Volvulus, or a twisted bowel, is a severe intestinal obstruction requiring immediate medical attention. This condition is a surgical emergency because it restricts the flow of contents through the digestive tract and rapidly cuts off the blood supply to a segment of the intestine. Without prompt intervention, the lack of blood flow leads to irreversible tissue damage. The patient’s outcome hinges almost entirely on the speed of diagnosis and the subsequent life-saving surgical procedure to untwist the intestine and restore circulation.
Understanding Volvulus: The Mechanism of a Twisted Bowel
Volvulus occurs when a loop of the intestine rotates around itself and the mesentery that supports it, creating a closed-loop obstruction. The mesentery is a fold of tissue attaching the intestine to the abdominal wall and contains the blood vessels that supply the bowel. This mechanical rotation simultaneously causes a blockage of the digestive tract and a restriction of blood flow.
In adults, the most common site for twisting is the sigmoid colon (sigmoid volvulus), followed by the cecum (cecal volvulus). Sigmoid volvulus often affects older individuals with chronic constipation, leading to an elongated loop of the colon prone to twisting. Cecal volvulus is frequently associated with incomplete fixation of the colon during embryonic development, making that section of the bowel more mobile and susceptible to rotation.
The torsion physically obstructs the passage of gas and stool, causing the intestine to rapidly distend. This distension exacerbates pressure on the blood vessels. The twisting motion also constricts the mesentery, pinching the arteries and veins. This compromised circulation quickly deprives the bowel tissue of oxygen, initiating the life-threatening process.
The Critical Timeframe: Why Untreated Volvulus is Fatal
Survival with a twisted bowel is measured in hours, not days, due to the rapid onset of tissue death. The immediate threat is the cessation of blood flow (ischemia), which begins the countdown to necrosis. Venous outflow is often compromised first, causing the bowel to swell with congested blood, which then leads to a complete stoppage of arterial blood supply.
Once the blood supply is cut off, the affected segment can become gangrenous within 24 hours, often sooner. This tissue death allows bacteria from the bowel to leak into the abdominal cavity, causing a massive infection called peritonitis. The body’s response to this severe infection can quickly spiral into septic shock, causing a dangerous drop in blood pressure and organ malfunction.
The window for successful treatment is extremely narrow, especially with a complete vascular cutoff. Patients presenting with signs of peritonitis or gangrene face a significantly higher mortality risk. The goal of immediate care is to intervene within the first few hours of symptom onset, before the cascade of necrosis and sepsis becomes unstoppable. Without timely surgical correction, the mortality rate approaches 100% as infection and multi-organ failure quickly overwhelm the body.
Immediate Warning Signs and Diagnosis
Recognizing the sudden onset of symptoms is necessary for rapid diagnosis and intervention. The classic presentation includes the sudden onset of severe, cramping abdominal pain that often becomes unbearable. This pain is typically accompanied by significant abdominal distension, making the abdomen visibly swollen and taut.
The mechanical obstruction results in constipation and the inability to pass gas. As the blockage persists, patients frequently experience vomiting, which may contain bile. Signs of systemic distress, such as a rapid heart rate and low blood pressure, can signal the onset of shock or severe dehydration.
Physicians must work quickly to confirm the diagnosis using imaging techniques. Abdominal X-rays can show a greatly distended loop of the colon, sometimes described as a “bent inner tube” sign in sigmoid volvulus. A Computed Tomography (CT) scan is the definitive diagnostic tool, often revealing the characteristic “whirl sign,” where the twisted bowel and its mesentery are visible as a spiraling pattern. These diagnostic steps must be executed quickly to move the patient toward definitive treatment.
Life-Saving Medical Intervention
Treatment for volvulus is urgent, aiming to untwist the bowel and restore blood flow before necrosis occurs. For sigmoid volvulus without signs of gangrene or peritonitis, a non-surgical approach called endoscopic detorsion may be attempted first. This procedure involves inserting a flexible tube through the rectum and colon to gently untwist the bowel, providing immediate relief and allowing for the insertion of a rectal tube to prevent immediate recurrence.
If there is suspicion of compromised blood supply or if the non-surgical attempt fails, emergency surgery (laparotomy) is required. During this procedure, the surgeon directly untwists the bowel and assesses tissue viability. If the bowel is healthy, it is untwisted and often secured to prevent future recurrence; this securing procedure is called cecopexy if the cecum is involved.
Resection and Ostomy
If the tissue is necrotic, the damaged section must be urgently removed (resection). For sigmoid volvulus, this involves a sigmoid colectomy, and for cecal volvulus, a right hemicolectomy is typically performed. If the patient is unstable or contamination is significant, the healthy ends of the bowel may not be immediately reconnected. Instead, a temporary colostomy or ileostomy (Hartmann procedure) may be created, which is a safer initial approach in an emergency setting.
Prognosis and Recovery Following Treatment
The prognosis depends heavily on the condition of the bowel at the time of the operation. If the twisted segment is successfully untwisted before tissue death occurs, the outlook is generally favorable with a high rate of successful recovery. Patients who undergo successful endoscopic detorsion are typically scheduled for an elective, definitive surgical resection shortly after, as the recurrence rate is high without this measure.
When the bowel requires resection due to necrosis, recovery is more complex and prolonged. The extent of the resection is a major factor, as removing a large segment of the small intestine can result in short bowel syndrome. Recovery from major abdominal surgery usually involves several days in the hospital for close monitoring, followed by a gradual return to normal activities over several weeks.