Sigmoid Volvulus — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] Ischemia/perforation/peritonitis?
   Any ischemia/perforation/peritonitis? (Sigmoid colon twisting on its mesenteric axis → closed-loop large bowel obstruction, the third most common cause of colonic obstruction; elderly men, chronic constipation, neuropsychiatric illness/bedbound, megacolon, prior abdominal surgery. Progressive distension + constipation/obstipation + colicky pain, vomiting is a late sign; severe pain/peritonitis = ischemia/perforation. Diagnosis: abdominal X-ray 'coffee-bean sign', CT 'whirl sign + bird-beak sign' (assess ischemia/perforation).)
   • Ischemia/perforation/peritonitis/failed endoscopic detorsion → Ischemia/perforation → emergency surgery
   • Uncomplicated (stable) → Uncomplicated · endoscopic detorsion + elective resection
2. [End] Uncomplicated · endoscopic detorsion + elective resection
   Uncomplicated (no ischemia/perforation/peritonitis): fluids, NG decompression; endoscopic detorsion/decompression (flexible sigmoidoscopy/colonoscopy) is first-line + place a rectal tube (gentle, minimal insufflation); high recurrence (40–70%) → elective sigmoid colectomy during the same admission to prevent recurrence (consider PEC in those unfit for surgery).
3. [End] Ischemia/perforation → emergency surgery
   Ischemia/perforation/peritonitis/failed endoscopic detorsion: emergency surgery (Hartmann's or sigmoid resection); preoperative aggressive resuscitation, NG decompression, broad-spectrum antibiotics; delay to bowel necrosis/perforation → sepsis with poor prognosis.

Source guidelines & references

• Sigmoid volvulus (colorectal emergency consensus; ASCRS)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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