Volvulus and bowel twist: when the gut rotates on itself

Volvulus and Bowel Obstruction: When the Intestine Twists on Itself

In everyday speech "twisted bowel" is used for bowel obstruction, meaning that bowel contents cannot pass on. Volvulus is one specific cause of obstruction, where the bowel twists on itself. The two are not the same: all volvulus causes obstruction, but far from all obstruction is caused by volvulus. Volvulus is a state where a section of the intestine twists around itself or its mesentery (the tissue that attaches the intestine to the abdominal wall). This twisting cuts off both the passage of intestinal contents and the blood supply. It is an acute condition that can lead to tissue death within hours if not treated. Fortunately, in many cases, it can be resolved without surgery if caught early.

Volvulus most commonly affects the sigmoid colon (the lower part of the large intestine just before the rectum) or the caecum (the first part of the large intestine). In infants, a particularly dangerous variant called midgut volvulus is seen, often due to congenital malrotation.

What are the symptoms?

Symptoms often appear rapidly and are characteristic:

• Sudden, severe abdominal pain, often colicky
• Significant abdominal distension, "like a drum"
• Cessation of both bowel movements and passing gas
• Nausea and vomiting
• Rapid pulse, fever, and general malaise in advanced stages
• In older individuals: confusion, dehydration, low blood pressure

If the blood supply to the twisted segment of the intestine is cut off for long enough, the intestinal wall dies. This leads to perforation, peritonitis (inflammation of the abdominal lining), and circulatory collapse. The time factor is crucial.

Sigmoid volvulus is most often seen in older individuals, particularly in nursing homes, in those with chronic constipation, and in patients with neurological diseases (Parkinson's, dementia, spinal cord injuries). Many have experienced milder episodes over the years with spontaneous untwisting.

Why does it happen?

The intestine can twist if two conditions are present: a long, mobile segment of the intestine and a narrow attachment to the posterior abdominal wall (mesentery). Factors that increase the risk include:

• Chronic constipation which lengthens and stretches the sigmoid colon
• High-fibre diet over years combined with poor motility
• Neurological diseases with weak intestinal transport
• Previous abdominal surgery with adhesions
• Pregnancy which displaces the intestine
• Congenital malrotation in children (midgut volvulus)
• Mobile caecum (a caecum that is not fixed) in caecal volvulus

Geographically, sigmoid volvulus is particularly common in countries with high-fibre diets and high altitudes ("volvulus belt"), such as Ethiopia, Iran, and Peru. In Denmark, it is less common but regularly seen in elderly institutionalised patients.

How is it diagnosed?

Diagnosis is often made quickly in the emergency department:

1. Clinical examination: distended, drum-like abdomen with absent bowel sounds
2. Erect abdominal X-ray shows the classic "coffee bean sign" in sigmoid volvulus or a large air-filled loop
3. CT scan of the abdomen is now standard. It clearly shows the twist, the "whirl sign" around the mesenteric vessels, and signs of ischaemia or perforation
4. Endoscopy (sigmoidoscopy) is used for both diagnosis and treatment of sigmoid volvulus

Blood tests may show elevated lactate and leukocytes in cases of ischaemia.

Treatment

Treatment depends on the location and whether the intestine is viable.

Sigmoid volvulus without ischaemia:

• The first choice is endoscopic detorsion (untwisting) via sigmoidoscopy or colonoscopy
• After untwisting, a soft tube is inserted past the twist to keep the intestine empty
• The success rate of endoscopic treatment is 60-90 percent
• Recurrence is common after endoscopic detorsion without subsequent resection (reported as frequent in published case series, with wide variation between reports), so elective sigmoid resection during the hospital stay is recommended to prevent a new acute attack

Caecal volvulus:

• Endoscopic untwisting is rarely successful
• Surgery is usually necessary: either right hemicolectomy or fixation of the caecum (caecopexy)

Acute ischaemia or perforation:

• Emergency surgery to remove the dead bowel segment
• Often a temporary stoma
• Intensive monitoring due to the risk of septic shock

Midgut volvulus in infants:

• Emergency surgery (Ladd procedure). Every minute counts.

When should you seek medical attention?

Call 112 for reduced consciousness, collapse, signs of circulatory collapse or another life-threatening deterioration.

Contact the acute medical helpline (1813 in the Capital Region of Denmark, otherwise your local out-of-hours doctor) straight away and ask for urgent hospital assessment for:

• Sudden, severe abdominal pain with a bloated abdomen
• Cessation of both bowel movements and passing gas for several hours
• Vomiting that does not provide relief
• Abdominal pain accompanied by fever, dizziness, or a feeling of collapse

In a nursing home resident or an elderly patient with chronic constipation, a distended abdomen is an acute condition until proven otherwise. It is better to have it assessed one time too many.

A small child with severe vomiting, especially with green (bile) vomit, should be taken to the hospital immediately. Midgut volvulus is a surgical emergency.

Frequently Asked Questions

Can bowel obstruction occur spontaneously? Yes, and that's what makes the condition insidious. Many older individuals have had milder episodes over the years that resolved on their own. When it "locks up" once, they typically present acutely.

Is it the same as an ileus? Volvulus is a form of ileus (bowel obstruction), but ileus can also be caused by adhesions, hernias, tumours, inflammation, or constipation alone. Volvulus is distinguished by its rapid onset and the risk of ischaemia.

Why are diet and constipation important? Long-term constipation stretches the sigmoid colon, and the lengthened segment of the intestine can twist more easily. Regular bowel emptying in elderly institutionalised patients is a simple, important preventative measure.

Do I always need to have a piece of my intestine removed after an episode? If you have had one confirmed sigmoid volvulus, elective surgery is recommended during the same hospital stay or shortly thereafter, because the risk of recurrence is very high. In very frail patients, the risks and benefits must be weighed individually.

Sources

1. Vogel JD, Feingold DL, Stewart DB, et al. Clinical Practice Guidelines for Colon Volvulus and Acute Colonic Pseudo-Obstruction. Dis Colon Rectum. 2016;59(7):589-600. PubMed
2. Atamanalp SS. Sigmoid volvulus: an update for diagnosis and treatment. Eurasian J Med. 2023;55(1):76-83.
3. Sundhed.dk. Volvulus (lægehåndbogen).
4. Perrot L, Fohlen A, Alves A, Lubrano J. Management of the colonic volvulus in 2016. J Visc Surg. 2016;153(3):183-192.

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This article provides general information and does not replace a medical consultation. Contact your doctor if you experience symptoms.

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About the figures on this page: incidence, complication, recurrence and survival figures for rare diseases come from international series at specialist centres with relatively few patients, often across different time periods and using different definitions. The figures therefore vary between series and cannot be transferred directly to the individual patient.