In the setting of sigmoid volvulus, which scenario most clearly requires surgical intervention rather than endoscopic decompression?

• A. Complicated sigmoid volvulus with peritonitis
• B. Uncomplicated sigmoid volvulus
• C. Ischemic colitis with mild symptoms
• D. Diverticulitis with mild symptoms

Answer: (A)

Peritoneal signs in a patient with sigmoid volvulus indicate a surgical emergency because they suggest bowel necrosis or perforation. Endoscopic decompression can relieve obstruction in stable patients without signs of compromised bowel, but it does not address viability or a perforation, and attempting it when perforation or necrosis is present can worsen sepsis. Therefore, urgent surgical exploration with resection of nonviable bowel and, if needed, restoration of continuity is required.

Uncomplicated sigmoid volvulus, on the other hand, is typically managed with endoscopic detorsion to decompress the colon, followed by definitive surgical resection to prevent recurrence. Ischemic colitis with mild symptoms would prompt a different assessment and management plan focused on bowel viability, and diverticulitis with mild symptoms is not the same presentation as sigmoid volvulus and does not dictate decompression of a twisted sigmoid colon. The clear scenario needing surgery rather than endoscopic relief is the one with peritoneal signs.