Procedures

Endoscopic reduction of volvulus. This procedure is indicated for sigmoid volvulus when peritoneal signs are absent, which would imply dead bowel or perforation. It also is indicated when evidence of mucosal ischaemia is not present upon endoscopy. An experienced person should perform the procedure. A rigid sigmoidoscope may be used if a flexible instrument is not available. The endoscopist must have sufficient experience with this technique. Reduction of a volvulus does not imply cure.

The sigmoid usually revolvulizes if definitive treatment is not carried out. These patients generally are admitted, subjected to mechanical bowel preparation, and managed surgically by sigmoid resection, unless contraindications are present.

Barium enema for reduction of intussusception. This is useful and often successful in children in whom a pathological leading point for the intussusception is unlikely. It should be performed by an experienced radiologist because the risk of perforation is significant. In adults, typically a pathologic leading point for the intussusception is present. Success is far less likely, and patients still require surgery to deal with their pathology.

Cleansing enemas. Perform these if obstipation is suspected rather than true large bowel obstruction. Also perform them to prepare the distal colon for endoscopic evaluation.

Endoscopic dilation and stenting of colonic obstruction This procedure is indicated for colonic near total obstruction through which some small amount of lumen remains. The procedure may be palliative in a high-risk patient with an unresectable malignancy, accepting a risk of reobstruction of the stent, or preparatory to surgical resection. In cases in which the stent is deployed prior to surgery, it permits relief of the acute obstruction, resuscitation of the patient, and mechanical bowel preparation prior to a one-stage colonic resection and reanastomosis, thus avoiding temporary or permanent colostomy. The procedure should be performed only by an endoscopist experienced in such procedures. Surgical consultation and backup should be available, as the risk of perforation is increased during attempts at such procedures, with a potentially catastrophic result.