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 thirdspacing, 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 diation

Risk Factors[1][2]

  • 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 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

Gastric volvulus (Borchardt's triad)

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

Differential Diagnosis

Diffuse Abdominal pain

Constipation

Evaluation

Abdominal X-ray of a cecal 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
  • Lactic acid
  • UA, Upreg (if female)
  • CT abdomen/pelvis

Evaluation

  • Gastric volvulus
    • Upright CXR and abdominal XR
      • 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

References

  1. Weerakkody Y et al. Caecal volvulus. http://radiopaedia.org/articles/caecal-volvulus.
  2. Morgan MA et al. Sigmoid volvulus. http://radiopaedia.org/articles/sigmoid-volvulus