Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction

Guideline Citation

Alavi K, Poylin V, Davids JS, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction. Dis Colon Rectum. 2021;64(9):1046-1057.[1]

Statement of the Problem

Large-bowel obstruction (LBO) in adults results from either mechanical or nonmechanical causes, and the 3 most common mechanical causes of LBO include obstructing colon or rectal cancer, diverticular stricture, and colonic volvulus.[2],[3] Colonic volvulus is the twisting of a redundant segment of colon on its mesentery that may lead to luminal occlusion in and proximal to the volvulized segment and compromise of colonic blood supply resulting in ischemia, gangrene, and potentially perforation.[4][5],[6] Colonic volvulus accounts for 10% to 15% of all large-bowel obstructions in the United States and western Europe, although its worldwide incidence is variable with a slightly higher rate in India, Africa, and the Middle East (the so-called “volvulus belt”).[6] Although volvulus can occur in any redundant colonic segment, it most commonly involves the sigmoid (60%–75% of all cases) and cecum (25%–40% of all cases).[7],[8],[9] Sigmoid volvulus preferentially affects older men in the United States and westernized countries, although younger men are more commonly affected in the volvulus belt.[7] In the United States and westernized countries, sigmoid volvulus primarily presents during the 6th to 8th decade of life, in institutionalized patients, and in patients with chronic constipation, neuropsychological impairment, or significant comorbidities.[4],[6],[8],[10] In contrast, cecal volvulus typically presents in younger patients and has a female predominance.[4] The management of volvulus depends on its location and clinical presentation. Pillars of management include the assessment of colonic viability, relief of obstruction, and prevention of recurrence. Without operative intervention, recurrent volvulus rates are high, and each subsequent recurrence event risks ischemia and perforation.[11],[12],[13],[14]

Meanwhile, acute colonic pseudo-obstruction (ACPO), or Ogilvie syndrome, is a nonmechanical, functional cause of LBO thought to be a consequence of dysregulation of the autonomic impulses of the colonic enteric nervous system.[15],[16] Whereas ACPO presents as a large-bowel obstruction in the absence of a mechanical cause that can progress to ischemia and subsequent perforation,[15],[17],[18],[19],[20],[21],[22],[23],[24] patients’ specific clinical presentations vary according to the degree of colonic distension, whether or not the ileocecal valve is competent, and the overall condition of the patient. Most commonly, ACPO affects elderly patients or patients admitted to the hospital for unrelated reasons, including elective surgery, trauma, or the management of an acute medical condition. This practice guideline focuses on the evaluation and treatment of adult patients with sigmoid or cecal volvulus or ACPO.

Full Text PDF

Colonic Volvulus Guideline (Full Text PDF)

References

  1. Alavi K, Poylin V, Davids JS, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction. Dis Colon Rectum. 2021;64(9):1046-1057.  [PMID:34016826]
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Last updated: December 21, 2021