Volvulus

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Volvulus
Volvulus.PNG
Coronal CT of the abdomen, demonstrating a volvulus as indicated by twisting of the bowel stock
Specialty General surgery
Symptoms Abdominal pain, abdominal bloating, vomiting, constipation, bloody stool [1] [2]
Complications Ischemic bowel [1]
Usual onsetRapid or more gradual [2]
Risk factors Intestinal malrotation, enlarged colon, Hirschsprung disease, pregnancy, abdominal adhesions, chronic constipation [1] [3]
Diagnostic method Medical imaging (plain X-rays, GI series, CT scan) [1]
Treatment Sigmoidoscopy, barium enema, bowel resection [3]
Frequency2.5 per 100,000 per year [4] [2]

A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction. [1] Symptoms include abdominal pain, abdominal bloating, vomiting, constipation, and bloody stool. [1] [2] Onset of symptoms may be rapid or more gradual. [2] The mesentery may become so tightly twisted that blood flow to part of the intestine is cut off, resulting in ischemic bowel. [1] In this situation there may be fever or significant pain when the abdomen is touched. [2]

Contents

Risk factors include a birth defect known as intestinal malrotation, an enlarged colon, Hirschsprung disease, pregnancy, and abdominal adhesions. [1] Long term constipation and a high fiber diet may also increase the risk. [3] The most commonly affected part of the intestines in adults is the sigmoid colon with the cecum being second most affected. [1] In children the small intestine is more often involved. [5] The stomach can also be affected. [6] Diagnosis is typically with medical imaging such as plain X-rays, a GI series, or CT scan. [1]

Initial treatment for sigmoid volvulus may occasionally occur via sigmoidoscopy or with a barium enema. [3] Due to the high risk of recurrence, a bowel resection within the next two days is generally recommended. [3] If the bowel is severely twisted or the blood supply is cut off, immediate surgery is required. [1] In a cecal volvulus, often part of the bowel needs to be surgically removed. [3] If the cecum is still healthy, it may occasionally be returned to a normal position and sutured in place. [1] [3]

Cases of volvulus were described in ancient Egypt as early as 1550 BC. [3] It occurs most frequently in Africa, the Middle East, and India. [3] [7] [8] Rates of volvulus in the United States are about 2–3 per 100,000 people per year. [2] [4] Sigmoid and cecal volvulus typically occurs between the ages of 30 and 70. [1] [9] Outcomes are related to whether or not the bowel tissue has died. [2] The term volvulus is from the Latin "volvere"; which means "to roll". [3]

Signs and symptoms

Regardless of cause, volvulus causes symptoms by two mechanisms: [10]

Depending on the location of the volvulus, symptoms may vary. For example, in patients with cecal volvulus, the predominant symptoms may be those of small bowel obstruction (nausea, vomiting and lack of stool or flatus), because the obstructing point is close to the ileocecal valve and small intestine. In patients with sigmoid volvulus, although abdominal pain may be present, symptoms of constipation may be more prominent.

Volvulus causes severe pain and progressive injury to the intestinal wall, with accumulation of gas and fluid in the portion of the bowel obstructed. [11] Ultimately, this can result in necrosis of the affected intestinal wall, acidosis, and death. This is known as a closed-loop obstruction because there exists an isolated ("closed") loop of bowel. Acute volvulus often requires immediate surgical intervention to untwist the affected segment of bowel and possibly resect any unsalvageable portion. [11]

Volvulus occurs most frequently in middle-aged and elderly men. [11] Volvulus can also arise as a rare complication in persons with redundant colon, a normal anatomic variation resulting in extra colonic loops. [12]

Sigmoid volvulus is the most-common form of volvulus of the gastrointestinal tract. [13] and is responsible for 8% of all intestinal obstructions.[ citation needed ] Sigmoid volvulus is particularly common in elderly persons and constipated patients. Patients experience abdominal pain, distension, and absolute constipation.

Cecal volvulus is slightly less common than sigmoid volvulus and is associated with symptoms of abdominal pain and small bowel obstruction.

Volvulus can also occur in patients with Duchenne muscular dystrophy due to smooth muscle dysfunction.[ citation needed ]

Gastric volvulus causes nausea, vomiting, and pain in the upper abdomen. The Borchardt triad is a group of symptoms that help doctors to identify gastric volvulus. The symptoms are intractable retching, pain in the upper abdomen and inability to pass nasogastric tube into the stomach. [14]

Complications

Causes

Midgut volvulus occurs in people (usually babies) that are predisposed because of congenital intestinal malrotation. Segmental volvulus occurs in people of any age, usually with a predisposition because of abnormal intestinal contents (e.g. meconium ileus) or adhesions. Volvulus of the cecum, transverse colon, or sigmoid colon occurs, usually in adults, with only minor predisposing factors such as redundant (excess, inadequately supported) intestinal tissue and constipation. [15]

Types

Diagnosis

After taking a thorough history, the diagnosis of colonic volvulus is usually easily included in the differential diagnosis. Abdominal plain x-rays are commonly confirmatory for a volvulus, especially if a "bent inner tube" sign or a "coffee bean" sign are seen. These refer to the shape of the air-filled closed loop of colon which forms the volvulus. Should the diagnosis be in doubt, a barium enema may be used to demonstrate a "bird's beak" at the point where the segment of proximal bowel and distal bowel rotate to form the volvulus.[ citation needed ]

This area shows an acute and sharp tapering and looks like a bird's beak. If a perforation is suspected, barium should not be used due to its potentially lethal effects when distributed throughout the free intraperitoneal cavity. Gastrografin, which is safer, can be substituted for barium.[ citation needed ]

The differential diagnosis includes the much more common constricting or obstructing carcinoma. In approximately 80 percent of colonic obstructions, invasive carcinoma is found to be the cause of the obstruction. This is usually easily diagnosed with endoscopic biopsies.

Diverticulitis is a common condition with different presentations. Although diverticulitis may be the source of a colonic obstruction, it more commonly causes an ileus, which appears to be a colonic obstruction. [16] Endoscopic means can be used to secure a diagnosis although this may cause a perforation of the inflamed diverticular area. CT scanning is the more common method to diagnose diverticulitis. The scan will show mesenteric stranding in the involved segment of edematous colon which is usually in the sigmoid region. Micro perforations with free air may be seen.[ citation needed ]

Ulcerative colitis or Crohn's disease may cause colonic obstruction. The obstruction may be acute or chronic after years of uncontrolled disease leads to the formation of strictures and fistulas. The medical history is helpful in that most cases of inflammatory bowel disease are well known to both patient and doctor.

Other rare syndromes, including Ogilvie's syndrome, chronic constipation and impaction may cause a pseudo obstruction. [17]

Treatment

Volvulus with gangrene of the sigmoid Volvulus (Dickdarm).JPG
Volvulus with gangrene of the sigmoid

Sigmoid

Treatment for sigmoid volvulus may include sigmoidoscopy. If the mucosa of the sigmoid looks normal and pink, a rectal tube for decompression may be placed, and any fluid, electrolyte, cardiac, kidney or pulmonary abnormalities should be corrected. The affected person should then be taken to the operating room for surgical repair. If surgery is not performed, there is a high rate of recurrence. [10]

For people with signs of sepsis or an abdominal catastrophe, immediate surgery and resection are advised.

Cecal

In a cecal volvulus, the cecum may be returned to a normal position and sutured in place, a procedure known as cecopexy. [1] If identified early, before presumed intestinal wall ischemia has resulted in tissue breakdown and necrosis, the cecal volvulus can be detorsed laparoscopically. [18] It has been associated to several diseases, including Huntington's disease. [19]

Other

Laparotomy for other forms of volvulus, especially anal volvulus.

Related Research Articles

<span class="mw-page-title-main">Defecation</span> Expulsion of feces from the digestive tract via the anus

Defecation follows digestion, and is a necessary process by which organisms eliminate a solid, semisolid, or liquid waste material known as feces from the digestive tract via the anus. The act has a variety of names ranging from the common, like pooping or crapping, to the technical, e.g. bowel movement, to the obscene (shitting), to the euphemistic, to the juvenile. The topic, usually avoided in polite company, can become the basis for some potty humor.

<span class="mw-page-title-main">Hirschsprung's disease</span> Medical condition

Hirschsprung's disease is a birth defect in which nerves are missing from parts of the intestine. The most prominent symptom is constipation. Other symptoms may include vomiting, abdominal pain, diarrhea and slow growth. Most children develop signs and symptoms shortly after birth. However, others may be diagnosed later in infancy or early childhood. About half of all children with Hirschsprung's disease are diagnosed in the first year of life. Complications may include enterocolitis, megacolon, bowel obstruction and intestinal perforation.

<span class="mw-page-title-main">Bowel obstruction</span> Medical condition

Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion. Either the small bowel or large bowel may be affected. Signs and symptoms include abdominal pain, vomiting, bloating and not passing gas. Mechanical obstruction is the cause of about 5 to 15% of cases of severe abdominal pain of sudden onset requiring admission to hospital.

<span class="mw-page-title-main">Abdominal pain</span> Stomach aches

Abdominal pain, also known as a stomach ache, Is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given that, approaching the examination of a person and planning of a differential diagnosis is extremely important.

<span class="mw-page-title-main">Diverticulitis</span> Digestive disease of the large intestine

Diverticulitis, also called colonic diverticulitis, is a gastrointestinal disease characterized by inflammation of abnormal pouches—diverticula—that can develop in the wall of the large intestine. Symptoms typically include lower-abdominal pain of sudden onset, but the onset may also occur over a few days. There may also be nausea; and diarrhea or constipation. Fever or blood in the stool suggests a complication. Repeated attacks may occur.

<span class="mw-page-title-main">Diverticulosis</span> Condition of the wall of the intestine

Diverticulosis is the condition of having multiple pouches (diverticula) in the colon that are not inflamed. These are outpockets of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall. Diverticula do not cause symptoms in most people. Diverticular disease occurs when diverticula become clinically inflamed, a condition known as diverticulitis.

<span class="mw-page-title-main">Meckel's diverticulum</span> Medical condition

A Meckel's diverticulum, a true congenital diverticulum, is a slight bulge in the small intestine present at birth and a vestigial remnant of the vitelline duct. It is the most common malformation of the gastrointestinal tract and is present in approximately 2% of the population, with males more frequently experiencing symptoms.

<span class="mw-page-title-main">Gastrointestinal disease</span> Medical condition

Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the esophagus, stomach, small intestine, large intestine and rectum, and the accessory organs of digestion, the liver, gallbladder, and pancreas.

Colic in horses is defined as abdominal pain, but it is a clinical symptom rather than a diagnosis. The term colic can encompass all forms of gastrointestinal conditions which cause pain as well as other causes of abdominal pain not involving the gastrointestinal tract. What makes it tricky is that different causes can manifest with similar signs of distress in the animal. Recognizing and understanding these signs is pivotal, as timely action can spell the difference between a brief moment of discomfort and a life-threatening situation. The most common forms of colic are gastrointestinal in nature and are most often related to colonic disturbance. There are a variety of different causes of colic, some of which can prove fatal without surgical intervention. Colic surgery is usually an expensive procedure as it is major abdominal surgery, often with intensive aftercare. Among domesticated horses, colic is the leading cause of premature death. The incidence of colic in the general horse population has been estimated between 4 and 10 percent over the course of the average lifespan. Clinical signs of colic generally require treatment by a veterinarian. The conditions that cause colic can become life-threatening in a short period of time.

<span class="mw-page-title-main">Intussusception (medical disorder)</span> Medical condition

Intussusception is a medical condition in which a part of the intestine folds into the section immediately ahead of it. It typically involves the small bowel and less commonly the large bowel. Symptoms include abdominal pain which may come and go, vomiting, abdominal bloating, and bloody stool. It often results in a small bowel obstruction. Other complications may include peritonitis or bowel perforation.

Intestinal malrotation is a congenital anomaly of rotation of the midgut. It occurs during the first trimester as the fetal gut undergoes a complex series of growth and development. Malrotation can lead to a dangerous complication called volvulus. Malrotation can refer to a spectrum of abnormal intestinal positioning, often including:

<span class="mw-page-title-main">Colectomy</span> Surgical removal of any extent of the colon

Colectomy is bowel resection of the large bowel (colon). It consists of the surgical removal of any extent of the colon, usually segmental resection. In extreme cases where the entire large intestine is removed, it is called total colectomy, and proctocolectomy denotes that the rectum is included.

<span class="mw-page-title-main">Gastrointestinal perforation</span> Medical condition

Gastrointestinal perforation, also known as ruptured bowel, is a hole in the wall of part of the gastrointestinal tract. The gastrointestinal tract includes the esophagus, stomach, small intestine, and large intestine. Symptoms include severe abdominal pain and tenderness. When the hole is in the stomach or early part of the small intestine, the onset of pain is typically sudden while with a hole in the large intestine onset may be more gradual. The pain is usually constant in nature. Sepsis, with an increased heart rate, increased breathing rate, fever, and confusion may occur.

<span class="mw-page-title-main">Megacolon</span> Medical condition

Megacolon is an abnormal dilation of the colon. This leads to hypertrophy of the colon. The dilation is often accompanied by a paralysis of the peristaltic movements of the bowel. In more extreme cases, the feces consolidate into hard masses inside the colon, called fecalomas, which can require surgery to be removed.

<span class="mw-page-title-main">Bowel resection</span> Surgical procedure in which a part of an intestine is removed

A bowel resection or enterectomy is a surgical procedure in which a part of an intestine (bowel) is removed, from either the small intestine or large intestine. Often the word enterectomy is reserved for the sense of small bowel resection, in distinction from colectomy, which covers the sense of large bowel resection. Bowel resection may be performed to treat gastrointestinal cancer, bowel ischemia, necrosis, or obstruction due to scar tissue, volvulus, and hernias. Some patients require ileostomy or colostomy after this procedure as alternative means of excretion. Complications of the procedure may include anastomotic leak or dehiscence, hernias, or adhesions causing partial or complete bowel obstruction. Depending on which part and how much of the intestines are removed, there may be digestive and metabolic challenges afterward, such as short bowel syndrome.

Stercoral ulcer is an ulcer of the colon due to pressure and irritation resulting from severe, prolonged constipation due to a large bowel obstruction, damage to the autonomic nervous system, or stercoral colitis. It is most commonly located in the sigmoid colon and rectum. Prolonged constipation leads to production of fecaliths, leading to possible progression into a fecaloma. These hard lumps irritate the rectum and lead to the formation of these ulcers. It results in fresh bleeding per rectum. These ulcers may be seen on imaging, such as a CT scan but are more commonly identified using endoscopy, usually a colonoscopy. Treatment modalities can include both surgical and non-surgical techniques.

<span class="mw-page-title-main">Epiploic appendagitis</span> Medical condition

Epiploic appendagitis (EA) is an uncommon, benign, self-limiting inflammatory process of the epiploic appendices. Other, older terms for the process include appendicitis epiploica and appendagitis, but these terms are used less now in order to avoid confusion with acute appendicitis.

An ileosigmoid knot is a form of volvulus in which ileum wraps around the base of the sigmoid and passes beneath itself forming a knot.

Hinchey Classification is used to describe perforations of the colon due to diverticulitis. The classification was developed by Dr. E John Hinchey (1934–present), a general surgeon at the Montreal General Hospital and professor of surgery at McGill University.

<span class="mw-page-title-main">Sigmoid colon volvulus</span> Medical condition

Sigmoid colon volvulus, also known as sigmoid volvulus, is volvulus affecting the sigmoid colon. It is a common cause of bowel obstruction and constipation. It is common in Asia, India and especially South India because of the high fibre diet. It is a very common cause of large bowel obstruction in Peru and Bolivia due to high altitude.

References

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  2. 1 2 3 4 5 6 7 8 Marx, John; Walls, Ron; Hockberger, Robert (2013). "95". Rosen's Emergency Medicine - Concepts and Clinical Practice. Elsevier Health Sciences. ISBN   978-1455749874. Archived from the original on 2016-08-16.
  3. 1 2 3 4 5 6 7 8 9 10 Gingold, D; Murrell, Z (December 2012). "Management of colonic volvulus". Clinics in Colon and Rectal Surgery. 25 (4): 236–44. doi:10.1055/s-0032-1329535. PMC   3577612 . PMID   24294126. The Papyrus Ebers, ca. 1550 BC, described the natural course of volvulus to be spontaneous reduction or "rotting" of the intestines
  4. 1 2 Gordon, Philip H.; Nivatvongs, Santhat (2007). Principles and Practice of Surgery for the Colon, Rectum, and Anus, Third Edition. CRC Press. p. 971. ISBN   9781420017991. Archived from the original on 2016-08-17.
  5. ↑ Wilkins, Lippincott Williams & (2009). Professional Guide to Diseases . Lippincott Williams & Wilkins. p.  283. ISBN   9780781778992.
  6. ↑ Feldman, Mark; Friedman, Lawrence S.; Brandt, Lawrence J. (2010). Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management, Expert Consult Premium Edition - Enhanced Online Features (9 ed.). Elsevier Health Sciences. p. 384. ISBN   978-1437727678. Archived from the original on 2016-08-16.
  7. ↑ Brothwell, Don R.; R, Dawson Warren R. Sandison A. T. Brothwell Don; Sandison, A. T. (14 May 2014). Diseases in Antiquity: A Survey of the Diseases, Injuries, and Surgery of Early Populations. Charles C. Thomas Publisher, Limited. ISBN   978-0-398-08909-2.
  8. ↑ Ballantyne, Garth H. (July 1982). "Review of sigmoid volvulus: History and results of treatment". Diseases of the Colon & Rectum. 25 (5): 494–501. doi:10.1007/BF02553666.
  9. ↑ Beck, David; Beck, David E. (2012). "23". Handbook of Colorectal Surgery: Third Edition. JP Medical Ltd. ISBN   9781907816208. Archived from the original on 2016-08-16.
  10. 1 2 "Volvulus". The Lecturio Medical Concept Library. Retrieved 12 July 2021.
  11. 1 2 3 Wedding, Mary Ellen; Gylys, Barbara A. (2004). Medical Terminology Systems: A Body Systems Approach (Medical Terminology (W/CD & CD-ROM) (Davis)). Philadelphia, Pa: F. A. Davis Company. ISBN   0-8036-1249-4.
  12. ↑ Mayo Clinic Staff (2006-10-13). "Redundant colon: A health concern?". Ask a Digestive System Specialist. MayoClinic.com. Archived from the original on 2007-09-29. Retrieved 2007-06-11.
  13. ↑ Turan M, Sen M, Karadayi K, et al. (January 2004). "Our sigmoid colon volvulus experience and benefits of colonoscope in detortion process". Rev Esp Enferm Dig. 96 (1): 32–5. doi: 10.4321/s1130-01082004000100005 . PMID   14971995. Archived from the original on 2011-07-11.
  14. ↑ Peterson, Christine M.; Anderson, John S.; Hara, Amy K.; Carenza, Jeffrey W.; Menias, Christine O. (September 2009). "Volvulus of the Gastrointestinal Tract: Appearances at Multimodality Imaging". RadioGraphics. 29 (5): 1281–1293. doi:10.1148/rg.295095011. ISSN   0271-5333. PMID   19755596.
  15. ↑ Le CK, Nahirniak P, Anand S, Cooper W (2023). "Volvulus". National Center for Biotechnology Information, U.S. National Library of Medicine. PMID   28722866 . Retrieved 12 July 2021.
  16. ↑ Hoffman, Gary H. (2007-08-16). "Diverticulosis/Diverticulitis - For Physicians". Time To Call The Surgeon?. Los Angeles Colon and Rectal Surgical Associates. LAcolon.com. Archived from the original on 2013-02-26. Retrieved 2012-07-07.
  17. ↑ Hoffman, Gary H. (2009-10-27). "What is Constipation?". What Can Be Done About Constipation. Los Angeles Colon and Rectal Surgical Associates. LAcolon.com. Archived from the original on 2012-06-13. Retrieved 2012-07-06.
  18. ↑ Jones, Riley G.; Wayne, Erik J.; Kehdy, Farid J. (May 2012). "Laparoscopic detorsion and cecopexy for treatment of cecal volvulus". The American Surgeon. 78 (5): E251–252. doi: 10.1177/000313481207800503 . ISSN   1555-9823. PMID   22546094. S2CID   5812146.
  19. ↑ Ferrer-Inaebnit, Ester; Segura-Sampedro, Juan José; Molina-Romero, Francesc Xavier; González-Argenté, Xavier (October 2020). "Oclusión e isquemia por vólvulo de ciego en corea de Huntington". Gastroenterología y Hepatología (in Spanish). 43 (10): 633–634. doi:10.1016/j.gastrohep.2020.03.005. PMID   33051047. S2CID   241550167.
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