Sigmoid Volvulus

You are the general surgery CT1 asked to see a 50-year old lady with a gradual onset of steady abdominal pain accompanied by episodic cramping pain over the past 2 days. She feels nauseous and has vomited a few times. Her abdomen is distended, and she has not passed wind for 24 hours. How would you proceed? 

Example answer introduction

IIn this scenario I would be most worried about a large bowel obstruction, although my differentials will include paralytic ileus, gastroenteritis, diverticulitis and colitis. I would assess this patient using an A-E approach, take a focused history and perform an abdominal examination. I would arrange further investigations to confirm my diagnosis depending on my clinical suspicions and escalate the surgical registrar.

Initial Assessment and Simultaneous Resuscitation

 

On arrival, manage the patient using an A to E approach according to the Advance Life Support algorithm.

  • Airway 

  • Breathing - check oxygen saturations, respiratory rate, listen to chest, assess work of breathing, breathing depth - if concerns  give high flow oxygen 

  • Circulation

    • Pulse, Blood pressure, capillary refill time, mucus membranes, skin turgor, fluid input/output, catheter is septic

    • IV access - large bore and bloods including CRP

    • Give fluid challenge of 250ml crystalloid solution if evidence of shock 

    • If suspecting bleeding, you may need to activate the Major Haemorrhage Protocol

  • Disability - GCS, pupillary response, blood sugar, temperature

  • Exposure - rashes, systemic signs of shock - expose the whole abdomen - there may be clues!!

 

During this acute phase state remember to provide constant reassessment

During initial assessment I would send bloods for FBC, U&E, LFTs, CRP, Lactate, Amylase, blood glucose, clotting studies, Group and Save and blood and urine cultures if spiking a temperature. 

Focused history​

  • Allergies

  • Medications - anticoagulants, antiplatelets

  • Past medical history – previous bowel surgery

  • Last meal

  • Events leading up to this point – nature of pain, nausea and vomiting, diarrhoea, constipation, weight loss, PR bleeding

Abdominal examination

  • Inspect – distention, surgical/traumatic scars, discolouration, hernia

  • Auscultate – decreased or absent bowel sounds

  • Palpate – Tenderness, guarding, rebound tenderness, peritonism

  • Percussion – Resonant, hyper-resonant

  • Digital rectal examination –melena/fresh blood, masses, external genitalia 

Example questions to progress the station

Q1 In this case what initial simple investigations might you order?

I would then request the following initial investigations: 

 

  • Bloods as above

  • Urine dip – looking for blood, leukocytes, nitrites, glucose, ketones

  • Abdominal x-ray – Evidence of bowel obstruction

  • Erect chest x-ray – Air under diaphragm signifying perforated viscus. 

 

Q2 Her abdomen is tender and distended with hyperresonant sounds on percussion. The x-rays come back showing the below. What is the diagnosis? 

PLEASE CLICK HERE FOR ABDOMINAL X-RAY

This is an abdominal plain film showing a segment of dilated large bowel displaying the ‘coffee bean’ sign signifying a volvulus. It appears to be arising from the right lower quadrant indicating that this is a caecal volvulus. 

Q3 - Why is the Chest X-ray relevant and what would your initial management be?

That a PA chest x-ray with normal appearances, in-particularly without air under the diaphragm which would signify perforated viscus. 

Initial management

  • Analgesia according to the WHO pain ladder

  • IV crystalloids and catheter to maintain urine output of 0.5ml/kg/hr 

  • Keep nil-by-mouth

  • Prep for theatre – P-POSSUM score. Inform surgical registrar, emergency theatre, anaesthetist on call. The possible procedures to treat this include:​

    • Flexible sigmoidoscopy​ + insertion of a flatus tube (may be performed in ED/Ward)

    • Rigid sigmoidoscopy + insertion of flatus tube (may be performed in ED/Ward)

    • Laparotomy 

  • VTE Prophylaxis

  • Keep patient and any relatives informed

  • Document, document, document!!!

Key additional points

 

Volvulus can appear as ‘coffee bean’ sign on abdominal x-rays. Sigmoid volvulus arises from the left lower quadrant whilst caecal volvulus arises from the right lower quadrant. If the ileocecal valve is incompetent, then there may also be signs of small bowel dilatation. The key point here is the knowledge that majority of sigmoid volvuli (60-70%) settle with conservative management – decompression with a flexible sigmoidoscope and insertion of a flatus tube, whilst caecal volvuli rarely settle with conservative management (<5%) therefore surgical management is advised. 

Escalation
This depends on severity of the case. 
The surgical Regestrar will need to be informed of all cases as they will likely need to perform a bedside sigmoidoscopy. 
Depending on the deterioration of the patient discussions with theatre staff, anaesthetics and ICU may be important. 
Useful Resources

Clinical Practice Guidelines for Colon Volvulus and Acute Colonic Pseudo-Obstruction

Management of Colonic Volvulus

Note: You may need an institutional or personal access to view some of these resources. Your medical education department or local NHS library may be able to help with access.
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