DR. M. Ravichandra,M. S
tarix 01.05.2017 ölçüsü 446 b. #16444
DR.M.RAVICHANDRA,M.S DR.M.RAVICHANDRA,M.S RIMS,SRIKAKULAM A VOLVULUS IS TWISTING OR AXIAL ROTATION OF A PORTION OF BOWEL ABOUT IT’S MESENTRY A VOLVULUS IS TWISTING OR AXIAL ROTATION OF A PORTION OF BOWEL ABOUT IT’S MESENTRY OBSTRUCTION CAUSED BY TWISTING OF THE INTESTINES MORE THAN 180 DEGREES ABOUT THE AXIS OF THE MESENTERY OBSTRUCTION CAUSED BY TWISTING OF THE INTESTINES MORE THAN 180 DEGREES ABOUT THE AXIS OF THE MESENTERY 1-5% OF LARGE BOWEL OBSTRUCTIONS SIGMOID ~ 65% CECUM ~25% TRANSVERSE COLON ~4% SPLENIC FLEXURE PRIMARY&SECONDARY PRIMARY&SECONDARY PRIMARY CONGENITAL MALROTATION OF GUT ABNORMAL MESENTERIC ATTACHMENTS CONGENITAL BANDS SECONDARY ACQUIRED ADHESION (OR) STOMA WORLDWIDE - UP TO 50% OF OBSTRUCTION WORLDWIDE - UP TO 50% OF OBSTRUCTION MORE COMMONLY SEEN IN ELDERLY PATIENTS IN WESTERN SOCIETIES RISK FACTORS CHRONIC CONSTIPATION PSYCHIATRIC PROBLEMS NON-WESTERN SOCIETIES BAND OF ADHESIONS(PERIDIVERTICULITIS) BAND OF ADHESIONS(PERIDIVERTICULITIS) OVER LOADED PELVIC COLON LONG PELVIC MESOCOLON NARROW PELVIC MESOCOLON SOMETIMES A BOWEL-COIL GETS OUT OF PLACE SOMETIMES A BOWEL-COIL GETS OUT OF PLACE BY TWISTING ROUND A NARROW BASE WITH GRADUAL STRANGULATING OF THE BLOOD SUPPLY AND DANGER THAT THE AFFECTED COIL WILL DIE THIS IS AVOLVULUS WHICH YOU SHOULD LEARN IS FROM THE LATIN-VOLVERE-TO-TURN HX: ABDOMINAL PAIN , DISTENSION,ABSTIPATION,VOMITING OCCURS LATE,HICCOUGH&RETCHING NO FLATUS OR BOWEL MOVEMENTS HX: ABDOMINAL PAIN, DISTENSION,ABSTIPATION,VOMITING OCCURS LATE,HICCOUGH&RETCHING NO FLATUS OR BOWEL MOVEMENTS EXAM: TYMPANITIC ABDOMEN, DISTENSION, MILD TENDERNESS, PALPABLE MASS “BENT INNER TUBE” APPEARANCE “BENT INNER TUBE” APPEARANCE DILATED SIGMOID LOOP WITH LIMBS POINTING TOWARDS THE RLQ THOUGH SOMETIMES IN A PERSON WHO IS FAT THOUGH SOMETIMES IN A PERSON WHO IS FAT “COFFEE BEAN” APPEARANCE WITH THE TWO TWISTED LOOPS WITH A CENTRAL DOUBLE WALL COMPONENT “COFFEE BEAN” APPEARANCE WITH THE TWO TWISTED LOOPS WITH A CENTRAL DOUBLE WALL COMPONENT CONTRAINDICATED IN PATIENTS WITH FREE AIR ON AXR , CLINICAL SIGNS OF PERITONITIS, OR SUSPICION FOR NECROSED BOWEL CONTRAINDICATED IN PATIENTS WITH FREE AIR ON AXR, CLINICAL SIGNS OF PERITONITIS, OR SUSPICION FOR NECROSED BOWEL BIRD’S BEAK CAN DECOMPRESS ENDOSCOPIC DECOMPRESSION ENDOSCOPIC DECOMPRESSION RIGID OR FLEXIBLE PROCTOSIGMOIDOSCOPE INSERTED INTO RECTUM GUSH OF AIR/FECES --> SUCCESSFUL DECOMPRESSION RECTAL TUBE SUCCESSFUL IN 85-90% OF CASES RECURRENCE RATE >60% DECREASED RISK FOR BOWEL NECROSIS IF TREATED EARLY COLON ISCHEMIA, PERFORATION ELECTIVE RESECTION ELECTIVE RESECTION ELECTIVE RESECTION EMERGENT LAPAROTOMY OPERATION DEPENDS ON VIABILITY OF THE BOWEL RESECTION AND ANASTOMOSIS HARTMANN RESECTION EXTERIORIZATION RESECTION (PAUL MICKULISZ PROCEDURE) DETORSION DETORSION WITH COLOPEXY PERCUTANEOUS COLOSTOMY PERCUTANEOUS SIGMOIDPEXY DELAYED RESECTION WITH PRIMARY ANASTOMOSIS DELAYED RESECTION WITH PRIMARY ANASTOMOSIS OPERATIVE MORTALITY RELATED TO VIABILITY OF BOWEL VIABLE 12% VS NONVIABLE 53% MORTALITY A FRAGILE LADY IN HER MID 80S SUFFERED ONE EPISODE AFTER ANOTHER BUT EACH TIME SHE WAS THOUGHT UNFIT FOR AN ELECTIVE OPERATION ON A BENIGN CONDITION. AFTER HER 12TH VOLVULUS SHE HAD PROVED HER CASE AND WAS SUBJECTED TO SIGMOIDECTOMY FROM WHICH SHE RECOVERED UNEVENTFULLY AND WAS DISCHARGED AFTER 5 DAYS A FRAGILE LADY IN HER MID 80S SUFFERED ONE EPISODE AFTER ANOTHER BUT EACH TIME SHE WAS THOUGHT UNFIT FOR AN ELECTIVE OPERATION ON A BENIGN CONDITION. AFTER HER 12TH VOLVULUS SHE HAD PROVED HER CASE AND WAS SUBJECTED TO SIGMOIDECTOMY FROM WHICH SHE RECOVERED UNEVENTFULLY AND WAS DISCHARGED AFTER 5 DAYS LESS COMMON THAN SIGMOID VOLVULUS LESS COMMON THAN SIGMOID VOLVULUS PARIETAL PERITONEUM FAILS TO CONNECT WITH THE CECUM AND RIGHT COLON INCREASED MOBILITY OF BOWEL, RESULTING IN IT FOLDING ON ITS AXIS OR UPWARD TORSION OCCURS PROXIMAL TO CECUM RISK FACTORS: DISTAL OBSTRUCTION, PREGNANCY, ADHESIONS, CONGENITAL BANDS, PROLONGED CONSTIPATION, METEORISM (AIR IN INTESTINES) THAT OCCURS WITH NON-PRESSURIZED AIR TRAVEL HX: ABDOMINAL PAIN, COLICKY HX: ABDOMINAL PAIN, COLICKY AXIAL TORSION TYPE TWIST 180-360 DEGREES ON LONGITUDINAL AXIS OF ASCENDING COLON (DISTAL ILEUM AND ASCENDING COLON) ASSOCIATED WITH BOWEL COMPROMISE, ISCHEMIA, AND PERFORATION CECAL BASCULE “COMMA” SHAPED “COMMA” SHAPED CONVEXITY TOWARD RIGHT AND DOWNWARD BE - RISK OF PERFORATION WITH GETTING AIR/CONTRAST TO RIGHT COLON DECOMPRESSION WITH COLONOSCOPE DECOMPRESSION WITH COLONOSCOPE LESS SUCCESSFUL THAN WITH SIGMOID VOLVULUS EMERGENT OPERATION IF SIGNS OF VASCULAR COMPROMISE DETORSION ± APPENDECTOMY DETORSION ± APPENDECTOMY CECOPEXY/LAPAROSCOPIC CECOPEXY SUTURE R COLON TO LATERAL PARACOLIC GUTTER OR USE LATERAL PERITONEAL FLAP CECOSTOMY RESECTION RIGHT COLECTOMY WITH PRIMARY ANASTOMOSIS DETORSION ± APPENDECTOMY DETORSION ± APPENDECTOMY HIGH RATE OF RECURRENCE (NOT COMMONLY DONE ANYMORE) CECOPEXY CECOSTOMY ± CECOPEXY COMBINED PROCEDURE MORE EFFECTIVE IN PREVENTING RECURRENCE RESECTION PRIMARY ANASTOMOSIS UNLESS PERITONEAL CONTAMINATION IS PRESENT LESS COMMON AREA FOR VOLVULUS(4%) LESS 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 PREDISPOSED BY ARRESTED ROTATION OF GUT WITH A RESULTANT NARROW MESENTERY OF SMALL BOWEL & CAECUM PREDISPOSED BY ARRESTED ROTATION OF GUT WITH A RESULTANT NARROW MESENTERY OF SMALL BOWEL & CAECUM SYMPTOMS – VOMITINGS,ABDOMINAL DISTENTION, & DEHYDRATION LAPAROTOMY REVEALS DISTENDED STOMACH & COILS OF INTESTINE TORSION IS IN CLOCKWISE DIRECTION OPERATION REDUCTION BY UNTWISTING & DIVISION OF ANY SECONDARY OBSTRUCTIVE LESIONS LIKE TRANSDUODENAL BAND OF LADD OCCURS IN LOWER ILEUM OCCURS IN LOWER ILEUM PRIMARY & SECONDARY PRIMARY SPONTANEOUS IN AFRICANS FOLLOWING CONSUMPTION OF LARGE VOLUME OF VEGETABLE MATTER SECONDARY WEST ADHESIONS PASSING TO PARIETIES/FEMALE PELVIC ORGANS TREATMENT - REDUCTION OF TWIST & TREAT UNDER LYING CAUSE ROTATION OF STOMACH AROUND THE AXIS AND 2 FIXED POINTS THE CARDIA & THE PYLORUS ROTATION OF STOMACH AROUND THE AXIS AND 2 FIXED POINTS THE CARDIA & THE PYLORUS 2 TYPES HORIZONTAL(ORGANO AXIAL) M.C VERTICAL(MESENTERIO AXIAL) USUALLY ASSOCIATED WITH A DIAPHRAMATIC DFEFECT AROUND ESOPHAGUS AND THERE IS PARAESOPHAGEAL HERNIATION TRANSVERSE COLON MOVES UPWARDS TO LIE UNDER THE LEFT HEMIDIAPHRAGM DURING THIS PROCESS IT TAKES STOMACH ALONG WITH IT STOMACH& COLON BOTH ENTER THE CHEST THROUGH THE EVENTRATION OF DIAPHRAGM CHRONIC- DIFFICULTY IN EATING ACUTE MAY PRESENT WITH ISCHAEMIA TREATMENT TREATMENT BOTH OPEN&LAP REDUCTION OF SAC & CONTENTS CLOSURE OF DEFECT IN DIAPHRAGM WITH MESH SEPARATE STOMACH FROM TRANS. 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