Sigmoid Volvulus

Nina J Abramson, MD
Harry Z Mellins, MD

December 14, 1995

Presentation

A 79-year-old man with a history of Parkinson's disease presented to the emergency ward with lower abdominal pain.

Imaging Findings

Supine Radiograph of Abdomen

Barium Enema Study

Supine radiograph of abdomen shows a markedly distended loop of sigmoid colon with a convex superior margin projecting into the right upper abdomen. It is essentially devoid of haustral markings. While gas distends the descending colon proximal to the twist, the rectum has emptied. The twisted loop forms two large compartments with a central double wall (arrows) ending at the point of the twist --"coffee bean" sign. A single wall forms the outer margin of the two compartments.

Barium enema study demonstrates the narrow twisted portion of lumen (arrows) with proximal gaseous distention of the sigmoid colon. Barium has coursed through the sigmoid and fills the remainder of the colon.

Differential Diagnosis

Although the findings are characteristic of sigmoid volvulus, a distended and downwardly displaced transverse colon may mimic it, by forming a pseudovolvulus. A distended transverse colon, however, has a convex inferior margin, with the double central wall extending ephalad, the opposite of sigmoid volvulus.

Diagnosis

Sigmoid volvulus

Discussion

Sigmoid volvulus is produced when a long redundant sigmoid twists about its mesenteric axis in either direction and forms a closed loop obstruction. The degree of torsion in 50% of cases is 360 degrees, 180 degrees in 35% of cases, and 540 degrees in 10% of cases [3]. Volvulus of sigmoid most commonly occurs in elderly and psychiatrically disturbed patients.

As with any colonic obstruction, bowel ischemia and perforation can occur if prompt decompression is not achieved. Fluoroscopic or sigmoidoscopic guidance of a rectal tube is often therapeutic, if vascular compromise is not severe. Alternatively, if the obstruction is not complete, it may occasionally be reduced during a barium enema examination. The high recurrence rate of sigmoid volvulus (up to 80%) usually dictates resection of the redundant sigmoid.

References

1. Eisenberg RL. Gastrointestinal radiology: A pattern approach. 2nd ed. Lippincott, 1990: 728-9.

2. Margulis AR, Burhenne HJ, editors. Alimentary Tract Radiology. 4th ed. St.Louis: Mosby Co., 1989: 348-350.

3. Dahnert W. Radiology Review Manual. 2nd ed. City: Williams and Wilkins, 1993:501.

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