A 70-year-old woman presents with absolute constipation for 3 days, massively distended abdomen, and minimal pain. Plain X-ray shows a 'coffee bean' or 'omega loop' sign arising from the left iliac fossa pointing to the right upper quadrant. CT confirms sigmoid volvulus without peritonitis. What is the first-line non-surgical management and when is emergency surgery indicated?

• A Emergency Hartmann's procedure (sigmoid resection + end colostomy) as first-line treatment
• B Water-soluble contrast enema to reduce the volvulus radiologically under fluoroscopy
• C Rigid/flexible sigmoidoscopic decompression + flatus tube placement; surgery indicated if gangrenous bowel, perforation, or failed endoscopy ✓
• D Colonoscopic decompression followed by immediate elective resection in the same admission to prevent recurrence

Explanation

In uncomplicated sigmoid volvulus (no peritonitis or bowel ischaemia), non-operative decompression by rigid or flexible sigmoidoscopy + flatus tube passage is successful in 70-80% of cases. This deflates the volvulus and allows elective sigmoid resection in the same admission (to prevent high recurrence rate of ~50-90%). Immediate emergency surgery is reserved for peritonitis, failure of endoscopic decompression, suspected gangrenous bowel, or haemodynamic instability. Contrast enema is used for caecal volvulus, not sigmoid. After successful decompression, definitive sigmoid resection (sigmoid colectomy with primary anastomosis in a prepped bowel) is performed during the same admission, not merely surveillance.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.