Large Intestine: Volvulus

Cecal Volvulus

Basics

  • Twisting of the Cecum Around Itself
  • Second Most Common Colonic Volvulus (35%)
  • Causes a Closed Loop Obstruction That Can Cause Vascular Compromise

Types

  • Type I: Axial Twisting Along the Long Axis
    • Most Often Clockwise
  • Type II: Twisting of Cecum & Terminal Ileum
    • Most Often Counterclockwise
  • Type III: “Cecal Bascule” – Anterosuperior Folding of the Cecum without Any Axial Twisting
    • Less Common (20%)

Risk Factors

  • Increased Mobility of the Cecum
  • Adhesions
  • Younger Age
  • Female or Pregnancy
  • Chronic Constipation
  • Colonic Dysmotility

Presentation

  • Abdominal Pain
  • Abdominal Distention
  • Nausea & Vomiting
  • Large Bowel Obstruction

Diagnosis

  • Dx: Abdominal XR or CT
    • “Coffee-Bean” Sign with Apex in the LUQ
    • “Whirl” Sign if Mesentery Twisted

Treatment

  • Avoid Endoscopic Detorsion – Technically Difficult with Risk of Perforation & Missed Injury
  • Primary Treatment: Surgery
  • Surgical Detorsion
    • If Grossly Necrotic: Do Not Detorse – Risk of Reperfusion Bacteremia & Sepsis
    • If Not Grossly Necrotic – Detorse to Evaluate Bowel Viability
  • Surgical Resection
    • Resect All Compromised Bowel
    • Resection Even for Viable Bowel Offers the Most Definitive Results
    • May Consider Detorsion Alone if Bowel Viable & Patient is Unstable/Unfit for Resection
      • May Add Cecopexy and/or Cecostomy Tube to Fix and Decompress
      • 25% Recurrence Rate
  • Consider Colopexy to Posterior Peritoneum if Residual Bowel Redundant
  • Consider Ileostomy if Malnourished, Unstable or Significant Contamination

Cecal Volvulus 1

Cecal Bascule

Sigmoid Volvulus

Sigmoid Volvulus

  • Twisting of the Sigmoid Around Itself
  • Most Common Colonic Volvulus (30-60%)

Risk Factors

  • High Fiber Diet #1 – Lengthens the Intestine & Mesentery
    • More Common in African Populations
  • Increased Mobility of the Cecum
  • Adhesions
  • Male
  • Older Age
  • Psychiatric Disorders
  • Neurologic Dysfunction
  • Laxative Abuse
  • Colonic Dysmotility

Presentation

  • Abdominal Pain
  • Abdominal Distention
  • Nausea & Vomiting
  • Large Bowel Obstruction
    • May See an Explosive Bowel Movement if Spontaneously Detorses

Diagnosis

  • Dx: Abdominal XR or CT
    • “Bent Inner-Tube” Sign with Apex in the RUQ
      • “Omega Sign” or “Coffee-Bean” Sign
    • “Whirl” Sign if Mesentery Twisted

Treatment

  • Stable: Colonoscopic Decompression & Elective Sigmoidectomy
    • If Signs of Ischemia or Perforation are Present Do Not Detorse & Proceed with Surgery
    • Endoscopic Detorsion Outcomes:
      • 80-95% Success Rate
      • 40-75% Recur if Not Resected
    • Perform Surgery During Index Admission
    • Primary Anastomosis if Stable
  • Unstable, Peritonitis, Necrosis or Perforation: Emergent Resection
    • Consider Hartmann’s Procedure (Generally Preferred) vs. Primary Anastomosis

Sigmoid Volvulus 2

Sigmoid Volvulus 3

Sigmoid Volvulus Swirl on Sigmoidoscopy 4

Other Volvulus

Splenic Flexure Volvulus

  • More Rare Colonic Volvulus (1-2%)
  • Dx: Abdominal XR or CT
  • Tx: Surgical Resection
    • Avoid Endoscopic Detorsion

Transverse Colon Volvulus

  • More Rare Colonic Volvulus (1-4%)
  • Generally Younger Age
  • Much Higher Mortality (3x) After Resection than Cecal or Sigmoid Volvulus
  • Dx: Abdominal XR or CT
  • Tx: Surgical Resection
    • Avoid Endoscopic Detorsion

References

  1. James B, Kelly B. The abdominal radiograph. Ulster Med J. 2013 Sep;82(3):179-87. (License: CC BY-NC-SA-4.0)
  2. Elia F, Pagnozzi F, Busolli P, Aprà F. Frail patient with abdominal pain. West J Emerg Med. 2010 Sep;11(4):400-1. (License: CC BY-NC-4.0)
  3. Qadir I, Salick MM, Barakzai A, Zafar H. Isolated adult hypoganglionosis presenting as sigmoid volvulus: a case report. J Med Case Rep. 2011 Sep 8;5:445. (License: CC BY-2.0)
  4. Atamanalp SS, Atamanalp RS. The role of sigmoidoscopy in thediagnosis and treatment of sigmoid volvulus. Pak J Med Sci. 2016 Jan-Feb;32(1):244-8. (License: CC BY-3.0)