Volvulus

Backgound

• Twisting of loop of bowel causing bowel obstruction and if severe, ischemia, gangrene, perforation
• Affects adults aged 60-70
• Severe thirdspacing, electrolyte abnormality, and abdominal distention
• Common sites include sigmoid and cecum
  • Sigmoid volvulus
    • Redundant sigmoid attached to narrow mesentery twists on itself causing obstruction and further diation
  • Cecal Volvulus
    • Mobile segment of cecum causing volvulus and cecal folding

Risk Factors

• Sigmoid Volvulus
  • More common in elderly as opposed to cecal volvulus
  • High fiber diet
  • Chronic constipation
  • Chagas disease (S. America)
  • Pts of long term care facilities/psychiatric institutions
• Cecal Volvulus
  • Most between 30-60 yoa
  • Prior abdominal surgery
  • Pelvic mass, 3rd trimester pregnancy
  • Cecal mobility cause by congenital abnormality with cecal mesentery failing to fuse with posterior abdominal wall

Clinical Features

• Sigmoid/Cecal volvulus
  • 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.
  • 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

Differential Diagnosis

• Large bowel obstruction
• Colorectal CA
• Diverticulitis
• Strictures
• Fecal impaction

Diffuse Abdominal pain

• Abdominal aortic aneurysm
  • Aortocaval fistula
• Acute gastroenteritis
• Aortoenteric fisulta
• Appendicitis (early)
• Bowel obstruction
  • Large bowel obstruction
    • Ogilvie's syndrome
  • Small bowel obstruction
  • Malignant bowel obstruction
• Bowel perforation
• Diabetic ketoacidosis
• Gastroparesis
• Hernia
• Hypercalcemia
• Inflammatory bowel disease
• Mesenteric ischemia
  • Mesenteric vein thrombosis
• Pancreatitis
• Peritonitis
• Sickle cell crisis
• Spontaneous bacterial peritonitis
• Volvulus

Diagnosis

• 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
• 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

Treatment

• Resuscitation, antibiotics if gangrenous bowel/perforation, pain control
• Sigmoid volvulus
  
  • Endoscopic decompression and detorsion
    • If no signs of gangrenous bowel/perforation
  • Surgery
    • If gangrenous bowel or unsuccessful endoscopic detorsion
    • Elective resection of redundant sigmoid after resolution b/c high recurrence rate
• Cecal volvulus
  • Surgery
    • Surgical detorsion with resection and fixing cecum to abdominal wall
    • Rare recurrence rate after resection

Disposition

• Consult GI/Surgery
• Admit

See Also

• Volvulus (Peds)