Sigmoid Volvulus
It represents 60-75% of colon volvulus cases, usually this is presented as "a nursing home or debilitated elderly patient presenting to the ER with constipation, abdominal distention and generalized abdominal pain. The x-ray shows distal large bowel obstruction, with large sigmoidal loop reaching the umbilical area.
The management is simple and straightforward:
If the patient has signs of peritonitis, laparotomy should be done urgently.
If no peritoneal irritation signs exist, Gastrografin enema can help in diagnosing borderline cases but is certainly contraindicated if any suspicion of dead bowel is present, sigmoidoscopy with attempt to pass a rectal tube is a safe option to proceed with and should be done.
If successful, keep the rectal tube in place, admit the patient, prep the bowel over 2-3 days and do elective sigmoid resection with primary anastomosis (the recurrence rate without the surgery is almost 90%).
If the sigmoidoscopy fails to decompress and de-torse the sigmoid, do laparotomy and inspect the sigmoid. If viable, de-torse it and pass a rectal tube from the anus and close. Prep the bowel over 2-3 days and re-operate for elective sigmoid resection. If the sigmoid is ischemic on laparotomy, do sigmoid resection with colostomy and MF or Hartmann's pouch.
Cecal Volvulus
It represents 25 - 40 % of colon volvulus cases, this is usually presented to you in a younger patient with "chronic constipation problem", coming to the ER for constipation, abdominal distention and pain. The x-ray shows distal small bowel obstruction with dilated cecum in LUQ and very small distal colon. Again, if the patient has peritonitis signs he/she goes to the OR.
Gastrografin enema could confirm the diagnosis in borderline cases but it has to be done carefully.
Colonoscopy has very low success rate in cecal volvulus compared to sigmoid volvulus and carriers a little more potential risks of rupture.
The patient should be admitted and taken to OR for right hemicolectomy with primary anastomosis regardless of the cecum condition after detorsion (viable or not) unless you are concerned about the viability of the cut ends of the bowel , then, an ileostomy and mucus fistula are performed.
In general, Cecopexy results in these setting have been disappointing.