Volvulus

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

• 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)

• Abdominal and/or chest pain
• Retching, vomiting
• Inability to pass NGT

Differential Diagnosis

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

Constipation

• Behavioral-related
  • Lack of exercise
  • Diet-related
• Fecal impaction
  • Stercoral colitis
• Ileus from surgical abdomen
  • Appendicitis
  • Diverticulitis
• Bowel obstruction
  • Small bowel obstruction
  • Large bowel obstruction
    • Ogilvie's syndrome
  • Malignant bowel obstruction
  • Specific causes: tumor, stricture, hernia, adhesion, volvulus
• Painful anorectal disorders (e.g. anal fissure, hemorrhoids)
• Medical causes
  • Hypothyroidism
  • Electrolytes
    • Hypomagnesia
    • Hypercalcemia
  • Hypokalemia
• Medication-related
  • Opiods, antipsychotics, anticholinergics, antacid, antihistamines
• Constipation (peds)

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

• Volvulus (Peds)