A Twisted Bowel That Cuts Off Blood Flow
The following is a hypothetical situation designed to demonstrate a common form of medical error. It is not a real case, and no physician has reviewed it or offered an opinion about it.
Thirty-four hours of bowel regimen
A woman of 83 lived in a nursing home and had taken something for constipation nearly every day for 6 years. On a Tuesday at 6:40 in the morning the staff wrote that her belly was swollen. She had not had a bowel movement in 4 days. She was sent to an emergency department, where an abdominal x ray was read as a large amount of stool and gas. She was given an enema and admitted at 2:15 that afternoon for constipation. Her pulse was 96 on arrival and 118 by 10 that night. The nursing notes recorded a belly that kept growing and she was not moving her bowels. The next morning the note said no acute distress and continue bowel regimen. A CT scan was ordered at 4:30 that afternoon. It showed a twisted sigmoid colon with a hole in it, and she died in the intensive care unit 2 days after surgery.
The short answer
Volvulus means a segment of intestine has twisted on itself. The twist does two things at once. It blocks the bowel, and it wrings the blood vessels that feed the twisted segment.
That second part is what makes this an emergency rather than a plumbing problem. A loop that is blocked and starved of blood begins to die, and dead bowel tears open.
The failure that repeats in these cases is a diagnosis of constipation that nobody revisits. Treatment starts with laxatives and enemas, which is usually right. Then the plan never changes when nothing comes out.
There are two legal questions. Did the care fall below what a careful doctor, nurse, or hospital would have done? And would treatment at the point things turned have changed the outcome?
The rest of this page explains how to tell what happened in your own case. Our guide to severe abdominal pain emergencies covers the other conditions that go wrong this way.
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Article written by Gregory Unatin, Esq. Greg is a managing partner in the law firm of Lupetin & Unatin, a medical malpractice law firm located in Pittsburgh and serving Western Pennsylvania.
Our practice is limited to high-value catastrophic cases because that is where we can do the most for our clients and for patient safety.
What a twisted intestine actually is
The large intestine is held in place by a fan of tissue that carries its blood supply. When a segment of colon is long and floppy, and its attachment is narrow at the base, it can rotate around that attachment. That rotation is the volvulus.
It happens most often in two places. One is the sigmoid colon, the last portion of the large intestine on the lower left. The other is the cecum, where the small intestine joins the large intestine on the right. The sigmoid type is the one that shows up more often in older and institutionalized patients.
The twist closes the loop at both ends. Gas and fluid keep building inside it with nowhere to go, so the loop swells. The same twist has kinked the vessels in the tissue at its base. The loop is being inflated and starved at once.
Some twists do untwist on their own, which is why many of these patients have a history of episodes that came and went. That cuts both ways. It explains why an earlier episode resolved, and it explains why nobody treated this one as different.
Chronic constipation does not directly cause a volvulus. But a colon that has been sluggish for years and a colon that is long and floppy often belong to the same patient.
Why volvulus gets missed
Start with the part that is nobody’s fault. From the outside, a volvulus looks exactly like constipation. A swollen belly. No bowel movement. No gas passing. Those are the same complaints these patients have had for years.
The population is the second problem. Many of these patients cannot give a clear history. Dementia, a stroke, sedating medication, or a language barrier all mean the person cannot say this pain is different.
Then there is the baseline. For a patient who is constipated every week of her life, being constipated and distended is not a red flag. The signal is not the finding, it is the change in the finding. Seeing a change means comparing the patient’s medical condition as it is today to last month. An accurate medical history is critical. And in an ill elderly patient, a health care provider may need to look to family members or past medical records to find the concerning change from baseline.
In some cases, signs of twisted bowel on abdominal imaging are confused for non-specific findings. A plain abdominal x ray in these patients is often abnormal at baseline. A huge loop of twisted colon can be read as a bowel full of stool and gas. Plain abdominal X-rays often show classical signs in up to 60–75% of sigmoid volvulus cases (e.g., the “coffee bean sign” or inverted U-shape loop pointing toward the right upper quadrant). However, in early, partial, or cecal volvulus, abdominal x-rays are frequently non-specific or misinterpreted as severe fecal impaction or generalized ileus. Plain films cannot exclude a volvulus if clinical suspicion remains.
The diagnostic challenge is real, and we say so plainly. Chronic constipation is genuinely common in this population, and the presentations overlap closely. Laxatives and enemas are the correct first step for the great majority of these patients.
What is harder to defend is a plan that does not change. Nothing came out, the belly kept growing, and the note the next morning said continue.
The imaging that should have been done
The CT scan. A CT scan of the abdomen and pelvis is the study that settles this question. It shows where the bowel is twisted and which segment is involved. It can also show free air or fluid, meaning the bowel has already torn. Its ability to show whether the twisted bowel is still alive is less certain than its ability to find the twist. A scan that finds a volvulus and no dead bowel is a reason to move quickly, not a reason to relax.
The plain x ray. A plain film can suggest this diagnosis, and in the right hands it sometimes makes it. What it cannot do is rule it out. Where the film is equivocal, the next step is a CT scan and a surgeon, not another enema.
The examination and the output record. What comes out after an enema is a test result, and it lives in the nursing notes. An abdomen measurably larger than it was. A rectum empty on examination. No gas passing after an enema. None of those is specific by itself. Together, in a patient who is not improving, they are the reason to test again.
The clock
Once a segment is tightly twisted, the injury runs on its own schedule.
The loop keeps swelling because it is closed at both ends. Pressure rises inside it, and the vessels at the base stay kinked. The wall of the bowel begins to die, and dying bowel tears. Stool spills into the abdomen and causes peritonitis, meaning infection of the lining of the belly. Blood pressure falls and organs fail.
Nobody can put a reliable number of hours on how long a twisted loop survives. It varies with how tight the twist is and with the patient. What is not in dispute is the direction. Earlier treatment is more likely to find living bowel.
The treatment depends on where the twist is, and that difference matters. A sigmoid volvulus can often be untwisted with a scope passed from below, which lets the gas out. That is not a cure, because these twists come back, so an operation is usually planned afterward. A twist at the cecum generally needs an operation. If there are signs the bowel has died or torn, the scope is off the table for either one.
In this hypothetical case, the plan should have changed when the belly kept swelling and nothing came out. A CT scan that evening would likely have shown the twist in time to treat it.
Who is at highest risk
- Older adults, in whom this is far more common and tenderness and fever are often muted.
- Nursing home residents, where the baseline is already abnormal and the history comes secondhand.
- Chronic constipation, which travels with the kind of long, mobile colon that can rotate.
- Neurologic and psychiatric conditions, and several of the medicines used to treat them, which slow the bowel.
- A prior episode of the same thing, which means the anatomy that allowed it has not changed.
This article on severe abdominal pain covers the broader risk factors across these emergencies.
What to look for in the records
These are things you can check, or ask a lawyer to check.
- Prior imaging from earlier visits, and whether an old film shows the same oversized loop.
- Prior admissions or emergency visits for the same complaint, and how each ended.
- What imaging was ordered on this visit, how the film was read, and how many hours passed before any CT scan.
- The nursing notes on distension, including any girth measurements, and whether anything came out after each laxative or enema.
- The complete vital sign record, read as a trend rather than one number at a time.
- The daily progress notes, and whether the plan changed at any point or the same sentence was carried forward.
- Whether a surgeon was consulted, when the request was placed, and when it was answered.
- Records from the nursing facility, which establish what this patient’s normal actually was.
The central question: should someone have stopped treating this as constipation?
Chronic constipation in this population is real and it is everywhere. Laxatives and enemas are the first treatment for it, and that is correct far more often than it is wrong. A doctor who sends every constipated nursing home resident for a CT scan will send many people who did not need one. These patients often cannot describe their pain, and their x rays are abnormal at baseline. A defense expert will say the presentation overlapped almost completely with the condition this patient had every week. Sometimes that is right.
The two central questions remain. Did the care fall below what a careful doctor, nurse, or hospital would have done in the same situation? And would treatment at the point things turned have changed the outcome?
The argument here is not that a volvulus is easy to spot on arrival. It is narrower. It is that this chart already held the findings that called for a different question, at an hour you can point to. The belly grew, the pulse climbed, nothing came out after enema, and the plan stayed the same. The medical evidence must then show that looking again would have led to treatment in time.
How people die from this, and what happens to those who survive
Most patients with a volvulus who are treated in time recover and go home.
When it goes the other way, it usually goes one of two ways. The more common is perforation, meaning the dead bowel tears open. Stool spills into the abdomen, which causes peritonitis and then septic shock, where blood pressure stops responding and organs fail. The other is death in the days after an operation that came too late, in a patient too frail to survive it. These two overlap, because the operation is usually late for the same reason the bowel tore.
Among those who survive, the injuries that permanently change a life are these, most common first.
- Loss of a large amount of intestine. How much comes out depends on how much had died, which depends on when the twist was treated.
- A permanent ostomy, meaning the bowel empties through an opening in the skin into a bag. Some are reversed later. In a frail patient who barely survived the first operation, a second one is often never attempted.
- An open abdomen, where the belly cannot be closed at the end of the operation and is left open under a dressing for days. These patients often need a major reconstruction later.
One point of contrast with other bowel emergencies. Losing part of the colon does not cause the inability to absorb food that follows losing a long stretch of small intestine.
How we prove a case like this
A handful of records decide this condition.
Prior imaging and prior admissions for the same complaint turn this visit into a change rather than a baseline. They are also where an earlier missed chance shows up. The imaging ordered on this visit, and the order behind it, show what question anybody was asking. The nursing notes on distension and output are the record of a treatment that was not working. The time to surgical consultation shows where the hours went. The operative report tells us what was found, which is how we work backward to what an earlier operation would have found.
These cases usually need emergency medicine, general surgery or colorectal surgery, and radiology. Where the patient lived in a facility, a geriatrics expert often matters as much as the surgeon.
Pennsylvania also requires a licensed professional to certify that the care fell below the accepted standard before a case can move forward. Our hub article walks through the full investigation process.
Two other conditions on our site injure the bowel in the same way. One is a hernia with intestine trapped in it, which strangles a loop inside the hernia. The other is a blockage from scar tissue, where a band of scar does what the twist does here.
Frequently Asked Questions
By looking at what happened after she was treated. Constipation responds to treatment. A twisted colon does not. When an enema produces nothing, and the belly is bigger the next morning, the working diagnosis has failed a test. The years of constipation are why the first diagnosis was reasonable. They are not a reason to keep it after it stopped explaining what was in front of them.
It can be either, and sometimes both. A facility has its own duties, including recognizing a change in a resident and getting her evaluated. A hospital has its own duties once she arrives. We look at both timelines, because hours lost in one place do not excuse hours lost in the other.
No. The records that matter here are often the hardest ones to get, including nursing notes, output records, prior films, and the nursing facility chart. We request the complete record ourselves. If you already have paperwork, bring it, but do not wait on it.
No. An initial conversation is free, and so is our review of the case. We work on a contingency basis, which means a fee only if we recover money for you.
In Pennsylvania, a medical malpractice lawsuit must be filed in a proper court within two years of the date of death or in the absence of death, the date when the patient knew or should have known they suffered an injury which may have been related to health care. The practical point is that these cases depend on old films and facility records, and on staff who move on. Waiting costs you something even when no deadline is close.
What to do now
Gather what you have: hospital discharge paperwork, any operative report, the death certificate if there is one, and the nursing facility name and dates. Then write down what you saw, day by day, while it is fresh. When her belly looked bigger. What you told the nurse, and at what time. What you were told when you asked whether something else was wrong. Families notice a change before a chart does, and what you remember is evidence. Then call us.