Guideline sources The following summarized guidelines for the evaluation and management of colonic volvulus are prepared by our editorial team based on guidelines from the World Society of Emergency Surgery (WSES 2023), the American Society for Gastrointestinal Endoscopy (ASGE 2020), and the American Society of Colon and Rectal Surgeons (ASCRS 2016). 1 2 3 Guidelines 1. Diagnostic investigations Initial evaluation: As per WSES 2023 guidelines, elicit a focused history, perform a physical examination, and obtain a full panel of blood tests (including blood gas and lactate levels to assess for bowel ischemia) in the initial evaluation of patients with suspected sigmoid volvulus. B As per ASCRS 2016 guidelines, elicit a focused history, perform a physical examination, and obtain laboratory tests (including CBC, serum electrolytes, and renal function tests) in the initial evaluation of patients with suspected colonic volvulus. B Diagnostic imaging: As per WSES 2023 guidelines: https://web.pathway.md/diseases/recXWMjZJjrS67WQU 1/3 6/23/23, 3:35 AM Colonic volvulus Pathway Obtain a plain abdominal XR as initial diagnostic imaging for sigmoid volvulus to look for a classic coffee bean sign. B Consider obtaining CT if the diagnosis is in doubt or if ischemia or perforation is suspected. B As per ASCRS 2016 guidelines, obtain a plain abdominal XR for diagnosis of colonic volvulus, often followed by contrast enema or CT for confirmation. B 2. Therapeutic procedures Endoscopic detorsion, sigmoid volvulus: As per WSES 2023 guidelines: Perform flexible endoscopy as the first-line treatment modality to decompress the sigmoid colon if ischemia or perforation is not suspected clinically and/or radiologically. B Consider performing endoscopic fixation of the sigmoid colon in selected patients with a prohibitive risk for operative interventions. C As per ASGE 2020 guidelines: Consider performing endoscopy as the initial treatment modality in patients with uncomplicated sigmoid volvulus. E Consider placing a decompression tube after successful detorsion to maintain reduction and decrease the risk of recurrence. E As per ASCRS 2016 guidelines, perform rigid or flexible endoscopy to assess sigmoid colon viability and to allow initial detorsion and decompression of the colon. B Endoscopic detorsion, cecal volvulus: As per ASGE 2020 guidelines, avoid performing endoscopic interventions in patients with cecal volvulus given the high risk of perforation. D As per ASCRS 2016 guidelines, avoid performing endoscopic reduction in patients with cecal volvulus. D 3. Surgical interventions Operative management, sigmoid volvulus: As per WSES 2023 guidelines, perform urgent sigmoid resection when endoscopic detorsion of the sigmoid colon is unsuccessful and in cases of a nonviable or perforated colon. B Show 4 more As per ASGE 2020 guidelines: Obtain surgical consultation during the index admission of patients with sigmoid volvulus, given the high risk of recurrent volvulus and high morbidity and mortality associated with each episode. E Perform surgery in patients with sigmoid volvulus with overt perforation or signs of peritonitis. E https://web.pathway.md/diseases/recXWMjZJjrS67WQU 2/3 6/23/23, 3:35 AM Colonic volvulus Pathway As per ASCRS 2016 guidelines, perform urgent sigmoid resection if endoscopic detorsion of the sigmoid colon is not possible and in cases of a nonviable or perforated colon. B Operative management, cecal volvulus: As per ASGE 2020 guidelines: Perform surgery as initial treatment modality in patients with cecal volvulus. E Perform surgery in patients with cecal volvulus with overt perforation or signs of peritonitis. E As per ASCRS 2016 guidelines: Perform cecal resection in patients with cecal volvulus with nonviable or perforated bowel and in patients with viable bowel being good surgical candidates. B Consider performing nonresectional operative procedures as alternatives to resection in patients with cecal volvulus with viable bowel. C 4. Specific circumstances Pregnant patients: recognize that colonic volvulus is rare during pregnancy. Use a multidisciplinary approach to treatment, taking into account the stage of pregnancy. B 5. Preventative measures Prevention of recurrence: consider performing sigmoid colectomy after resolution of the acute phase of sigmoid volvulus for the prevention of recurrent volvulus. B Show 2 more References 1. Brian W C A Tian, Gabriele Vigutto, Edward Tan et al. WSES consensus guidelines on sigmoid volvulus management. World J Emerg Surg. 2023 May 15;18 1 34. Open 2. Mariam Naveed, Laith H Jamil, Larissa L Fujii-Lau et al. American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of acute colonic pseudo-obstruction and colonic volvulus. Gastrointest Endosc. 2020 Feb;91 2 228 235. Open 3. Vogel JD, Feingold DL, Stewart DB et al. Clinical Practice Guidelines for Colon Volvulus and Acute Colonic Pseudo-Obstruction. Dis Colon Rectum. 2016 Jul;59 7 589 600. Open https://web.pathway.md/diseases/recXWMjZJjrS67WQU 3/3