A 70-year-old man presents with absolute constipation, abdominal distension, and X-ray showing a grossly dilated sigmoid loop with a 'coffee bean' or 'omega loop' sign pointing to the right upper quadrant. There is no peritonitis. Initial management should be:

• A Emergency laparotomy and Hartmann's procedure
• B Water-soluble contrast enema to confirm diagnosis
• C Endoscopic decompression (flexible sigmoidoscopy with flatus tube insertion) ✓
• D Oral polyethylene glycol and conservative management

Explanation

The omega loop/coffee bean sign on plain X-ray is pathognomonic of sigmoid volvulus. In the absence of peritonitis or ischaemia, the first-line treatment is endoscopic decompression via flexible sigmoidoscopy with placement of a decompression/flatus tube. This achieves successful detorsion in approximately 80–90% of cases. After successful decompression, elective sigmoid colectomy is planned to prevent recurrence. Emergency surgery is reserved for failure of endoscopic decompression, ischaemia, or perforation.

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

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Written and medically reviewed by the StethoPrep medical team.