Volvulus

Dr Rajneesh Varshney Asst Professor SRMSIMS

Volvulus

Twisting or axial rotation of a portion of bowel of more than 180 degrees about the axis of the mesentery leading to obstruction

TypesPRIMARY: secondary to congenital malrotation of the gut, abnormal mesentric attachments or congenital bands e.g. Volvulus neonatorum Caecal volvulus Sigmoid volvulus SECONDARY( more common): actual rotation of a piece of bowel around an acquired adhesion or stoma e.g. Volvulus of small intestine Gastric Volvulus Volvulus of large intestine

Signs and symptomsRegardless of cause, volvulus causes symptoms by two mechanisms.

One is bowel obstruction, manifested as abdominal distension and vomiting. The other is ischemia (loss of blood flow) to the affected portion of intestine due to strangulation leading to gangrene

Sigmoid VolvulusWorldwide - up to 65% of obstruction

India, Africa, E. Europe

More commonly seen in elderly patients Rotation nearly always occurs in an anticlockwise direction. Predisposing factors

Chronic constipation Psychiatric problems High residue diet

Risk Factors

elongated mesocolon or movable sigmoid colon that is unattached to the left sidewall of the abdomen narrow attatchment of mesocolon that allows twisting at its base Band of adhesions Overloaded pelvic colon

PresentationVaries in severity and acuteness Younger patients develop more acute form Abdominal distension is an early or progressive sign associated with hiccough and wretching Vomiting occurs late Absolute constipation Crampy abdominal pain Shock

PresentationExam: Tympanic abdomen, distension, tenderness, palpable mass

Sigmoid volvulusbent inner tube appearance Dilated sigmoid loop with limbs pointing towards the RLQ

Barium EnemaContraindicated in free air on AXR, clinical signs of peritonitis, suspicion for necrosed bowel Birds beak Can decompress

Management of choiceEndoscopic decompression

Rigid or flexible proctosigmoidoscope inserted into rectum Gush of air/feces --> successful decompression Rectal tube insertion Successful in 85-90% of cases Recurrence rate >60% Decreased risk for bowel necrosis if treated earlyColon ischemia, perforation

Elective resection

Operative management for sigmoid volvulusEmergent laparotomyOperation depends on viability of the bowel Resection and anastomosis Hartmann procedure Detorsion Detorsion with sigmoidopexy

Delayed resection with primary anastomosis

Mortality rate 8%

Operative mortality related to viability of bowel

Viable 12% vs nonviable 53% mortality

Cecal VolvulusLess common than sigmoid volvulus Parietal peritoneum fails to connect with the cecum and right colon

Present in about 10% of population

Increased mobility of bowel, resulting in it folding on its axis or upward Clockwise rotation Risk factors:

Distal obstruction, pregnancy, adhesions, congenital bands, prolonged constipation

Presentation: Features of obstruction abdominal pain colicky Distention Cecum folds anteriorly on ascending colon May result in intermittent obstructive symptoms Palpable tympanic swelling in midline or left side of abdomen

X-rayscomma shaped Barium Enema Absence of barium in caecum Bird beak deformity risk of perforation

ManagementDecompression with colonoscope

Less successful than with sigmoid volvulus

Emergent operation if signs of vascular compromise

Operative management for cecal volvulusDetorsion with caecopexy Suture Caecum and ascending colon to right lateral paracolic gutter Cecostomy Resection Right hemicolectomy with primary anastomosis or ileostomy

Transverse colon volvulusLess common area for volvulus(4%) Associated with mobile right colon, distal obstruction, chronic constipation, congenital malrotation of the midgut Usually not diagnosed preoperatively No characteristic radiological findings except colonic dilatation Resection of transverse colon

High rate of recurrence if treated with detorsion alone

Volvulus neonatorumArrested gut rotation with narrow mesentry of small bowel and caecum Abdominal distension and rapid dehydration Clockwise rotation X ray reveal sign of duodenal obstruction Laparotomy reveals distended stomach Treatment- untwisting and division of any band( transduodenal band of Ladd)