VolvulusVolvulus

Yonatan Abraham schuldenfreiYonatan Abraham schuldenfrei

VolvulusVolvulusObstruction caused by Obstruction caused by twisting of the intestines more twisting of the intestines more than 180 degrees about the than 180 degrees about the axis of the mesenteryaxis of the mesentery

EpidemiologyEpidemiology

5% of large bowel obstructions in the US 50% in 5% of large bowel obstructions in the US 50% in Russia, accounts for about half of all causes of Russia, accounts for about half of all causes of colonic obstruction, and it is a common cause of colonic obstruction, and it is a common cause of colonic obstruction in Iran, India, and some parts colonic obstruction in Iran, India, and some parts of Africa * sabiston 19of Africa * sabiston 19thth edition editionSigmoid ~ 65%Sigmoid ~ 65% Cecum ~25%Cecum ~25% Transverse colon ~4%Transverse colon ~4% Splenic FlexureSplenic Flexure

Sigmoid VolvulusSigmoid VolvulusWorldwide - up to 50%Worldwide - up to 50% of obstruction of obstruction India, Africa, E. EuropeIndia, Africa, E. Europe

More commonly seen in elderly patients in More commonly seen in elderly patients in western societieswestern societiesRedundant colon, mesocolon narrowed, Redundant colon, mesocolon narrowed, twisting at mesenterytwisting at mesenteryRisk factors

Chronic constipation Psychiatric problems Non-western societies

high residue diet

PresentationPresentation

Hx: Abdominal pain, Hx: Abdominal pain, distension, no flatus distension, no flatus or bowel movementsor bowel movementsExam: tympanitic Exam: tympanitic abdomen, distension, abdomen, distension, mild tenderness, mild tenderness, palpable masspalpable mass

Sigmoid volvulusSigmoid volvulus

““bent inner tube” bent inner tube” appearanceappearance

Dilated sigmoid loop Dilated sigmoid loop with limbs pointing with limbs pointing towards the RLQtowards the RLQ

Sigmoid volvulusSigmoid volvulus

““Coffee bean” Coffee bean” appearance with the appearance with the two twisted loops with two twisted loops with a central doubled wall a central doubled wall componentcomponent

Barium EnemaBarium Enema

Contraindicated in Contraindicated in patients with free patients with free air on AXR, clinical air on AXR, clinical signs of peritonitis, signs of peritonitis, or suspicion for or suspicion for necrosed bowelnecrosed bowel

Bird’s beakBird’s beak

Can decompress Can decompress

Management of choiceManagement of choice

Endoscopic decompressionEndoscopic decompression Rigid or flexible Rigid or flexible

proctosigmoidoscope inserted proctosigmoidoscope inserted into rectuminto rectum

Gush of air/feces --> Gush of air/feces --> successful decompressionsuccessful decompression

Rectal tubeRectal tube Successful in 85-90% of casesSuccessful in 85-90% of cases Recurrence rate >50%Recurrence rate >50% Decreased risk for bowel Decreased risk for bowel

necrosis if treated earlynecrosis if treated earlyColon ischemia, perforationColon ischemia, perforation

Elective resectionElective resection

Operative management for Operative management for sigmoid volvulussigmoid volvulus

Elective resectionElective resection Same admissionSame admission

Emergent laparotomyEmergent laparotomy Operation depends on Operation depends on

viability of the bowelviability of the bowelHartmann resectionHartmann resectionResection and Resection and anastomosisanastomosisExteriorization resectionExteriorization resectionDetorsionDetorsionDetorsion with colopexyDetorsion with colopexyPercutaneous colostomyPercutaneous colostomyPercutaneous sigmoidpexyPercutaneous sigmoidpexy

Cecal VolvulusCecal Volvulus

Less common than sigmoid volvulusLess common than sigmoid volvulusParietal peritoneum fails to connect with the Parietal peritoneum fails to connect with the cecum and right coloncecum and right colon Present in about 10% of populationPresent in about 10% of population

Increased mobility of bowel, resulting in it Increased mobility of bowel, resulting in it folding on its axis or upwardfolding on its axis or upwardTorsion occurs proximal to cecumTorsion occurs proximal to cecumRisk factors:Risk factors: Distal obstruction, pregnancy, adhesions, Distal obstruction, pregnancy, adhesions,

congenital bands, prolonged constipation, congenital bands, prolonged constipation, meteorism (air in intestines) that occurs with non-meteorism (air in intestines) that occurs with non-pressurized air travelpressurized air travel

Hx: abdominal pain, Hx: abdominal pain, colickycolicky

DistentionDistention

Axial torsion typeAxial torsion type Twist 180-360 degrees Twist 180-360 degrees

on longitudinal axis of on longitudinal axis of ascending colon (distal ascending colon (distal ileum and ascending ileum and ascending colon)colon)

Associated with bowel Associated with bowel compromise, ischemia, compromise, ischemia, and perforationand perforation

Cecal basculeCecal bascule Cecum folds anteriorly Cecum folds anteriorly

on ascending colonon ascending colon May result in intermittent May result in intermittent

obstructive symptomsobstructive symptoms

X-raysX-rays

““comma” shapedcomma” shaped

Convexity toward Convexity toward right and downwardright and downward

BE - risk of BE - risk of perforation with perforation with getting air/contrast to getting air/contrast to right colon right colon

ManagementManagement

Decompression with Decompression with colonoscopecolonoscope Less successful than Less successful than

with sigmoid volvuluswith sigmoid volvulus

Emergent operation if Emergent operation if signs of vascular signs of vascular compromisecompromise

Operative management for Operative management for cecal volvuluscecal volvulus

Detorsion ± appendectomyDetorsion ± appendectomyCecopexy/Laparoscopic Cecopexy/Laparoscopic cecopexycecopexy

Suture R colon to lateral Suture R colon to lateral paracolic gutter or use lateral paracolic gutter or use lateral peritoneal flapperitoneal flap

CecostomyCecostomyResectionResection

Right colectomy with primary Right colectomy with primary anastomosisanastomosis

ResultsResultsDetorsion ± appendectomyDetorsion ± appendectomy High rate of recurrence (not commonly done High rate of recurrence (not commonly done

anymore)anymore)

CecopexyCecopexy Do not need to have prepped bowelDo not need to have prepped bowel Recurrence 25%Recurrence 25%

Cecostomy ± cecopexyCecostomy ± cecopexy Combined procedure more effective in preventing Combined procedure more effective in preventing

recurrencerecurrence

ResectionResection Primary anastomosis unless peritoneal Primary anastomosis unless peritoneal

contamination is presentcontamination is present

Transverse colon volvulusTransverse colon volvulusVery rareVery rareAssociated with mobile right Associated with mobile right colon, distal obstruction, colon, distal obstruction, chronic constipation, chronic constipation, congenital malrotation of the congenital malrotation of the midgutmidgutUsually not diagnosed Usually not diagnosed preoperativelypreoperativelyNo characteristic radiological No characteristic radiological findings except colonic findings except colonic dilatationdilatationResection of transverse colonResection of transverse colon

High rate of recurrence if High rate of recurrence if treated with detorsion alonetreated with detorsion alone