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
Sigmoid Volvulus
Worldwide - up to 50% of obstruction
India, Africa, E. Europe
More commonly seen in elderly patients in western societies
Redundant colon, mesocolon narrowed, twisting at mesentery
Risk factors
Chronic constipation
Psychiatric problems
Non-western societies
high residue diet
Presentation
Hx: Abdominal pain, distension, no flatus or bowel movements
Exam: tympanitic abdomen, distension, mild tenderness, palpable mass
Sigmoid volvulus
“bent inner tube” appearance
Dilated sigmoid loop with limbs pointing towards the RLQ
Sigmoid volvulus
“Coffee bean” appearance with the two twisted loops with a central doubled wall component
Barium Enema
Contraindicated in patients with free air on AXR, clinical signs of peritonitis, or suspicion for necrosed bowel
Bird’s beak
Can decompress
Management of choice
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
Operative management for sigmoid volvulus
Elective resection
Same admission
Emergent laparotomy
Operation depends on viability of the bowel
Resection and anastomosis
Hartmann resection
Exteriorization resection
Detorsion
Detorsion with colopexy
Percutaneous colostomy
Percutaneous sigmoidpexy
Delayed resection with primary anastomosis
Delayed resection with primary anastomosis
Mortality rate 8%
Operative mortality related to viability of bowel
Viable 12% vs nonviable 53% mortality
Cecal Volvulus
Less 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
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
Distention
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
Cecum folds anteriorly on ascending colon
May result in intermittent obstructive symptoms
X-rays
“comma” shaped
Convexity toward right and downward
BE - risk of perforation with getting air/contrast to right colon
Management
Decompression with colonoscope
Less successful than with sigmoid volvulus
Emergent operation if signs of vascular compromise
Operative management for cecal volvulus
Detorsion ± appendectomy
Cecopexy/Laparoscopic cecopexy
Suture R colon to lateral paracolic gutter or use lateral peritoneal flap
Cecostomy
Resection
Right colectomy with primary anastomosis
Results
Detorsion ± appendectomy
High rate of recurrence (not commonly done anymore)
Cecopexy
Do not need to have prepped bowel
Recurrence 25%
Cecostomy ± cecopexy
Combined procedure more effective in preventing recurrence
Resection
Primary anastomosis unless peritoneal contamination is present
Transverse colon volvulus
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
