Volvulus: Difference between revisions

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{{Adult top}} [[volvulus (peds)]].''
==Backgound==
==Backgound==
*Twisting of loop of bowel causing bowel obstruction and (if severe) ischemia, gangrene, perforation  
[[File:Volvulus (Dickdarm).jpg|thumb|Volvulus with gangrene of the sigmoid.]]
*Twisting of loop of bowel causing [[bowel obstruction]] and (if severe) ischemia, gangrene, perforation  
*Generally affects adults aged 60-70
*Generally affects adults aged 60-70
*Can cause severe thirdspacing, electrolyte abnormality, and abdominal distention  
*Can cause severe third-spacing, [[electrolyte abnormality]], and abdominal distention  
*Common sites include cecum and sigmoid  
*Common sites include cecum and sigmoid  
**Cecal volvulus - mobile segment of cecum causing volvulus and cecal folding
**Cecal volvulus - mobile segment of cecum causing volvulus and cecal folding
**Sigmoid volvulus - redundant sigmoid attached to narrow mesentery twists on itself causing obstruction and further diation
**Sigmoid volvulus - redundant sigmoid attached to narrow mesentery twists on itself causing obstruction and further dilation


===Risk Factors<ref>Weerakkody Y et al. Caecal volvulus. http://radiopaedia.org/articles/caecal-volvulus.</ref><ref>Morgan MA et al. Sigmoid volvulus. http://radiopaedia.org/articles/sigmoid-volvulus</ref>===
===Risk Factors<ref>Weerakkody Y et al. Caecal volvulus. http://radiopaedia.org/articles/caecal-volvulus.</ref><ref>Morgan MA et al. Sigmoid volvulus. http://radiopaedia.org/articles/sigmoid-volvulus</ref>===
*Sigmoid Volvulus
*Sigmoid volvulus
**More common in elderly as opposed to cecal volvulus
**More common in elderly as opposed to cecal volvulus
**High fiber diet  
**High fiber diet  
**Chronic constipation
**Chronic [[constipation]]
**Chagas disease
**[[Chagas disease]]
**Patients of long term care facilities/psychiatric institutions
**Patients of long term care facilities/psychiatric institutions
*Cecal Volvulus
*Cecal volvulus
**Most between 30-60 years of age
**Most between 30-60 years of age
**Prior abdominal surgery
**Prior abdominal surgery
**Pelvic mass, 3rd trimester pregnancy
**Pelvic mass, 3rd trimester [[pregnancy]]
**Cecal mobility cause by congenital abnormality with cecal mesentery failing to fuse with posterior abdominal wall
**Cecal mobility cause by congenital abnormality with cecal mesentery failing to fuse with posterior abdominal wall
*[[Gastric volvulus]]
**Most common between 40-50 years of age
**Paraesophageal hernias


==Clinical Features==
==Clinical Features==
*Sigmoid/Cecal volvulus  
===Sigmoid/Cecal volvulus===
**Triad: Abdominal pain, distention, constipation  
*Triad: [[Abdominal pain]], distention, [[constipation]]
**Vomiting only occurs late as obstruction is rather distal. If so, may be faeculant in nature and indicates long-standing obstruction.  
*[[Vomiting]] only occurs late as obstruction is rather distal. If so, may be feculent in nature and indicates long-standing obstruction.  
**Vary from subtle to dramatic presentations  
*Vary from subtle to dramatic presentations  
**Physical Exam:  
*Physical Exam:  
***Distended, tympanitic abdomen (mostly upper abdomen and unilateral)  
**Distended, tympanitic abdomen (mostly upper abdomen and unilateral)  
***Severe abdominal tenderness, peritonitis, fever, shock highly suggestive for gangrenous bowel
**Severe abdominal tenderness, [[peritonitis]], [[fever]], [[shock]] highly suggestive for gangrenous bowel
 
===[[Gastric volvulus]] (Borchardt's triad)===
*[[Abdominal pain|Abdominal]] and/or [[chest pain]]
*Retching, [[vomiting]]
*Inability to pass NGT


==Differential Diagnosis==
==Differential Diagnosis==
*Large bowel obstruction
*Colorectal cancer
*[[Diverticulitis]]
*Strictures
*Fecal impaction
{{Abdominal Pain DDX Diffuse}}
{{Abdominal Pain DDX Diffuse}}
{{Constipation DDX}}


==Evaluation==
==Evaluation==
*Sigmoid Volvulus
[[File:CecalVolvulusXray.png|thumb|Abdominal X-ray of a cecal volvulus]]
**Abdominal Series X-rays
[[File:Sigmoidvolvulus.jpg|thumb|Abdominal X-ray of a sigmoid volvulus]]
***May not be diagnostic
[[File:Volvulus.png|thumb|Coronal CT of the abdomen, demonstrating a volvulus as indicated by twisting of the bowel stock.]]
***Grossly distended loop of colon (no haustral markings) either on R/L side.
===Workup===
***Coffee-bean sign
*CBC, chem 7
***"Bent inner tube" sign
*[[LFTs]], lipase, PT/PTT
***Free air on upright chest/lateral decubitus if perforation
*[[Lactate]]
**Contrast enema
*[[UA]], Upreg (if female)
***Bird's beak sign-contrast fills colon up to point of torsion
*CT abdomen/pelvis
**Sigmoidoscopy (both diagnostic and therapeutic)
 
===Evaluation===
*[[Gastric volvulus]]
**Upright [[CXR]] and [[abdominal Xray]]
***Intrathoracic, upside-down stomach
***Double air fluid level in stomach
***Collapsed small bowel
**CT
**CT
***Gastric herniation around points of torsion
***Ischemia seen a lack of contrast enhancement of gastric wall
*Cecal Volvulus  
*Cecal Volvulus  
**Abdominal Series X-rays  
**[[KUB|Abdominal Series X-rays]]
***Not definitive in many cases  
***Not definitive in many cases  
***Dilated cecum with air fluid level  
***Dilated cecum with air fluid level  
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**Contrast enema  
**Contrast enema  
***Helpful to differentiate between sigmoid/cecal volvulus
***Helpful to differentiate between sigmoid/cecal volvulus
**Ultrasound  
**[[ultrasound: Abdomen|Ultrasound]]
***Not particularly helpful
***Not particularly helpful
**CT  
**CT  
***Mesocolon "whirl sign"- twisted mesentery
***Mesocolon "whirl sign"- twisted mesentery
**Many only definitively diagnosed at surgery
**Many only definitively diagnosed at surgery
*Sigmoid Volvulus
**[[KUB|Abdominal Series X-rays]]
***May not be diagnostic
***Grossly distended loop of colon (no haustral markings) either on R/L side.
***Coffee-bean sign
***"Bent inner tube" sign
***Free air on upright chest/lateral decubitus if perforation
**Contrast enema
***Bird's beak sign-contrast fills colon up to point of torsion
**Sigmoidoscopy (both diagnostic and therapeutic)
**CT


==Management==
==Management==
*[[Fluid resuscitation]]
*[[Analgesia]]
*[[Antibiotics]] with bowel coverage if perforation or gangrene suspected (e.g. [[ceftriaxone]] plus [[flagyl]])
*Emergent surgery consult
*Emergent surgery consult
*Fluid resuscitation
**[[Gastric volvulus]]
*Analgesia
***Endoscopic reduction
*Antibiotics if perforation or gangrene suspected
***Recurrence possible, which would mandate surgical repair
*Sigmoid volvulus may be managed with endoscopic decompression/detorsion (if no signs of gangrenous bowel/perforation)
**Cecal volvulus always requires surgical repair with resection (preferred) or cecopexy
**Recurrence possible, which would mandate surgical repair
***Endoscopy relatively contraindicated in signs of ischemia such as significantly elevated lactate
*Cecal volvulus always requires surgical repair with resection (preferred) or cecopexy
**Sigmoid volvulus may be managed with endoscopic decompression/detorsion (if no signs of gangrenous bowel/perforation)


==Disposition==
==Disposition==
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[[Category:GI]]
[[Category:GI]]
[[category:Surgery]]

Latest revision as of 17:14, 20 January 2021

This page is for adult patients. For pediatric patients, see: volvulus (peds).

Backgound

Volvulus with gangrene of the sigmoid.
  • Twisting of loop of bowel causing bowel obstruction and (if severe) ischemia, gangrene, perforation
  • Generally affects adults aged 60-70
  • Can cause severe third-spacing, electrolyte abnormality, and abdominal distention
  • Common sites include cecum and sigmoid
    • Cecal volvulus - mobile segment of cecum causing volvulus and cecal folding
    • Sigmoid volvulus - redundant sigmoid attached to narrow mesentery twists on itself causing obstruction and further dilation

Risk Factors[1][2]

  • Sigmoid volvulus
    • More common in elderly as opposed to cecal volvulus
    • High fiber diet
    • Chronic constipation
    • Chagas disease
    • Patients of long term care facilities/psychiatric institutions
  • Cecal volvulus
    • Most between 30-60 years of age
    • Prior abdominal surgery
    • Pelvic mass, 3rd trimester pregnancy
    • Cecal mobility cause by congenital abnormality with cecal mesentery failing to fuse with posterior abdominal wall
  • Gastric volvulus
    • Most common between 40-50 years of age
    • Paraesophageal hernias

Clinical Features

Sigmoid/Cecal volvulus

  • Triad: Abdominal pain, distention, constipation
  • Vomiting only occurs late as obstruction is rather distal. If so, may be feculent in nature and indicates long-standing obstruction.
  • Vary from subtle to dramatic presentations
  • Physical Exam:
    • Distended, tympanitic abdomen (mostly upper abdomen and unilateral)
    • Severe abdominal tenderness, peritonitis, fever, shock highly suggestive for gangrenous bowel

Gastric volvulus (Borchardt's triad)

Differential Diagnosis

Diffuse Abdominal pain

Constipation

Evaluation

Abdominal X-ray of a cecal volvulus
Abdominal X-ray of a sigmoid volvulus
Coronal CT of the abdomen, demonstrating a volvulus as indicated by twisting of the bowel stock.

Workup

  • CBC, chem 7
  • LFTs, lipase, PT/PTT
  • Lactate
  • UA, Upreg (if female)
  • CT abdomen/pelvis

Evaluation

  • Gastric volvulus
    • Upright CXR and abdominal Xray
      • Intrathoracic, upside-down stomach
      • Double air fluid level in stomach
      • Collapsed small bowel
    • CT
      • Gastric herniation around points of torsion
      • Ischemia seen a lack of contrast enhancement of gastric wall
  • Cecal Volvulus
    • Abdominal Series X-rays
      • Not definitive in many cases
      • Dilated cecum with air fluid level
      • Distended small bowel
      • Distal colon with paucity of gas
      • "Coffee bean sign"-Large oval gas shadow with line down middle in middle of abdomen
      • Free air on upright chest/lateral decubitus if perforation
    • Contrast enema
      • Helpful to differentiate between sigmoid/cecal volvulus
    • Ultrasound
      • Not particularly helpful
    • CT
      • Mesocolon "whirl sign"- twisted mesentery
    • Many only definitively diagnosed at surgery
  • Sigmoid Volvulus
    • Abdominal Series X-rays
      • May not be diagnostic
      • Grossly distended loop of colon (no haustral markings) either on R/L side.
      • Coffee-bean sign
      • "Bent inner tube" sign
      • Free air on upright chest/lateral decubitus if perforation
    • Contrast enema
      • Bird's beak sign-contrast fills colon up to point of torsion
    • Sigmoidoscopy (both diagnostic and therapeutic)
    • CT

Management

  • Fluid resuscitation
  • Analgesia
  • Antibiotics with bowel coverage if perforation or gangrene suspected (e.g. ceftriaxone plus flagyl)
  • Emergent surgery consult
    • Gastric volvulus
      • Endoscopic reduction
      • Recurrence possible, which would mandate surgical repair
    • Cecal volvulus always requires surgical repair with resection (preferred) or cecopexy
      • Endoscopy relatively contraindicated in signs of ischemia such as significantly elevated lactate
    • Sigmoid volvulus may be managed with endoscopic decompression/detorsion (if no signs of gangrenous bowel/perforation)

Disposition

  • Admit

See Also

References

  1. ↑ Weerakkody Y et al. Caecal volvulus. http://radiopaedia.org/articles/caecal-volvulus.
  2. ↑ Morgan MA et al. Sigmoid volvulus. http://radiopaedia.org/articles/sigmoid-volvulus
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