Management of colonic volvulus and acute colonic pseudo-obstruction- ASCRS guidelines

USA: The American Society of Colon & Rectal Surgeons (ASCRS) has released an updated clinical practice guideline for the management of colonic volvulus and acute colonic pseudo-obstruction (ACPO). The guideline, published in the journal Diseases of the Colon & Rectum (DC&R), is developed by the ASCRS Clinical Practice Guidelines Committee. 

Colonic volvulus (twisting of the large intestine) is a potentially life-threatening cause of large-bowel obstruction. ACPO can mimic the symptoms of large bowel obstruction.  

"These guidelines reflect the best available evidence on current practice for specialist management of colonic volvulus and ACPO," comments Daniel L. Feingold, MD, of Rutgers University, New Brunswick, N.J., on behalf of the Committee.

Updated recommendations for colonic volvulus and ACPO

Colonic volvulus occurs when part of the colon becomes twisted, causing obstruction and reduced blood flow, with the potential for intestinal damage and death. Although colonic volvulus is relatively uncommon in the United States, colonic obstruction of any cause is a medical emergency requiring immediate evaluation and treatment. Acute colonic pseudo-obstruction is a rare condition that may cause symptoms of large-bowel obstruction without mechanical blockage, requiring different treatment.

The updated 2021 guidelines consist of 15 recommendations related to the diagnosis and treatment of colonic volvulus, based on 125 research reports. The new document reflects the latest research evidence since publication of the previous guidelines in 2016. Recommendations for colonic volvulus address:

Initial evaluation. When first evaluated, about one-fourth to one-third of patients have symptoms of infection or shock related to loss of intestinal blood flow (ischemia) or perforation.

Imaging studies. Radiographs or CT scans can detect the presence and location of colonic volvulus. Early detection may enable treatment before irreversible intestinal injury develops.

Sigmoid volvulus. Management depends on where the volvulus is located. For volvulus in the sigmoid colon (near the end of the large bowel), colonoscopy can be performed to assess and sometimes relieve the obstruction (detorsion/decompression). If the bowel cannot be untwisted, or if intestinal damage or perforation is present, urgent surgery is needed. After successful detorsion, surgery may be recommended to prevent the problem from recurring.

Cecal volvulus. If volvulus is located in the cecum (at the beginning of the large bowel), surgical treatment is recommended. The risks for intestinal damage or tissue death are higher in patients with cecal volvulus, although more recent studies suggest that outcomes have improved.

The remaining recommendations address management of ACPO: a less-common condition with symptoms similar to those of large-bowel obstruction, despite the absence of mechanical blockage. The guidelines focus on diagnostic steps to exclude the presence of colonic volvulus, cancer, or other causes of obstruction. Treatment starts with supportive care to eliminate or correct other medical conditions that can predispose to ACPO.

Although most of the guideline recommendations are graded as "strong," many are based on "low-quality" evidence – highlighting remaining gaps in the available research on colonic volvulus and ACPO. Dr. Feingold adds, "We hope these recommendations will provide the basis for a scientifically informed approach to management of these serious conditions, always informed by the physician's judgment and tailored to the individual patient's situation."

Reference:

"The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction," is published in the journal Diseases of the Colon & Rectum.

DOI: 10.1097/DCR.0000000000002159