Overview

Sigmoid volvulus is the most common form of volvulus of the gastrointestinal tract; it is
responsible for 8% of all intestinal obstructions. Sigmoid volvulus is particularly common in
elderly persons. Patients present with abdominal pain, distention, and absolute constipation.
[1, 2]
Predisposing factors to sigmoid volvulus include chronic constipation, megacolon, and an
excessively mobile colon. Plain abdominal radiograph findings are usually diagnostic. (See the
images below.)
This radiograph demonstrates a greatly dilated sigmoid that almost
fills the entire abdomen. Note the coffee bean sign. The remainder of the large bowel is not
dilated, presumably because the proximal point of the twist is not causing obstruction and thus
allows drainage into the sigmoid. Erect abdominal radiograph. This
image shows fluid levels in the distended sigmoid loop.
Decompression may be achieved with the introduction of a stiff tube per the rectum, aided by
endoscopy or fluoroscopy. The mortality rates associated with sigmoid volvulus are 20-25%,
depending on the interval between when the diagnosis is made and treatment is rendered.
Therefore, early radiographic recognition of sigmoid volvulus is important. (See the image
below.)
[1, 2, 3, 4, 5, 6]

This radiograph shows decompression of the sigmoid loop following
retrograde passage of a flatus tube.
The key radiologic features of sigmoid volvulus are those of a double-loop obstruction, which
has been reported in approximately 50% of patients. The key finding consists of a dilated loop of
pelvic colon, associated with features of small-bowel obstruction and retention of feces in an
undistended proximal colon. The dilated loop usually lies in the right side of the abdomen, and
the limbs taper inferiorly into the right lower quadrant. Medial deviation of the distal descending
colon is a rare but highly specific finding.
Preferred examination
Plain abdominal radiographic findings are usually diagnostic of sigmoid volvulus.
Decompression may be achieved by the introduction of a stiff tube per rectum, aided by
endoscopy or fluoroscopy. A single-contrast barium enema examination is usually adequate if it
is required, as in cases when the diagnosis is in doubt.
Computed tomography (CT) scanning is the least invasive imaging technique that allows
assessment of mural ischemia. Unlike barium enema examination, CT scanning has a high
likelihood of revealing other causes of abdominal pain if the source of the patient's symptoms is
not sigmoid volvulus. Results of conventional mesenteric angiography with intravenously
administered contrast material or magnetic resonance angiography (MRA) may be more
definitive in the diagnosis of mesenteric ischemia.
Plain radiographs readily permit the distinction of sigmoid volvulus from primary volvulus of the
small intestine and from other nonobstructive surgical emergencies. However, volvulus of the
right colon, closed-loop small intestinal obstruction, and sigmoid volvulus complicated by
peritonitis may simulate sigmoid volvulus on radiographs. Sigmoidoscopy, rather than barium
enema examination, is the procedure of choice if an ileosigmoid knot is suspected.
Limitations of techniques
Diagnostic difficulties may occur with plain abdominal radiographs if the degree of proximal
dilatation is so marked that the sigmoid loop may not be recognized as such. Similar difficulties
may be encountered when a large amount of fluid is associated with a small amount of air. This
situation causes poor definition of the sigmoid colon on a supine radiograph, and the high air-
fluid levels demonstrated on erect images may be inadequate to define the sigmoid loop
accurately.
Barium enema examination is contraindicated in patients in whom a gangrenous bowel is
suspected or when a pneumoperitoneum is noted on a plain abdominal radiograph or erect chest
radiograph. Barium enema examination is also contraindicated in patients who have clinical
signs of peritonitis.
Radiography
Plain radiographs show a markedly distended sigmoid loop, which assumes a bent inner tube or
inverted U -shaped appearance, with the limbs of the sigmoid loop directed toward the pelvis.
[7]
(See the images below.)

This radiograph demonstrates a greatly dilated sigmoid that almost fills the entire abdomen. Note
the coffee bean sign. The remainder of the large bowel is not dilated, presumably because the
proximal point of the twist is not causing obstruction and thus allows drainage into the sigmoid.

Erect abdominal radiograph. This image shows fluid levels in the distended sigmoid loop.

This radiograph shows decompression of the sigmoid loop following retrograde passage of a
flatus tube
.
Supine abdominal radiograph in a 6-year-old child from an area in which roundworms are
endemic. This image shows a sigmoid volvulus. The sigmoid loop is dilated and associated with
mild proximal large-bowel dilatation.

This erect radiograph shows fluid levels in the sigmoid loop and in the transverse colon.

Erect abdominal radiograph demonstrating a giant sigmoid diverticulum. This image shows a
dilated loop of bowel with air-fluid levels and intraluminal feces. This appearance mimics that of
an enlarged cecum or sigmoid loop.

Radiograph from an enema examination with water-soluble contrast material in an unprepared
bowel. This image shows a giant sigmoid diverticulum that contains feces.
The colonic haustra are lost, and progressive distention elevates the sigmoid loop under one side
of the diaphragm.
An upright radiograph shows a greatly distended sigmoid loop with air-fluid levels mainly on the
left side of the abdomen and extending toward the right hemidiaphragm.
The involved bowel walls are edematous, and the contiguous walls form a dense white line on
radiographs. This line is surrounded by the curved and dilated gas-filled lumen, resulting in a
coffee bean-shaped structure; this is the coffee bean sign.
[8]

If more fluid than air is in the obstructed loop of the sigmoid, the volvulus may be demonstrable
by a soft-tissue mass or a pseudotumor sign.
A dilated sigmoid colon that ascends to the transverse colon (northern exposure sign) is said to
be a reliable sign of a sigmoid volvulus on a supine abdominal radiograph.
[9]

Barium enema
A single-contrast barium enema examination is adequate because the barium readily enters the
empty rectum and usually encounters a complete stenosis, which is likened to a beak, the so-
called bird's beak or bird-of-prey sign.
Barium enema examination demonstrates obstruction at the rectosigmoid junction. The most
common and clinically significant twist of the sigmoid occurs in the mesenteric axis, although a
less frequent and more benign form of the twist may occur around the longitudinal axis of the
sigmoid loop. This longitudinal twist has been variably termed the kink, axial torsion, or
physiologic incomplete torsion. Patients with this twist are usually not symptomatic, and it may
be an incidental finding on a routine barium enema examination.
If barium can enter the obstructed segment, spiraling of the mucosal folds may be seen. Signs of
bowel ischemia, such as thumbprinting, transverse ridging, and mucosal ulceration, may be
observed.
Take care not to perform a barium enema examination in patients with suspected gangrenous
bowel, a pneumoperitoneum (as seen on plain abdominal radiographs), or clinical signs of
peritonitis.
Sigmoidoscopy, rather than barium enema examination, is the procedure of choice if an
ileosigmoid knot is suspected.
Degree of confidence
In 60-70% of patients, the diagnosis of sigmoid volvulus can be made by using plain abdominal
radiographic findings. In 20-30% of patients, the 2 limbs of the twisted sigmoid colon may
overlap or deviate to the right or left, obscuring the remainder of the colon. In these instances,
the findings are those of a nonspecific large-bowel obstruction, and barium enema examination is
required for confirmation of the diagnosis.
False positives/negatives
Other forms of large-bowel obstruction, especially those due to sigmoid colon carcinoma,
pseudo-obstruction, cecal volvulus, and an ileosigmoid knot, may mimic or be confused with a
sigmoid volvulus. At times, emphysematous cystitis and a giant sigmoid diverticulum may also
mimic a sigmoid volvulus.
Computed Tomography
CT scan findings of sigmoid volvulus include the whirl sign, which represents tension on the
tightly twisted mesocolon by the afferent and efferent limbs of the dilated colon.
[10, 11, 12]

CT scanning may be useful in identifying the etiology and site of the obstruction that result from
other pathologies, as well as in demonstrating ischemia that results from strangulation.
CT scan signs of ischemia include a serrated beak at the site of the obstruction, mesenteric
edema or engrossment, and moderate to severe thickening of the bowel wall.
Intramural gas or portal venous gas may be seen (grave prognostic signs), and in patients in
whom a perforation has occurred, a large amount of free intraperitoneal gas or fluid may be
noted.
Many imaging signs have been described for sigmoid volvulus, but the classic appearance may
be absent in up to half of the patients on scanograms and one fourth of CT scans. Levsky et al
retrospectively reviewed 36 patients with sigmoid volvulus with an aim to evaluate the features
of sigmoid volvulus on CT scanograms and cross-sectional images. Cross-sectional images of
classic signs and 2 novel imaging signs, including X-marks-the-spot and the-split-wall sign, were
analyzed. The authors concluded that the new signs of X-marks-the-spot for more complete
twisting and split-wall sign for less severe twisting may improve diagnostic confidence.
[13]

Degree of confidence
CT scanning is the least invasive imaging technique that allows assessment of mural ischemia.
This imaging modality helps in identifying the cause of an acute large-bowel obstruction in 74-
86% of cases, although the sensitivity of the investigation is not yet defined.
False positives/negatives
False-positive findings may involve other forms of volvulus or obstruction and causes of large-
bowel ischemia.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) has been used successfully in the assessment of large-bowel
obstruction (not specifically in sigmoid volvulus). These examinations were performed with the
retrograde insufflation of 1000-1200 mL of air through a Foley catheter that was placed in the
rectum and with scopolamine to inhibit peristalsis in order to demonstrate the site of bowel
obstruction. In addition, MRI has been used in the diagnosis of mural necrosis in infants and,
theoretically, this modality can be used in adults.
[14]

Ultrasonography
Ultrasonography might occasionally be useful in assessing large-bowel obstruction.
[15, 16]
However, the confidence level for ultrasonography in the diagnosis of sigmoid volvulus is low.
In the limited experience in diagnosing sigmoid volvulus by ultrasonography, the images fail to
depict the cause in most patients.