Volvulus

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • Severe intermittent colicky abdominal pain

  • Abdominal distention

  • Nausea, vomiting

  • Constipation leading to obstipation

Laboratory Findings

• • No specific findings

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

Imaging Findings

• • 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

• • 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

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

  • Abdominal x-ray

  • Barium enema

When to Admit

• • Signs and symptoms of bowel obstruction

Surgery

• • 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

Indications

• • Peritoneal findings due to strangulation or perforation

  • Failure to resolve volvulus with endoscopic decompression

  • Prevention of recurrence even after successful detorsion

Contraindications

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

  • Signs of perforation or peritonitis preclude endoscopic decompression

Complications

• • Bowel infarction

Prognosis

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

  • Mortality rate of perforated sigmoid volvulus, 50%

References