with near 100% specificity

Clinical significance: The presence of a whirl sign confirms volvulus and guides management. It is more sensitive and specific than plain radiography (AXR) for diagnosis." [11,25]

Question 7: "What is Borchardt's triad in gastric volvulus?"

Model Answer: "Borchardt's triad describes the classic clinical presentation of acute gastric volvulus, first described by German surgeon Ludwig Borchardt in 1904. It consists of three features: [49,50]

1. Severe, sudden-onset epigastric pain - visceral pain from gastric distension and ischaemia, often described as "tearing" or "ripping", may radiate to left shoulder from phrenic nerve irritation

2. Violent retching with inability to vomit (pathognomonic) - patient has intense urge to vomit but cannot produce vomitus, may produce only small amounts of saliva or mucus ("dry heaves"), results from gastro-oesophageal junction obstruction preventing vomitus escape

3. Inability to pass a nasogastric tube - NG tube meets resistance at the GOJ twist point, may pass initially then coil in obstructed stomach, forcing the tube risks perforation in ischaemic stomach

Clinical Significance:

• Present in 70-80% of acute organoaxial volvulus [4]
• Only 30-40% of mesenteroaxial volvulus (less complete obstruction)
• High specificity (95%) but moderate sensitivity (50-70%) [50]
• Absence does NOT exclude diagnosis, especially in chronic or partial volvulus
• Presence mandates urgent CT imaging (high pre-test probability of acute volvulus)

Additional features include persistent hiccups from phrenic nerve irritation, succussion splash, and epigastric tympany." [49,50]

Question 8: "Compare organoaxial versus mesenteroaxial gastric volvulus."

Model Answer: "Gastric volvulus is classified by the axis of rotation: [41,44]

Key Clinical Distinction: Organoaxial volvulus is a true surgical emergency with high ischaemia risk due to mesenteric vessel kinking, while mesenteroaxial tends to be chronic and recurrent with lower immediate risk but still requires definitive repair to prevent progression." [41,43,44]

Question 9: "What are the key CT findings in gastric volvulus and their significance?"

Model Answer: "CT is the gold standard for diagnosing gastric volvulus with 95-100% sensitivity and specificity. [51,52]

Pathognomonic Findings:

1. Gastric Whirl Sign (85-90% of cases)

   • Twisted gastric wall and mesentery spiralling around axis
   • Organoaxial: whirl at longitudinal cardiopyloric axis
   • Mesenteroaxial: whirl perpendicular to long axis
   • Similar to colonic whirl sign

2. Transition Point (100% sensitivity)

   • Abrupt change in stomach orientation
   • 'X' configuration: GOJ and pylorus cross each other (organoaxial)
   • Duodenum superior to antrum (mesenteroaxial - abnormal)

3. Abnormal Gastric Positioning

   • Pylorus at same level or above GOJ (normal = inferior)
   • Antrum in left upper quadrant or mediastinum

CT Signs of Ischaemia/Gangrene (mandate immediate surgery): [52,53]

• Gastric wall thickening \u003e5 mm (oedema, venous congestion)
• Loss of mural stratification (transmural oedema)
• Pneumatosis (gas in gastric wall - mucosal necrosis)
• Portal venous gas (advanced ischaemia, poor prognosis)
• Lack of mural enhancement (arterial insufficiency, gangrene)
• Pneumoperitoneum (perforation - immediate laparotomy)

CT also identifies underlying cause (paraesophageal hernia 60-70%, diaphragmatic defect) and guides surgical planning for operative approach." [51,52,53]

Question 10: "Describe the surgical management of gastric volvulus associated with a large paraesophageal hernia. Why is Nissen fundoplication the gold standard?"

Model Answer: "For gastric volvulus associated with large paraesophageal hernia (60-70% of organoaxial cases), the gold standard is laparoscopic reduction + crural repair + Nissen fundoplication. [71,72,73]

Surgical Technique:

1. Reduction of hernia contents: Reduce stomach into abdomen, excise hernia sac if large

2. Oesophageal mobilization: Create 4-5 cm intra-abdominal oesophageal length, divide short gastric vessels for 'floppy' fundus

3. Crural repair: Approximate right and left crura posteriorly with non-absorbable interrupted figure-of-eight sutures (0 Ethibond), narrow hiatus to 2.5-3 cm to accommodate oesophagus plus NG tube

4. Nissen fundoplication: Wrap mobilized fundus 360° around distal oesophagus (2-3 cm 'floppy' wrap), suture fundus to itself anteriorly with 3-4 interrupted 2-0 silk sutures including anterior oesophagus

5. Gastropexy (inherent): Fundoplication anchors stomach to oesophagus; crural repair anchors oesophagus to hiatus; result is stomach cannot rotate (fixed to immobile structures)

Why Nissen Fundoplication is Gold Standard: [71,73,75]

The combination achieves three therapeutic goals simultaneously:

1. Reduces and repairs hernia: Crural closure reconstructs hiatus, prevents re-herniation

2. Prevents recurrent volvulus: Stomach is permanently fixed to oesophagus (immobile structure), gastropexy effect without additional sutures, recurrence rate \u003c2% (vs \u003c5% simple gastropexy)

3. Prevents GORD: 360° wrap creates competent GOJ, controls reflux in 85-95%, addresses common post-gastropexy complication

Outcomes:

• Recurrence: \u003c2% (excellent)
• GORD control: 85-95%
• Dysphagia: 10-20% early, 5-10% long-term
• Mortality (elective): \u003c1-2%
• Patient satisfaction: 85-90%

Alternative: Toupet 270° posterior fundoplication has lower dysphagia rate (5-10%) and is preferred if pre-existing dysphagia or oesophageal dysmotility. [74]

This comprehensive approach is definitive and addresses all aspects of the pathology in a single operation." [71,72,73,75]

Question 11: "What are the indications for immediate laparotomy versus endoscopic decompression in gastric volvulus?"

Model Answer: "The decision between immediate laparotomy versus endoscopic decompression in gastric volvulus depends on clinical stability and CT findings. [57,58]

Indications for IMMEDIATE Laparotomy (bypass endoscopy):

1. Clinical peritonitis: Rebound tenderness, guarding, rigidity
2. Haemodynamic instability: Shock despite resuscitation (SBP \u003c90 mmHg), persistent tachycardia
3. CT signs of gangrene: Mural non-enhancement, pneumatosis (gas in gastric wall), portal venous gas
4. Pneumoperitoneum: Free air indicates perforation
5. Systemic sepsis: SIRS criteria, septic shock (qSOFA ≥2)
6. Elevated lactate \u003e4 mmol/L: High suspicion of bowel ischaemia

Proceed to Endoscopic Decompression if:

• Stable haemodynamics
• No peritonitis
• CT shows volvulus without ischaemia/gangrene signs
• Lactate \u003c4 mmol/L

Endoscopic Approach: [55,59,60]

• Flexible gastroscopy under sedation or GA
• Advance through twist with gentle rotation (clockwise for organoaxial)
• Assess mucosal viability (if dusky/cyanotic/ulcerated - STOP, requires surgery)
• Decompress and aspirate gastric contents
• Place NG tube on free drainage post-derotation

Success Rates:

• Acute organoaxial: 60-70%
• Acute mesenteroaxial: 70-80%
• Complications: Perforation 2-5%, aspiration 1-2%

Critical Point: Endoscopic derotation is NOT definitive treatment. Recurrence without surgery is 80-90%. [60] All patients require definitive surgical gastropexy within same admission unless prohibitive surgical risk. Think of it as a bridge to surgery, not curative therapy - similar principle to sigmoid volvulus management." [55,57,58,60]

Question 12: "A 72-year-old patient has successful endoscopic derotation of acute organoaxial gastric volvulus. What is your post-decompression management plan?"

Model Answer: "After successful endoscopic derotation, the management plan focuses on stabilization and definitive surgical repair to prevent recurrence. [60,62,79]

Immediate Post-Decompression (0-24 hours):

1. Admission: Surgical ward or HDU (if unstable)
2. NBM: Nil by mouth for 24-48 hours (allow gastric rest)
3. NG tube: Keep on free drainage (prevents re-distension, monitor output)
4. IV fluids: Maintenance crystalloid + replace NG losses
5. Serial monitoring:
   • 4-hourly observations (BP, HR, temperature)
   • Daily lactate (ensure downtrending)
   • Repeat clinical examination (watch for peritonitis)
6. Analgesia: Regular paracetamol ± opiates
7. VTE prophylaxis: LMWH unless contraindicated

Days 1-3:

8. Surgical planning: Arrange definitive surgery within same admission
9. Optimize comorbidities: Cardiology input if needed, physiotherapy
10. Consent: Discuss laparoscopic gastropexy + fundoplication + hiatus repair

Definitive Surgery (Days 2-7):

Procedure: Laparoscopic Nissen fundoplication + crural repair (gold standard for organoaxial with hernia) [71]

Timing: Urgent/semi-elective within 2-7 days after decompression

Why Surgery is Mandatory:

• Recurrence after endoscopic derotation alone: 80-90% [60]
• Recurrence after Nissen + gastropexy: \u003c2% [75]
• This is a large paraesophageal hernia-associated volvulus (60-70% of organoaxial), so Nissen addresses hernia + volvulus + GORD prevention

If Patient Refuses/Unfit for Surgery:

• PEG gastropexy as palliative option (tube anchors stomach) - recurrence 15-30% [76]
• Aggressive counselling on recurrence risk (80-90%)
• Low threshold for emergency representation

Key Principle: Endoscopic derotation is a temporising measure, not curative. Without surgery, recurrence is almost inevitable. The definitive operation must be performed during same admission while patient is stable." [60,62,71,75,79]

Common Exam Pitfalls

1. "Endoscopic decompression cures sigmoid volvulus": FALSE. Recurrence is 40-70% without resection. Always plan for elective surgery.

2. "Caecal volvulus should be managed like sigmoid volvulus": FALSE. Caecal volvulus requires surgery (right hemicolectomy), not endoscopy.

3. "Cecopexy is an acceptable treatment for caecal volvulus": FALSE. Recurrence is 10-30%. Right hemicolectomy is gold standard.

4. "Normal lactate excludes bowel ischaemia": FALSE. Lactate may be normal in early ischaemia. Serial lactates and clinical assessment are key.

5. "Always do primary anastomosis after sigmoid volvulus resection": FALSE. Hartmann's is safer in gangrenous/perforated cases with shock/sepsis.

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14. Related Topics and Further Reading

Prerequisites

• Large Bowel Obstruction
• Acute Abdomen Assessment
• Bowel Anatomy (Mesenteric Attachments)

Related Conditions

• Bowel Ischaemia and Infarction
• Peritonitis
• Pseudo-obstruction (Ogilvie's Syndrome)
• Toxic Megacolon
• Colorectal Cancer (differential for LBO)

Advanced Topics

• Chagas Disease and Megacolon
• Small Bowel Volvulus
• Midgut Volvulus (paediatric)
• Damage Control Surgery

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