Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction

Patient Guideline Summary

Publication Date: August 31, 2021

Last Updated: March 3, 2023

Objective

This patient summary means to discuss key recommendations from the American Society of Colon and Rectal Surgeons (ASCRS) for the management of colonic volvulus and acute colonic pseudo-obstruction. It is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

We will use the abbreviation ACPO throughout this summary to refer to acute colonic pseudo-obstruction.

Colonic volvulus describes the twisting of a loop of the large bowel that obstructs the flow of its contents and threatens its blood supply. ACPO occurs when flow in the large bowel stops without a physical obstruction.

Causes of colonic volvulus include a cancer mass and a floppy loop of the bowel. Colonic volvulus can occur anywhere in the large bowel.
- Sigmoid volvulus usually occurs in elderly men in poor health.
- Cecal volvulus most often occurs in younger women.
ACPO is the result of a failure of the nerves that regulate bowel motion and occurs mainly in acutely ill elderly patients.

Symptoms of both conditions include abdominal pain, bloating, nausea, vomiting, and altered bowel function.

Complications — dead bowel, perforation, sepsis, shock, and death — are guaranteed unless the obstruction is relieved and the blood supply is restored.

This patient summary focuses on the management of both volvulus and psuedo-obstruction.

Diagnosis

Colonic Volvulus

The initial evaluation should include a focused history, physical examination, and basic laboratory assessment.
In stable patients, colonic volvulus is often initially evaluated with plain abdominal x-rays.
Computed tomography (CT) imaging may be used to confirm the diagnosis.

Treatment

Because recurrence is common, treatment includes the prevention of repeated episodes.
High-risk patients require urgent treatment. They have unstable blood pressure and evidence of perforation or peritonitis (infection in the abdomen).

Sigmoid Volvulus

Patients with uncomplicated volvulus should typically undergo colonoscopy (looking inside the colon with a flexible telescope) to assess sigmoid colon viability, untwist the anatomy and decompress the colon.

Urgent surgical sigmoid resection (removal) is indicated when endoscopic untwisting of the sigmoid colon fails and in cases of a dead or perforated colon.

Patients who undergo successful endoscopic detorsion (untwisting) should be considered for sigmoid colectomy during the same hospital admission to prevent recurrent volvulus.
- Other methods of preventing recurrence are available for frail patients, but they are inferior to the removal of the sigmoid colon.

Cecal Volvulus

Segmental resection is the preferred treatment for patients with cecal volvulus.

Acute Colonic Pseudo-Obstruction

The initial evaluation should include a focused history and physical examination, baseline laboratory values, and diagnostic imaging.

Initial treatment of ACPO is supportive and includes eliminating or correcting conditions that predispose patients to ACPO or prolong its course.

Pharmacologic treatment with neostigmine is indicated when ACPO does not resolve with supportive therapy.

Endoscopic colonic decompression should be considered in patients with ACPO in whom neostigmine therapy is contraindicated (unsafe) or ineffective.

Surgical treatment is recommended for ACPO complicated by colon ischemia (inadequate blood supply) or perforation or ACPO refractory (unresponsive) to pharmacologic and endoscopic therapies.

Abbreviations

ACPO: Acute Colonic Pseudo-obstruction
ASCRS: American Society Of Colon And Rectal Surgeons
CT: Computed Tomography

Source Citation

Alavi K, Poylin V, Davids JS, Patel SV, Felder S, Valente MA, Paquette IM, Feingold DL; Prepared on behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction. Dis Colon Rectum. 2021 Sep 1;64(9):1046-1057. doi: 10.1097/DCR.0000000000002159. PMID: 34016826.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.