ConditionDigestive system
Volvulus (Twisted Bowel)
A volvulus is a twist of a loop of intestine around itself and the tissue that supplies it with blood. The twist blocks the bowel and can cut off blood flow, causing the bowel to die within hours. Symptoms are severe cramping abdominal pain, a swollen belly, vomiting and inability to pass stool or gas. In babies, green (bile-stained) vomiting is the key warning sign. Volvulus is a surgical emergency: untwisting the bowel by endoscopy or surgery, and removing damaged bowel, is lifesaving.
Also called: Twisted bowel, bowel twist, sigmoid volvulus, cecal volvulus, midgut volvulus, gastric volvulus
At a glance
- What it is
- A twist of the bowel causing obstruction and risk of lost blood supply.
- Types
- Sigmoid (most common in adults), cecal, midgut (babies with malrotation), gastric.
- Symptoms
- Severe cramping pain, swollen belly, vomiting, no stool or gas.
- Babies
- Green vomit is an emergency until proven otherwise.
- Diagnosis
- X-ray, CT scan; upper GI contrast study in infants.
- Treatment
- Endoscopic untwisting for some sigmoid cases, then surgery; emergency surgery for most others.
When to get help
Call 911 or go to the ER
- A baby or child vomiting green or yellow-green fluid (bile), even if they otherwise seem well: go to the ER immediately
- Severe abdominal pain with a swollen belly, vomiting and no passage of stool or gas
- Abdominal pain with blood in the stool, fever, a racing heart, confusion or collapse
- Constant, severe pain out of proportion to tenderness on touching the belly
See a doctor within a day or two
- Recurrent episodes of abdominal swelling and pain that resolve, especially in an older person with chronic constipation (possible intermittent volvulus)
- Abdominal bloating and constipation getting steadily worse over a day or two
How volvulus happens
The intestine is anchored to the back of the abdomen by a fan of tissue called the mesentery, which carries its blood vessels. If a section of bowel is long, floppy and loosely attached, it can rotate around the mesentery. A twist of 180 degrees or more blocks the bowel; with further twisting, veins and then arteries are pinched, and the bowel can become gangrenous and perforate.
Types of volvulus
| Type | Who it affects | Features |
|---|---|---|
| Sigmoid volvulus | Older adults, people with chronic constipation, neurological or psychiatric conditions, nursing home residents | Gradual severe distension, constipation; most common type in adults |
| Cecal volvulus | Younger adults (30 to 60) | More sudden pain and vomiting; right-sided origin |
| Midgut volvulus | Babies with intestinal malrotation, usually in the first month | Sudden green vomiting; can lose most of the small bowel within hours |
| Gastric volvulus | Older adults, often with a large hiatal hernia | Severe upper abdominal pain, retching without vomiting |
Causes and risk factors
- sigmoid: chronic constipation, a long redundant sigmoid colon, high-fiber diets in some regions, Chagas disease, Hirschsprung disease, Parkinson's disease, dementia, multiple sclerosis, diabetes, long-term use of medicines that slow the gut
- cecal: a congenitally mobile cecum, previous abdominal surgery, adhesions, pregnancy
- midgut: intestinal malrotation, a developmental abnormality present at birth
- gastric: hiatal and diaphragmatic hernias
- connective tissue disorders such as Ehlers-Danlos and Marfan syndromes
Symptoms
In adults
- cramping abdominal pain, becoming constant if the bowel loses blood supply
- marked swelling of the abdomen
- constipation and inability to pass gas
- nausea and vomiting
- blood in the stool, fever and a fast heart rate with bowel damage
- confusion and shock in severe cases, especially in older adults
In babies and children
- sudden green (bilious) vomiting
- abdominal pain shown by drawing up the legs and inconsolable crying
- swollen, tender belly
- bloody stools
- lethargy and signs of shock
Midgut volvulus can destroy most of the small intestine within hours, so green vomiting in an infant always needs emergency assessment.
Diagnosis
- abdominal X-ray: sigmoid volvulus may show a characteristic "coffee bean" loop
- CT scan: shows the twist ("whirl sign"), obstruction and signs of bowel damage
- upper GI contrast study in infants: shows malrotation and volvulus
- blood tests: lactate, white cell count, electrolytes and kidney function to assess severity
Treatment
Sigmoid volvulus
- if there are no signs of bowel death, a flexible sigmoidoscopy or colonoscopy can untwist the bowel and release gas, often with a tube left in place
- because recurrence is common, a planned sigmoid colectomy (removal of the loose sigmoid colon) is usually recommended during the same admission for those fit for surgery
- emergency surgery if the bowel is gangrenous, perforated, or endoscopic untwisting fails
Cecal volvulus
- surgery is usually required, typically removing the right colon (right hemicolectomy)
Midgut volvulus
- emergency surgery (Ladd procedure) to untwist the bowel, widen the mesentery and reposition the intestines; dead bowel is removed
Gastric volvulus
- endoscopic or surgical untwisting and fixation, with repair of any hernia
Supportive care
IV fluids, bowel rest, a nasogastric tube to decompress the stomach, antibiotics and correction of electrolytes.
Outlook
When treated before the bowel loses its blood supply, most people recover well. Once gangrene or perforation occurs, the risk of serious complications and death rises sharply, especially in older adults. Babies who lose a large length of small intestine may develop short bowel syndrome.
Frequently asked questions
What are the symptoms of volvulus?
Symptoms include severe cramping abdominal pain, a swollen belly, nausea and vomiting, and inability to pass stool or gas. Blood in the stool, fever and a racing heart suggest the bowel is losing its blood supply. In babies, green vomiting is the main warning sign.
What causes a twisted bowel?
A loose, mobile section of bowel can twist around its blood supply. Risk factors include chronic constipation, a long sigmoid colon, neurological conditions, previous surgery, and in babies, intestinal malrotation present from birth.
Is volvulus an emergency?
Yes. A twisted bowel can lose its blood supply within hours, causing tissue death and perforation. Anyone with symptoms of volvulus, and any baby with green vomiting, needs emergency care immediately.
Can sigmoid volvulus come back?
Yes. After endoscopic untwisting alone, sigmoid volvulus often recurs. Surgery to remove the redundant sigmoid colon is usually recommended to prevent this.
Sources
This guide was written from current patient and clinical guidance, including:
- American Society of Colon and Rectal Surgeons: Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction
- American Pediatric Surgical Association: Malrotation and volvulus
- MedlinePlus: Volvulus - childhood; Intestinal obstruction
- StatPearls (NCBI Bookshelf): Sigmoid volvulus; Cecal volvulus
- NHS: Intestinal obstruction