The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction

Abstract

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. Although not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician considering all the circumstances presented by the individual patient. STATEMENT OF THE PROBLEM Large-bowel obstruction (LBO) in adults results from either mechanical or nonmechanical causes, and the 3 most common mechanical causes of LBO include obstructing colon or rectal cancer, diverticular stricture, and colonic volvulus.1,2 Colonic volvulus is the twisting of a redundant segment of colon on its mesentery that may lead to luminal occlusion in and proximal to the volvulized segment and compromise of colonic blood supply resulting in ischemia, gangrene, and potentially perforation.3–5 Colonic volvulus accounts for 10% to 15% of all large-bowel obstructions in the United States and western Europe, although its worldwide incidence is variable with a slightly higher rate in India, Africa, and the Middle East (the so-called “volvulus belt”).5 Although volvulus can occur in any redundant colonic segment, it most commonly involves the sigmoid (60%–75% of all cases) and cecum (25%–40% of all cases).6–8 Sigmoid volvulus preferentially affects older men in the United States and westernized countries, although younger men are more commonly affected in the volvulus belt.6 In the United States and westernized countries, sigmoid volvulus primarily presents during the 6th to 8th decade of life, in institutionalized patients, and in patients with chronic constipation, neuropsychological impairment, or significant comorbidities.3,5,7,9 In contrast, cecal volvulus typically presents in younger patients and has a female predominance.3 The management of volvulus depends on its location and clinical presentation. Pillars of management include the assessment of colonic viability, relief of obstruction, and prevention of recurrence. Without operative intervention, recurrent volvulus rates are high, and each subsequent recurrence event risks ischemia and perforation.10–13 Meanwhile, acute colonic pseudo-obstruction (ACPO), or Ogilvie syndrome, is a nonmechanical, functional cause of LBO thought to be a consequence of dysregulation of the autonomic impulses of the colonic enteric nervous system.14,15 Whereas ACPO presents as a large-bowel obstruction in the absence of a mechanical cause that can progress to ischemia and subsequent perforation,14,16–23 patients’ specific clinical presentations vary according to the degree of colonic distension, whether or not the ileocecal valve is competent, and the overall condition of the patient. Most commonly, ACPO affects elderly patients or patients admitted to the hospital for unrelated reasons, including elective surgery, trauma, or the management of an acute medical condition. This practice guideline focuses on the evaluation and treatment of adult patients with sigmoid or cecal volvulus or ACPO. METHODOLOGY These guidelines were built on the ASCRS practice guidelines for colon volvulus and ACPO published in 2016.24 A systematic search of MEDLINE, PubMed, Scopus, and the Cochrane Database of Systematic Reviews was performed from January 1, 2014 through January 19, 2021. Individual literature searches were conducted for each statement within the guideline and were restricted to English language and adult patients (Fig. 1). Search strategies were based on the concepts of volvulus, pseudo-obstruction, and the various relevant diagnostic procedures and surgical interventions related to these diagnoses using multiple subject headings, text words, and descriptors. The 1577 screened articles were evaluated for their level of evidence, favoring clinical trials, meta-analysis and systematic reviews, comparative studies, and large registry retrospective studies over single-institutional series, retrospective reviews, and observational studies. Additional references identified through embedded references and other resources as well as practice guidelines or consensus statements from relevant societies were also reviewed. One hundred twenty-five tabulated citations were evaluated for methodologic quality, the evidence base was examined, and a treatment guideline was formulated by the subcommittee for this guideline. The final grade of recommendation and level of evidence for each statement were determined using the Grades of Recommendation, Assessment, Development, and Evaluation system (Table 1). When agreement was incomplete regarding the evidence base or treatment guideline, consensus from the committee chair, vice chair, and 2 assigned reviewers determined the outcome. Members of the ASCRS Clinical Practice Guidelines Committee worked in joint production of these guidelines from inception to final publication. Recommendations formulated by the subcommittee were reviewed by the entire Clinical Practice Guidelines Committee. The guideline was peer reviewed by Diseases of the Colon & Rectum and the final guideline was approved by the ASCRS Executive Council. In general, each ASCRS Clinical Practice Guideline is updated every 5 years. No funding was received for preparing this guideline and the authors have declared no competing interests related to this material. This guideline conforms to the Appraisal of Guidelines for Research and Evaluation (AGREE) checklist. TABLE 1. - The GRADE System: grading recommendations Grade Description Benefit versus risk and burdens Methodologic quality of supporting evidence Implications 1A Strong recommendation,High-quality evidence Benefits clearly outweigh risk and burdens or vice versa RCTs without important limitations or overwhelming evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation 1B Strong recommendation,Moderate-quality evidence Benefits clearly outweigh risk and burdens or vice versa RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation 1C Strong recommendation,Low- or very-low quality evidence Benefits clearly outweigh risk and burdens or vice versa Observational studies or case series Strong recommendation but may change when higher-quality evidence becomes available 2A Weak recommendation,High-quality evidence Benefits closely balanced with risks and burdens RCTs without important limitations or overwhelming evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patients’ or societal values 2B Weak recommendations,Moderate-quality evidence Benefits closely balanced with risks and burdens RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patients’ or societal values 2C Weak recommendation,Low- or very-low quality evidence Uncertainty in the estimates of benefits, risks and burden; benefits, risk and burden may be closely balanced Observational studies or case series Very weak recommendations; other alternatives may be equally reasonable GRADE = Grades of Recommendation, Assessment, Development, and Evaluation; RCT = randomized controlled trial.Adapted from Guyatt G, Gutermen D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians Task Force. Chest. 2006;129:174–181.25 Used with permission. FIGURE 1.: PRISMA literature search flow sheet.COLONIC VOLVULUS 1. Initial evaluation should include a focused history, physical examination, and basic laboratory assessment. Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. Presenting symptoms of both sigmoid and cecal volvulus are often nonspecific and may include abdominal pain, bloating, or cramping, nausea, emesis, and obstipation.4,5,7,12,26 It may be difficult to obtain an accurate history in patients with neuropsychiatric disorders and patients residing in long-term care facilities who rely on others to relay key historical events. Physical examination typically reveals a distended and tympanic abdomen with varying degrees of tenderness. Digital rectal examination usually reveals an empty vault.4,5,7,12,26–28 Although the duration of symptoms before presentation ranges from a few hours to several days, cecal volvulus tends to present more acutely, whereas sigmoid volvulus often has a more indolent presentation.4,11,27,29–31 Emergency presentation, with clinical signs of peritonitis or shock related to ischemia or perforation occurs in up to 25% and 35% of patients with sigmoid and cecal volvulus.12,28,30,32 Because patients with colonic volvulus frequently have comorbid conditions or may have electrolyte derangements or acute renal insufficiency secondary to emesis or dehydration, laboratory testing is often helpful during the initial evaluation of patients with suspected colonic volvulus. In general, the history and physical examination and radiological evaluations occur in parallel to facilitate care. 2. In hemodynamically stable patients, colonic volvulus is often initially evaluated with plain abdominal radiographs, whereas CT imaging may be used to confirm the diagnosis. Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. Imaging early during suspected volvulus can confirm the diagnosis and expedite care. Plain abdominal radiographs are typically performed, because the initial diagnostic evaluation and radiographs often demonstrate a distended loop of colon that may resemble a coffee bean or bent inner tube projecting toward the upper abdomen and, in patients with an incompetent ileocecal valve, may also show a distended small bowel with air-fluid levels.4,33–36 In a retrospective series of 103 of volvulus, and demonstrated that abdominal radiographs were or diagnostic for cecal and sigmoid volvulus in and of et in a retrospective of patients, that plain abdominal radiographs were diagnostic of cecal and sigmoid volvulus in and Plain abdominal radiographs may also other as or which can treatment. In clinical assessment and plain abdominal radiographs are to confirm the diagnosis of colon volvulus, CT imaging with or without rectal should be a of controlled imaging in this CT imaging is the diagnostic for both cecal and sigmoid volvulus. is and can that may be with plain radiographs or diagnoses that can the presentation of volvulus, as cecal obstruction secondary to or pseudo-obstruction, can also be with with can volvulus with and a In a retrospective of of sigmoid volvulus and of cecal volvulus by et CT without rectal an diagnostic of may a the of in the mesentery which bowel and are the diagnosis in imaging using rectal may the and confirm the diagnosis. In the diagnosis a may confirm the diagnosis by a of obstruction, as a the level of the et demonstrated that was of or diagnostic for cecal and sigmoid volvulus in and of et that the of plain abdominal radiographs and was diagnostic for cecal and sigmoid volvulus in and of retrospective studies using in of suspected volvulus and show that the of be identified in of VOLVULUS without or evidence of perforation should typically to sigmoid colon viability, the and the Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. In stable patients without colonic ischemia or the for sigmoid volvulus is which is in to of and assessment of the volvulized segment for ischemia or may be performed using or that can more proximal as may the the of obstruction before should be when patients for with signs and symptoms of bowel ischemia, or perforation should typically operative of of the sigmoid colon, a tube may be in to for colonic and to facilitate mechanical bowel as with sigmoid volvulus who without subsequent have a to recurrence The risk for recurrent volvulus and the and with each recurrent in the elderly the recommendation for operative during patients’ or sigmoid is when of the sigmoid colon and in of or Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. who present with colonic ischemia or or shock or in sigmoid is often by that the of the and the volvulized segment has the to a or should be considering multiple including the patients’ clinical the of surgery, health of the colon, and When the evidence it is important to that the studies operative for the management of sigmoid volvulus are retrospective in and include an degree of patient The the most commonly performed for patients who have sigmoid volvulus with a colon and has an rate of to Meanwhile, with has a rate of and a rate of according to a retrospective of patients from the American College of Surgeons Database who and et reviewed sigmoid volvulus with a sigmoid with = versus sigmoid with without proximal = In this a procedure was used more often in patients with a colon or peritonitis and was with and and whereas in of patients who not is often the most for patients the circumstances patients with higher evidence versus in volvulus is but available in who should be for sigmoid during the same hospital to recurrent volvulus. Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. Although treatment of volvulus is in most patients, the rate of recurrent volvulus is and patients with recurrent volvulus are risk for bowel ischemia and to 2 retrospective with and patients, patients with the of recurrent sigmoid volvulus higher and patients who elective their initial volvulus and et patients with sigmoid volvulus who without and recurrent sigmoid volvulus in patients a of these patients, and these patients, 5 were with a of volvulus a of 5 and 3 sigmoid et demonstrated recurrence in of patients a of management of sigmoid volvulus, and et recurrent sigmoid volvulus in of patients who were with A more evaluated patients with sigmoid volvulus who a of hospital In this a of were that were in patients without their a patients who a recurrence a of 2 and the of to recurrence was the of elective and that have for sigmoid volvulus, sigmoid with or without is the most recurrent these the segment of the redundant colon the risk of recurrence. of the the of is not typically the In patients with a sigmoid volvulus and sigmoid with can in and and in the is not usually and should be based on the operative and patient In a of patients with sigmoid volvulus using from the from to was with a a and overall Although and have in the management of volvulus, and patient the of the operative The and of the colon and the mesentery usually for a in patients with a history of volvulus in other of the colon or should be because it may be more in volvulus sigmoid without including and are to sigmoid for the prevention of recurrent volvulus. Grade of recommendation: Weak recommendation based on low-quality evidence, with or of the sigmoid mesentery to its base to recurrent have as for sigmoid volvulus in patients with retrospective studies of operative recurrence rates of to and rates of to all higher sigmoid Although small studies have and series report recurrence rates of to without of the sigmoid colon may be in patients in operative presents a Grade of recommendation: Weak recommendation based on low-quality evidence, to sigmoid have for patients treatment of sigmoid volvulus who are or for surgery. A of small case series have the of as a to recurrent sigmoid using or with or without can be used to the sigmoid colon to the abdominal recurrent vary in of the of used and whether are a these usually include patients deemed for to significant and report rates of tube or have in up to 25% of patients and recurrence rates from to within the in these studies, the to causes in these patient was higher the to the procedure on the available small case series, may be for the treatment of sigmoid volvulus in patients operative a VOLVULUS of cecal volvulus are not Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. sigmoid volvulus, studies do not as an initial to patients with cecal volvulus. from multiple retrospective studies from to a of patients in was in patients the of and the for of cecal volvulus operative and are not is the treatment for patients with cecal volvulus. Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. or cecum is present in to of patients with cecal volvulus and is with a significant of surgical in the of cecal volvulus with and bowel are from retrospective One of the historical series of cecal volvulus is a retrospective of published and in which of patients in this was performed primarily for volvulus by a cecum and the overall and recurrence rates for the patients who were and In a that patients with cecal volvulus who and the patients who bowel the rate of with bowel versus and no were and A more retrospective evaluated risk for and for cecal volvulus in In this although overall was the rate was and the rate was demonstrated that significant of and whereas of any and the of was Whereas the of the of bowel viability, may that a higher or and shock were more common in patients with the that overall with for cecal volvulus has over and that the rate is may be a reasonable to although the redundant in these can usually be addressed Although the regarding with in the of cecal volvulus are this should be in patients and in patients with the treatment recommendations for patients with cecal are to for patients with the more common form of cecal cecal volvulus with the use of operative procedures should be to patients who are for Grade of recommendation: Weak recommendation based on low-quality evidence, In patients with cecal volvulus with alternatives to include or with to the abdominal either by or each intervention, the risks of and should be the risk of recurrence. et surgical of patients with cecal volvulus from case series published and and higher rates of and with with and versus 15% and was with a recurrence whereas the no The authors which was with the and recurrence rates and In retrospective studies report rates for in with but and recurrence rates more operative available for cecal volvulus with the regarding the most should be with to the condition of the patient and the In general, the use of a should be to clinical circumstances a patient is for a of the volvulized Initial evaluation should include a focused history and physical examination, laboratory and diagnostic Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. colonic pseudo-obstruction most often affects or institutionalized patients who have comorbid have an or are from or signs and symptoms include abdominal pain, nausea, abdominal distension, bowel and of the and colon without evidence of mechanical obstruction on that patients with suspected ACPO frequently have comorbid conditions and may have electrolyte derangements or acute renal laboratory as a basic should be during the initial Because the management of mechanical LBO from a mechanical LBO and other conditions that can to colon is or can ACPO from a mechanical large-bowel is a for a obstruction, is not typically for diagnostic the risk of perforation in the of colon Initial treatment of ACPO is and or conditions that patients to ACPO or its Grade of recommendation: Strong recommendation based on low-quality evidence, 1C. 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