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Volvulus

Updated : May 20, 2023





Background

Volvulus is a condition characterized by twisting a loop of the intestine around itself and its supporting structure called the mesentery. This twisting leads to a blockage in the bowel, causing various symptoms. Common signs of volvulus include abdominal distension, abdominal pain, vomiting, constipation, and the presence of blood in the stools.

The onset of these symptoms can vary, with some individuals experiencing a gradual progression while others may have a sudden onset. The twisting of the intestine and the accompanying mesentery can become so severe that it restricts the blood supply to the affected area, resulting in bowel ischemia.

This reduction in blood flow deprives the affected section of the bowel of essential oxygen and nutrients, leading to tissue damage and potentially life-threatening consequences. The resulting pain can be quite severe; in some cases, individuals may develop a fever as a response to the underlying infection or inflammation.

Epidemiology

Volvulus can occur worldwide, but its prevalence may differ in various regions. Certain areas, such as parts of Africa, Asia, and South America, have higher reported incidences of volvulus. In these regions, specific types of volvulus, such as sigmoid volvulus, are more common due to dietary and anatomical factors. Volvulus can affect individuals of all ages, but certain age groups have a higher risk.

In infants and young children, malrotation of the intestine is a common cause of volvulus. In adults, volvulus is more prevalent in the elderly population due to age-related changes in the bowel and underlying medical conditions. There is no significant gender predilection for volvulus, and males and females can be affected. Some studies suggest that there may be a seasonal variation in the incidence of volvulus, with increased cases during certain periods.

Certain ethnic groups may have a higher predisposition to specific types of volvulus. For example, sigmoid volvulus is more prevalent in individuals of African descent. Genetic factors may also contribute to the development of volvulus, but specific genetic markers or associations still need to be clearly identified.

Anatomy

Pathophysiology

The pathophysiology of volvulus involves the abnormal twisting of a segment of the intestine, resulting in bowel obstruction and compromised blood supply. Several factors contribute to the development of volvulus. Anatomically, the intestines are held in place by the mesentery, a fan-shaped tissue that provides support and carries the blood vessels to the intestines.

In cases of volvulus, a loop of the intestine rotates abnormally, causing the mesentery to twist. This twisting creates a mechanical obstruction, leading to the partial or complete blockage of the intestinal lumen. As the twist progresses, the mesentery becomes tightly constricted, compromising the blood vessels that supply the affected segment of the bowel. This leads to a reduced or complete cessation of blood flow, resulting in bowel ischemia.

The lack of oxygen and nutrients causes damage to the intestinal tissues, which can progress rapidly and become irreversible if left untreated. The compromised blood supply also releases inflammatory mediators, further exacerbating tissue injury and inflammation. The obstructed bowel segment becomes distended due to accumulated gas and fluid, resulting in abdominal distension. The increased pressure within the bowel causes stretching of the intestinal wall, leading to abdominal pain.

Vomiting may occur due to the obstruction, preventing the passage of ingested food and fluids beyond the point of obstruction. Constipation is another common symptom, as the twisted segment prevents the normal movement of stool through the intestines. In some cases, blood supply compromise can lead to blood in the stools, manifesting as melena or hematochezia.

Etiology

The etiology of volvulus involves a combination of anatomical, mechanical, and functional factors. Anatomically, volvulus can occur due to abnormalities in the intestinal structure or positioning. For example, malrotation of the intestines during fetal development can lead to abnormal fixation, making the intestines more prone to twisting later in life.

Mechanical factors also play a role, with conditions such as chronic constipation or adhesions from previous abdominal surgeries increasing the risk of volvulus. The functional aspect involves impaired intestinal motility, which can be caused by neurological disorders like Parkinson’s disease or conditions affecting the nerves and muscles of the intestines.

Additionally, factors such as aging, which can lead to weakened intestinal muscles and decreased elasticity, can contribute to the development of volvulus. Dietary habits, such as a high-fiber or low-residue diet, may also play a role in certain types of volvulus. While the exact cause of volvulus may vary depending on the specific type and individual factors, a combination of anatomical, mechanical, and functional factors collectively contributes to its etiology.

Genetics

Prognostic Factors

Timely diagnosis is crucial in cecal or sigmoid volvulus cases to prevent significant morbidity and mortality. The mortality rates associated with cecal volvulus tend to be higher than sigmoid volvulus. Delayed diagnosis and treatment can lead to severe complications.

Non-surgical interventions for volvulus have shown alarmingly high recurrence rates, ranging from 40% to 60%. In cases where surgery is performed on unstable patients, reported mortality rates range from 12% to 25%. Thus, swift surgical intervention is often necessary to achieve better outcomes and reduce the risk of complications and mortality.

Clinical History

Clinical History

Volvulus involving the sigmoid colon typically affects elderly males who have a pre-existing history of chronic constipation. While most patients experience a sudden and rapid onset of symptoms, it is worth noting that approximately one-third of cases may present with a more gradual and subtle manifestation.

Elderly individuals, especially males, are more susceptible to developing this condition due to age-related changes in the colon and a higher prevalence of chronic constipation. The long-standing history of constipation predisposes the sigmoid colon to become more mobile and susceptible to twisting. Other factors that can contribute to the development of sigmoid volvulus include a low-fiber diet, sedentary lifestyle, and a lack of physical activity.

Physical Examination

Physical Examination

Volvulus is characterized by the twisting or rotating a segment of the gastrointestinal tract, often resulting in a blockage of the normal flow of food, fluids, and gases. This condition can occur at any age and may present various signs and symptoms, depending on the patient’s age and the location of the volvulus. Common signs and symptoms of volvulus in adults and older children include abdominal pain, which can be severe and colicky.

The pain is typically located in the abdomen and may be accompanied by abdominal distension, where the abdomen appears bloated and swollen. Patients may experience vomiting, which can be persistent and may contain bile or blood in more severe cases. Another common symptom is constipation or obstipation, with significant difficulty or inability to pass stool. Hematochezia may also be observed.

When patients with volvulus experience significant delays in seeking medical attention, the condition can worsen and lead to complications such as perforation peritonitis. In these cases, patients may exhibit diffuse tenderness, guarding (involuntary muscle tensing to protect the abdomen), and rigidity, indicating inflammation and potential perforation of the intestines.

The presence of severe abdominal distension can further lead to hemodynamic instability, with the patient becoming hemodynamically compromised and experiencing respiratory difficulties. In newborns with midgut volvulus, distinct symptoms differ from those seen in adults and older children. These infants often present with sudden and forceful bilious emesis, regurgitating greenish-yellow fluid. Upper abdominal distension is also a common feature, as the intestines’ twisted segment leads to fluid and gas accumulation in the affected area.

Hematochezia, the passage of blood in the stool, may also be observed. Additionally, newborns with midgut volvulus may exhibit an inconsolable cry, indicating their distress. Older children with midgut volvulus may display symptoms such as episodic abdominal pain, which comes and goes in waves. They may also experience episodes of diarrhea, with loose or watery stools. Failure to thrive, characterized by inadequate weight gain or growth, may also be present in these cases.

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Differential Diagnoses

Appendicitis

Abdominal hernia

Colonic polyps

Colon cancer

Ogilvie syndrome

Pseudomembranous colitis

Intestinal perforation

Intussusception

Rectal cancer

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Patients with volvulus require resuscitation before surgery, and it is advisable to administer broad-spectrum antibiotics before the procedure. Regular vital signs monitoring, including urine output measurement, is necessary. Sigmoidoscopy serves as the initial treatment and aids in diagnosing sigmoid volvulus. Classic sigmoidoscopy findings include mucosal spiraling and difficulty advancing the scope beyond the point of obstruction.

Surgical options for sigmoid volvulus include bowel resection and conservative surgery. Bowel resection is preferred over conservative options like sigmoidopexy or mesenteric plication due to higher recurrence rates. Primary resection is suitable if there is no fecal peritonitis, while a Hartmann procedure is performed in cases of bowel perforation.

Minimally invasive approaches may be considered, especially for elderly patients with sigmoid volvulus, depending on the surgeon’s expertise and preference. Right hemicolectomy is the recommended procedure for cecal volvulus. If bowel necrosis is evident, resection with an ileostomy or colostomy is necessary. In critically ill patients unfit for general anesthesia, a percutaneous tube cecostomy can be performed as an interim measure.

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Media Gallary

References

Volvulus

Updated : May 20, 2023




Volvulus is a condition characterized by twisting a loop of the intestine around itself and its supporting structure called the mesentery. This twisting leads to a blockage in the bowel, causing various symptoms. Common signs of volvulus include abdominal distension, abdominal pain, vomiting, constipation, and the presence of blood in the stools.

The onset of these symptoms can vary, with some individuals experiencing a gradual progression while others may have a sudden onset. The twisting of the intestine and the accompanying mesentery can become so severe that it restricts the blood supply to the affected area, resulting in bowel ischemia.

This reduction in blood flow deprives the affected section of the bowel of essential oxygen and nutrients, leading to tissue damage and potentially life-threatening consequences. The resulting pain can be quite severe; in some cases, individuals may develop a fever as a response to the underlying infection or inflammation.

Volvulus can occur worldwide, but its prevalence may differ in various regions. Certain areas, such as parts of Africa, Asia, and South America, have higher reported incidences of volvulus. In these regions, specific types of volvulus, such as sigmoid volvulus, are more common due to dietary and anatomical factors. Volvulus can affect individuals of all ages, but certain age groups have a higher risk.

In infants and young children, malrotation of the intestine is a common cause of volvulus. In adults, volvulus is more prevalent in the elderly population due to age-related changes in the bowel and underlying medical conditions. There is no significant gender predilection for volvulus, and males and females can be affected. Some studies suggest that there may be a seasonal variation in the incidence of volvulus, with increased cases during certain periods.

Certain ethnic groups may have a higher predisposition to specific types of volvulus. For example, sigmoid volvulus is more prevalent in individuals of African descent. Genetic factors may also contribute to the development of volvulus, but specific genetic markers or associations still need to be clearly identified.

The pathophysiology of volvulus involves the abnormal twisting of a segment of the intestine, resulting in bowel obstruction and compromised blood supply. Several factors contribute to the development of volvulus. Anatomically, the intestines are held in place by the mesentery, a fan-shaped tissue that provides support and carries the blood vessels to the intestines.

In cases of volvulus, a loop of the intestine rotates abnormally, causing the mesentery to twist. This twisting creates a mechanical obstruction, leading to the partial or complete blockage of the intestinal lumen. As the twist progresses, the mesentery becomes tightly constricted, compromising the blood vessels that supply the affected segment of the bowel. This leads to a reduced or complete cessation of blood flow, resulting in bowel ischemia.

The lack of oxygen and nutrients causes damage to the intestinal tissues, which can progress rapidly and become irreversible if left untreated. The compromised blood supply also releases inflammatory mediators, further exacerbating tissue injury and inflammation. The obstructed bowel segment becomes distended due to accumulated gas and fluid, resulting in abdominal distension. The increased pressure within the bowel causes stretching of the intestinal wall, leading to abdominal pain.

Vomiting may occur due to the obstruction, preventing the passage of ingested food and fluids beyond the point of obstruction. Constipation is another common symptom, as the twisted segment prevents the normal movement of stool through the intestines. In some cases, blood supply compromise can lead to blood in the stools, manifesting as melena or hematochezia.

The etiology of volvulus involves a combination of anatomical, mechanical, and functional factors. Anatomically, volvulus can occur due to abnormalities in the intestinal structure or positioning. For example, malrotation of the intestines during fetal development can lead to abnormal fixation, making the intestines more prone to twisting later in life.

Mechanical factors also play a role, with conditions such as chronic constipation or adhesions from previous abdominal surgeries increasing the risk of volvulus. The functional aspect involves impaired intestinal motility, which can be caused by neurological disorders like Parkinson’s disease or conditions affecting the nerves and muscles of the intestines.

Additionally, factors such as aging, which can lead to weakened intestinal muscles and decreased elasticity, can contribute to the development of volvulus. Dietary habits, such as a high-fiber or low-residue diet, may also play a role in certain types of volvulus. While the exact cause of volvulus may vary depending on the specific type and individual factors, a combination of anatomical, mechanical, and functional factors collectively contributes to its etiology.

Timely diagnosis is crucial in cecal or sigmoid volvulus cases to prevent significant morbidity and mortality. The mortality rates associated with cecal volvulus tend to be higher than sigmoid volvulus. Delayed diagnosis and treatment can lead to severe complications.

Non-surgical interventions for volvulus have shown alarmingly high recurrence rates, ranging from 40% to 60%. In cases where surgery is performed on unstable patients, reported mortality rates range from 12% to 25%. Thus, swift surgical intervention is often necessary to achieve better outcomes and reduce the risk of complications and mortality.

Clinical History

Volvulus involving the sigmoid colon typically affects elderly males who have a pre-existing history of chronic constipation. While most patients experience a sudden and rapid onset of symptoms, it is worth noting that approximately one-third of cases may present with a more gradual and subtle manifestation.

Elderly individuals, especially males, are more susceptible to developing this condition due to age-related changes in the colon and a higher prevalence of chronic constipation. The long-standing history of constipation predisposes the sigmoid colon to become more mobile and susceptible to twisting. Other factors that can contribute to the development of sigmoid volvulus include a low-fiber diet, sedentary lifestyle, and a lack of physical activity.

Physical Examination

Volvulus is characterized by the twisting or rotating a segment of the gastrointestinal tract, often resulting in a blockage of the normal flow of food, fluids, and gases. This condition can occur at any age and may present various signs and symptoms, depending on the patient’s age and the location of the volvulus. Common signs and symptoms of volvulus in adults and older children include abdominal pain, which can be severe and colicky.

The pain is typically located in the abdomen and may be accompanied by abdominal distension, where the abdomen appears bloated and swollen. Patients may experience vomiting, which can be persistent and may contain bile or blood in more severe cases. Another common symptom is constipation or obstipation, with significant difficulty or inability to pass stool. Hematochezia may also be observed.

When patients with volvulus experience significant delays in seeking medical attention, the condition can worsen and lead to complications such as perforation peritonitis. In these cases, patients may exhibit diffuse tenderness, guarding (involuntary muscle tensing to protect the abdomen), and rigidity, indicating inflammation and potential perforation of the intestines.

The presence of severe abdominal distension can further lead to hemodynamic instability, with the patient becoming hemodynamically compromised and experiencing respiratory difficulties. In newborns with midgut volvulus, distinct symptoms differ from those seen in adults and older children. These infants often present with sudden and forceful bilious emesis, regurgitating greenish-yellow fluid. Upper abdominal distension is also a common feature, as the intestines’ twisted segment leads to fluid and gas accumulation in the affected area.

Hematochezia, the passage of blood in the stool, may also be observed. Additionally, newborns with midgut volvulus may exhibit an inconsolable cry, indicating their distress. Older children with midgut volvulus may display symptoms such as episodic abdominal pain, which comes and goes in waves. They may also experience episodes of diarrhea, with loose or watery stools. Failure to thrive, characterized by inadequate weight gain or growth, may also be present in these cases.

Differential Diagnoses

Appendicitis

Abdominal hernia

Colonic polyps

Colon cancer

Ogilvie syndrome

Pseudomembranous colitis

Intestinal perforation

Intussusception

Rectal cancer

Patients with volvulus require resuscitation before surgery, and it is advisable to administer broad-spectrum antibiotics before the procedure. Regular vital signs monitoring, including urine output measurement, is necessary. Sigmoidoscopy serves as the initial treatment and aids in diagnosing sigmoid volvulus. Classic sigmoidoscopy findings include mucosal spiraling and difficulty advancing the scope beyond the point of obstruction.

Surgical options for sigmoid volvulus include bowel resection and conservative surgery. Bowel resection is preferred over conservative options like sigmoidopexy or mesenteric plication due to higher recurrence rates. Primary resection is suitable if there is no fecal peritonitis, while a Hartmann procedure is performed in cases of bowel perforation.

Minimally invasive approaches may be considered, especially for elderly patients with sigmoid volvulus, depending on the surgeon’s expertise and preference. Right hemicolectomy is the recommended procedure for cecal volvulus. If bowel necrosis is evident, resection with an ileostomy or colostomy is necessary. In critically ill patients unfit for general anesthesia, a percutaneous tube cecostomy can be performed as an interim measure.