Volvulus (adults)

Backgound

  • 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

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

Differential Diagnosis

  • Large bowel obstruction
  • Colorectal cancer
  • Diverticulitis
  • Strictures
  • Fecal impaction

Diffuse Abdominal pain

Evaluation

  • 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
  • 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

Management

  • Emergent surgery consult
  • Fluid resuscitation
  • Analgesia
  • Antibiotics if perforation or gangrene suspected
  • Sigmoid volvulus may be managed with endoscopic decompression/detorsion (if no signs of gangrenous bowel/perforation)
    • Recurrence possible, which would mandate surgical repair
  • Cecal volvulus always requires surgical repair with resection (preferred) or cecopexy

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

Authors:

Michael Holtz