A 78-year-old man with an emotional disorder was admitted with progressive abdominal distention. He had three episodes of sigmoid volvulus. He refused surgical intervention, so each episode was treated by endoscopic decompression. A physical examination revealed a tympanitic, distended abdomen with hypoactive bowel sounds. There was no fever, rigidity, or guarding. Abdominal X-ray showed dilated bowel loops with a “coffee bean” appearance. We made a diagnosis of recurrence of sigmoid volvulus. The patient underwent a successful decompression colonoscopy with untwisting of the sigmoid loop. There was no sign of ischemia or tumor. Two days later, the volvulus recurred. Computed tomography demonstrated a mesenteric whirl pattern typical of sigmoid volvulus (Figure 1). Laboratory investigations showed a total white blood cell count of 10,130/mL and C-reactive protein of 0.5 mg/dl. Colonoscopy revealed a cobblestone appearance, which was composed of multiple polyp-like lesions in the area of the twisted sigmoid colon (Figure 2a). Again, the decompression colonoscopy was performed uneventfully. The follow-up colonoscopy revealed longitudinal ulcers without polyp-like lesions (Figure 2b).Abiopsy from the affected area revealed erosion, crypt atrophy, edema and hemorrhage, which is consistent with ischemic change. Later, the patient underwent elective sigmoidectomy. Sigmoid volvulus accounts for about 5% of cases of large bowel obstruction in developed countries. Risk factors include constipation, advanced age, and psychiatric disorders. The goals of treatment are to prevent recurrence and the development of gangrene. Endoscopic decompression followed by elective sigmoidectomy is the treatment of choice in uncomplicated patients. Endoscopic decompression has been successful in about 90% of cases. However, with endoscopic reduction alone, the recurrence rate can be more than 50%. Cobblestone appearance has been associated with longitudinal ulcers and is most often seen in untreated Crohn’s disease. Rarely, it can also be seen in ischemic colitis, intestinal tuberculosis, and cancer. To our knowledge, a cobblestone appearance has not been previously described in association with a sigmoid volvulus.