Volvulus

1
Volvulus

• Colorectal Conference
• 12/1/05
• Nicole Lee, MD

2
Volvulus

• 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

3
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

4
Presentation

• Hx Abdominal pain, distension, no flatus or
  bowel movements
• Exam tympanitic abdomen, distension, mild
  tenderness, palpable mass

5
Sigmoid volvulus

• bent inner tube appearance
• Dilated sigmoid loop with limbs pointing
  towards the RLQ

6
Sigmoid volvulus

• Coffee bean appearance with the two twisted
  loops with a central doubled wall component

7
Barium Enema

• Contraindicated in patients with free air on AXR,
  clinical signs of peritonitis, or suspicion for
  necrosed bowel
• Birds beak
• Can decompress

8
Management of choice

• Endoscopic decompression
• Rigid or flexible proctosigmoidoscope inserted
  into rectum
• Gush of air/feces --gt successful decompression
• Rectal tube
• Successful in 85-90 of cases
• Recurrence rate gt60
• Decreased risk for bowel necrosis if treated
  early
• Colon ischemia, perforation
• Elective resection

9
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

10

• Delayed resection with primary anastomosis
• Mortality rate 8
• Operative mortality related to viability of bowel
• Viable 12 vs nonviable 53 mortality

11
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

12

• 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

13
X-rays

• comma shaped
• Convexity toward right and downward
• BE - risk of perforation with getting
  air/contrast to right colon

14
Management

• Decompression with colonoscope
• Less successful than with sigmoid volvulus
• Emergent operation if signs of vascular compromise

15
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

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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

17
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