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

• 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

• Abdominal aortic aneurysm
  • Aortocaval fistula
• Acute gastroenteritis
• Aortoenteric fisulta
• Appendicitis (early)
• Bowel obstruction
  • Large bowel obstruction
    • Ogilvie's syndrome
  • Small bowel obstruction
• Bowel perforation
• Gastroparesis
• Diabetic ketoacidosis
• Inflammatory bowel disease
• Mesenteric ischemia
• Pancreatitis
• Peritonitis
• Sickle cell crisis
• Spontaneous bacterial peritonitis
• Volvulus

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

• Volvulus (Peds)

References

Authors

Michael Holtz