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  • • Rotation of a segment of intestine on an axis (bowel twists on its mesentery)

    • Most commonly sigmoid colon (65%) and cecum

    • May produce large or small bowel obstruction

    • Causes closed-loop obstruction

    • Predisposes to bowel infarction, perforation

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Epidemiology

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  • • Usually in older age groups

    • 25% of bowel obstruction in pregnant patients

    • 50% of patients > 70 years of age

    • Frequently seen in bedridden, debilitated patients

    • Associated with high fiber, high residue diet

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Symptoms and Signs

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  • • Severe intermittent colicky abdominal pain

    • Abdominal distention

    • Nausea, vomiting

    • Constipation leading to obstipation

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Laboratory Findings

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  • • No specific findings

    • Leukocytosis, metabolic acidosis should raise suspicion of bowel compromise, possible perforation

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Imaging Findings

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  • • Abdominal x-ray

    • - "Bent inner tube"

      - Signs of intestinal obstruction, including air-fluid levels and dilated loops of bowel

    • Barium enema: "Bird's beak" or "ace of spades" deformity

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  • • Functional bowel obstruction

    • -Adynamic ileus

      -Pseudo-obstruction

    • Other causes of mechanical obstruction

    • -Neoplasm

      -Stricture

      -Extrinsic compression

      -Hernia (external or internal)

      -Adhesion

    • Intussusception

    • Gallstone ileus

    • Inflammatory bowel disease

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  • • Complete history and physical exam, including surgical history, history of malignancy, medications (especially psychotropic)

    • Abdominal x-ray

    • Barium enema

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When to Admit

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  • • Signs and symptoms of bowel obstruction

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Surgery

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  • • NG decompression

    • Endoscopic evaluation and attempt at decompression for sigmoid volvulus

    • Placement of rectal tube

    • Exploratory laparatomy, untwisting of the bowel, resection of ischemic or necrotic bowel

    • Attempts at re-anastomosis vs exteriorization of bowel dependent on absence or presence of perforation, peritoneal soilage, gangrenous bowel

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Indications

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  • • Peritoneal findings due to strangulation or perforation

    • Failure to resolve volvulus with endoscopic decompression

    • Prevention of recurrence even after successful detorsion

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Contraindications

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  • • Extremely high-risk patients may have decompression via tube cecostomy

    • Signs of perforation or peritonitis preclude endoscopic decompression

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Complications

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  • • Bowel infarction

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Prognosis

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  • • Mortality rate following emergent operation for cecal volvulus, 12%; if cecum is gangrenous, mortality, 35%

    • Mortality rate of perforated sigmoid volvulus, 50%

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References

Feldman D: The coffee bean sign. Radiology 2000;216:178.  [PubMed: 10887245]
Grossmann EM et al: Sigmoid volvulus in Department of Veterans Affairs Medical Centers. Dis Colon Rectum 2000;43:414.  [PubMed: 10733126]
Madiba TE, Thomson SR: The management of sigmoid volvulus. J R Coll Surg Edinb 2000;45:74.  [PubMed: 10822915]

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