Volvulus

Excerpt

Volvulus occurs when a loop of intestine twists around itself and the mesentery that supplies it, causing a bowel obstruction. Symptoms include abdominal distension, pain, vomiting, constipation, and bloody stools. The onset of symptoms may be insidious or sudden. The mesentery becomes so tightly twisted that the blood supply is cut off, resulting in bowel ischemia. Pain may be significant, and fever may develop (See Image. Cecal Volvulus).

Risk factors for volvulus include intestinal malrotation, Hirschsprung disease, an enlarged colon, pregnancy, and abdominal adhesions. A higher incidence of volvulus is also noticed among hospitalized individuals with neuropsychiatric disorders such as Parkinson disease or multiple sclerosis. High fiber diet, chronic constipation with chronic use of laxatives and/or enema, and associated myopathy like Duchene muscular dystrophy are also associated with an increased risk of sigmoid volvulus. In adults, the sigmoid colon and cecum are the most commonly affected. On the contrary, splenic flexure is least prone to volvulus. In children, the small intestine and stomach are more commonly involved. Diagnosis is mainly clinical; however, characteristic radiological findings on plain radiographs, ultrasound, and upper gastrointestinal series help differentiate from other differentials (See Image. Cecal Volvulus Radiograph). The present topic covers volvulus in adults with specific differences from midgut volvulus in children. However, a detailed discussion of malrotation and midgut volvulus is beyond the scope of this topic.

Sigmoidoscopy or a barium enema can be attempted as an initial treatment for sigmoid volvulus. However, due to the high risk of recurrence, bowel resection with anastomosis within 2 days is generally recommended. If the bowel is severely twisted or the blood supply is cut off, emergent surgery is required. In a cecal volvulus, part of the bowel is usually removed. The cecum may be returned and sutured in place if it is still healthy. However, conservative treatment in both cases is associated with high recurrence rates.