What's the alternative imaging for sigmoid volvulus (coffee bean sign on axr) when plain film equivocal?

Q: What's the alternative imaging for sigmoid volvulus (coffee bean sign on axr) when plain film equivocal?

CT — Single-contrast water-soluble enema (or CT) (iv contrast).

Imaging recommendation · Abdomen · Pelvis

Sigmoid volvulus (coffee bean sign on AXR)

Recommended: CT Abdomen / Pelvis with IV contrast is the preferred imaging study for sigmoid volvulus (coffee bean sign on axr). Whirl sign in mesentery.

Recommended study

CT Abdomen / Pelvis with IV contrast

CT IV contrast Preferred Abdomen · Pelvis Emergency Reviewed 2026-05

Whirl sign in mesentery. Sigmoidoscopic decompression is first-line if no ischemia.

If the default doesn't apply

Plain film equivocal

CT Single-contrast water-soluble enema (or CT) IV contrast

Watch-outs

Signs of ischemia / perforation

Bowel wall pneumatosis, portal venous gas, peritoneal signs → surgical, not endoscopic, management.

Recurrence after decompression

Common — elective sigmoidectomy considered for recurrent / chronic megacolon.

Pearls

AXR 'coffee bean' sign points to LUQ for sigmoid volvulus, LLQ for cecal volvulus.
Endoscopic decompression successful in ~80% of sigmoid volvulus without ischemia.
Higher risk in elderly, institutionalized, neurogenic, and chronic constipation patients.