Volvulus

Volvulus is the rotation of a viscus around its mesenteric axis, producing closed-loop obstruction and, if unrelieved, ischemia and perforation. The three clinically important sites in adult GI practice are the sigmoid colon, the cecum, and the stomach.

Sigmoid volvulus is the commonest, particularly in older patients with chronic constipation or in regions with high-fiber diets. The classic plain film "coffee bean" sign points to a redundant sigmoid loop arising from the pelvis. Without peritonitis, endoscopic detorsion with a soft rectal decompression tube is first-line; recurrence is high, and elective sigmoidectomy is recommended after the first episode in fit patients.

Cecal volvulus tends to occur in younger patients, often related to abnormal peritoneal fixation of the right colon or prior pelvic surgery. Imaging shows a markedly distended cecum displaced into the upper abdomen. Endoscopic reduction has lower success rates than for sigmoid volvulus, and most patients require surgical correction (cecopexy or right hemicolectomy when the bowel is non-viable).

Gastric volvulus may be organoaxial or mesenteroaxial, often associated with a hiatal or paraesophageal hernia. Borchardt's triad (severe epigastric pain, retching without vomiting, inability to pass an NG tube) is the classic clue. Acute presentations with ischemia require emergent surgical intervention; chronic intermittent volvulus may be managed endoscopically with reduction and consideration of percutaneous endoscopic gastropexy.