Acute intestinal obstruction in the elderly due to sigmoid volvulus

INTRODUCTION

Volvulus of the sigmoid colon occurs when the bowel twists around its mesenteric attachment, resulting in mechanical obstruction and vascular compromise. Although this condition is infrequent in younger populations, it represents a recognized cause of acute intestinal obstruction in adults, particularly the elderly. Epidemiological studies suggest that sigmoid volvulus accounts for a small but significant proportion of colonic obstruction cases worldwide.^1,2

Failure to recognize the condition early may result in bowel ischemia, necrosis, perforation, and systemic sepsis. Geographic variation exists, with higher incidence reported in areas termed the “volvulus belt,” where dietary and anatomical factors contribute to disease development. Due to variable clinical presentation, diagnosis is often delayed, increasing morbidity and mortality. We report a case of sigmoid volvulus presenting as acute intestinal obstruction in an elderly patient.

CASE REPORT

A 60-year-old male presented to the emergency department complaining of worsening abdominal pain and distension for 2 days, accompanied by complete cessation of bowel movements and flatus. He later developed nausea and two episodes of vomiting containing undigested food. There was no history of fever, previous abdominal surgery, chronic constipation, or systemic illness.

On examination, the patient appeared dehydrated but was hemodynamically stable. Abdominal inspection revealed gross distension, with generalized tenderness on palpation and tympanic percussion. Bowel sounds were reduced. Digital rectal examination demonstrated an empty rectum with normal sphincter tone.

Laboratory investigations showed a hemoglobin concentration of 12.3 g/dl, electrolyte imbalance in the form of hyponatremia, and preserved renal function.

Plain abdominal radiography demonstrated a massively dilated colonic loop occupying much of the abdominal cavity, with an absence of distal rectal gas [Figure 1]. The configuration was consistent with a classical “coffee bean” morphology, with extension toward the upper abdomen and overlap of the hepatic shadow.

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Figure 1:

Topogram showing absent rectal gas and three dense lines (represented by white arrows) (sigmoid colon walls) seen converging to the site of obstruction (white star). The sigmoid loop is coursing along the right upper quadrant, overlapping the liver shadow, consistent with the liver overlap sign (represented by black star).

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Contrast-enhanced computed tomography revealed a markedly distended, fluid-filled sigmoid colon originating from the pelvis and tapering abruptly at the site of torsion [Figure 2]. A complete 360-degree rotation of the sigmoid mesentery was noted, producing a characteristic whirl-like appearance of mesenteric vessels [Figures 3–5]. Surrounding fat stranding suggested vascular congestion. The rectum was collapsed, and contrast enhancement of the sigmoid wall was absent, raising concern for bowel ischemia.

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Figure 2:

CT abdomen plain coronal section showing coffee bean sign. CT: Computed tomography.

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Figure 3:

CT abdomen plain, coronal section showing whirlpool sign (white arrow). CT: Computed tomography.

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Figure 4:

CECT abdomen, axial section showing split wall sign (white arrow). CECT: Contrast-enhanced computed tomography.

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Figure 5:

CECT abdomen, axial section showing the bird beak sign (white arrow). CECT: Contrast-enhanced computed tomography.

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Based on these findings, a diagnosis of acute sigmoid volvulus with probable gangrene was established.

The patient underwent urgent exploratory laparotomy. Intraoperative findings included a grossly dilated, necrotic sigmoid colon twisted completely around its mesenteric axis. The bowel was detorsed and resected, and a Hartmann’s procedure was performed.

Postoperative recovery was smooth, and the patient was discharged in stable condition on the fifth postoperative day.

DISCUSSION

Sigmoid volvulus represents a surgical emergency caused by abnormal mobility and elongation of the sigmoid colon. The resulting torsion compromises both intestinal lumen patency and mesenteric blood flow, predisposing the bowel to ischemic injury.³ Elderly patients are particularly vulnerable due to age-related anatomical and functional changes.

Multiple factors have been implicated in disease development, including chronic constipation, elongated mesentery, high-fiber diets, neurological disorders, and reduced physical activity.⁴ However, some patients, as in this case, may develop volvulus without identifiable predisposing conditions.

The clinical spectrum ranges from slowly progressive abdominal distension to rapidly evolving obstruction with systemic toxicity. Because physical findings lack specificity, imaging is essential for diagnosis. Plain radiographs may provide initial clues, but computed tomography remains the most reliable modality, allowing visualization of mesenteric twisting, transition points, and signs of ischemia.^5,6

In the absence of ischemia, nonoperative decompression may be attempted; however, recurrence rates are high. Surgical intervention becomes mandatory in the presence of gangrene, perforation, or failed conservative management. Resection of the affected segment provides definitive treatment and minimizes recurrence risk.⁷

CONCLUSION

This case demonstrates acute sigmoid volvulus as a cause of large bowel obstruction in an elderly patient. Prompt recognition of characteristic radiological features and timely surgical management resulted in a favorable outcome. Early intervention remains critical to prevent irreversible bowel injury and life-threatening complications.