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Thamer A. Bin Traiki
Definition
 Volvulus refers to a torsion or twist of an organ on a
pedicle.
 In colonic volvulus :
 The bowel becomes twisted on its mesenteric axis with partial or
complete obstruction & a variable degree of impairment of its blood
supply .
Cont…
 Could happen in any portion of large bowel if that
segment is attached to a long & floppy mesentery that fixed
to the retroperitonium by narrow base .
 The sigmoid colon is involved in up to 90% of cases,
 The cecum <20%(this involving Rt colon & TI Cecal volvulus or
cecum alone in highly mobile cecum called cecal bascule )
 Transverse colon.
Incidence
 Geographical variation .
 In an unusual report from the high-altitude area of the
Bolivian and Peruvian Andes at 13,000 feet above sea
level, sigmoid volvulus accounted for 79% of all
intestinal obstruction.
 The reason is not clear but may be related to the
increased gas volume in the bowel because of high
altitude .
Risk Factors
 Chronic constipation may produce a large, redundant colon
(chronic megacolon)
 Aging average age at presentation being in 7th to 8th decade
 Neuropsychiatric condition treated with psychotropic drugs
 High fiber & vegetable
Clinically
 A volvulus may reduce spontaneously, but more commonly
produces bowel obstruction (Acute or subacut) , which can
progress to strangulation, gangrene, and perforation.
 The abdomen is markedly distended & tympanic which
often more dramatic than in other causes of intestinal
obstruction .
 In case of previous attack resolved spontaneously there will
be marked distention with minimal tenderness .
Clinical presentation
 2 presentations :
 ‘‘Acute Fulminating type’’
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Patient is generally younger , onset is sudden, course is rapid.
Generally, there is little history of previous episodes,
Symptoms include early vomiting, diffuse abdominal pain and
tenderness, marked prostration, and the early appearance of gangrene.
Distention may be minimal,
In its classic form the acute fulminating variety of sigmoid volvulus
produces no distinctive diagnostic signs except for the clinical picture of
an acute abdominal catastrophe;
The actual diagnosis is made at celiotomy.
Ann Surg 1957; 146:52–60
 Subacute Progressive Type,
 The more common presentation.
 The patient is generally older, onset more gradual, and the early
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course more benign.
There is often a history of previous attacks and chronic
constipation.
Vomiting occurs late, pain is minimal,
Signs of peritonitis are usually not present.
Abdominal distention is generally extreme in this form,
Radiographic findings are usually diagnostic.
Ann Surg 1957; 146:52–60
Radiographic Finding
 characteristic bent inner tube or coffee bean
appearance, with the convexity of the loop lying in the
right upper quadrant (opposite the site of
obstruction).
 CT scan reveals characteristic mesenteric whirl sign .
 Gastrografin enema shows a narrowing at the site of
the volvulus and a pathognomonic bird's beak .
Treatment
 Resuscitation
 Nonoperative Treatment
 Operative Treatment
Nonoperative Treatment
 Depends on whether the surgeon believes that the bowel is
viable or nonviable .
 Attempt at reduction should be made by means of
proctosigmoidoscopy and insertion of a rectal tube.
 If the volvulus can be reduced, an explosive discharge of gas and
feces will occur.
 The rectal tube should be left in place, either taped or, ideally,
sutured to the buttock for about 48 hours to avoid the possibility
of immediate recurrence.
 Proctosigmoidoscopic examination should be undertaken
even if the patient has signs and symptoms of nonviable bowel
to confirm the extent of involvement and to establish the
diagnosis with certainty. ???!!!
 The procedure should be performed with great care to avoid
perforating the bowel.
Flexible sigmoidoscopy and colonoscopy
 It has the advantage of evaluating the viability of a greater area of
colonic mucosa.
 But the procedure must be performed with limited manipulation and
limited air to minimize the risk of perforation of the distended and
edematous bowel.
 Intraluminal stenting to prevent early recurrence can be accomplished
through the use of flexible plastic tubing or a blunt-ended guide wire .
 An attempt at colonoscopic reduction may be considered if
proctosigmoidoscopic manipulation has been unsuccessful.
Cont…
 Outcomes :
 More recent studies generally indicate that if the bowel
is viable, one may anticipate successful reduction of the
volvulus at least 90% of the time.
 The risk of recurrence is high (40%).
 For this reason, an elective sigmoid colectomy should be
performed after the patient has been stabilized and
undergone an adequate bowel preparation.
Operative treatment
 The presence of necrotic mucosa, ulceration, or dark
blood noted on endoscopy examination suggests
strangulation and is an indication for operation.
 If dead bowel is present at laparotomy, a sigmoid
colectomy with end colostomy (Hartmann procedure)
may be the safest operation to perform.
 Cecal volvulus results from nonfixation of the right
colon.
 Rotation occurs around the ileocolic blood vessels and
vascular impairment occurs early.
 Plain x-rays of the abdomen show a characteristic
kidney-shaped, air-filled structure in the left upper
quadrant (opposite the site of obstruction), and a
Gastrografin enema confirms obstruction at the level
of the volvulus
Treatment
 Unlike sigmoid volvulus, cecal volvulus can almost
never be detorsed endoscopically.
 Moreover, because vascular compromise occurs early
in the course of cecal volvulus, surgical exploration is
necessary when the diagnosis is made.
 Right hemicolectomy with a primary ileocolic
anastomosis can usually be performed safely and
prevents recurrence.
 Simple detorsion or detorsion and cecopexy are
associated with a high rate of recurrence.
 Extremely rare.
 Nonfixation of the colon and chronic constipation with
megacolon may predispose to transverse colon volvulus.
 The radiographic appearance of transverse colon volvulus
resembles sigmoid volvulus, but Gastrografin enema will
reveal a more proximal obstruction.
 Although colonoscopic detorsion is occasionally successful
in this setting, most patients require emergent exploration
and resection.
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