Intestinal Volvulus

Kasr El-Ainy | Dr Hosam Ghazy | Wikipedia

Definition Pathology

Defined as a complete twisting of a loop of intestine around its mesenteric attachment site. When the twisting is complete, it forms a closed loop of obstruction with resultant ischemia 2ry to vascular occlusion . Produce a combination of obstruction of the closed-loop type and occlusion of the main vessels at the base of the involved mesentery (strangulation) . In a closed-loop, the pressure rises rapidly which further increase the risk of gangrene & perforation. Commonest in sigmoid colon, may also affect caecum, stomach & small intestine . It may be primary or secondary:

The 1ry form occurs secondary to congenital malformation of the gut, abnormal mesenteric attachments or congenital bands . The 2ry form occurs due to actual rotation of a piece of bowel around an acquired adhesion or stoma .

Predisposing factors & Etiology

Occur more commonly in elderly chronically constipated males. Midgut volvulus: usually in infants predisposed because of congenital intestinal malformation. Segmental volvulus: in patients of any age with a predisposition because of abnormal intestinal contents (e.g. meconium ileus) & adhesion. Volvulus of caecum, transverse or sig moid colon: usually in adults, with a predisposition factor of redundant (excess, inadequately supported) intestinal tissue & constipation. Anatomically, the predisposing factors of sigmoid volvulus are:

Long sigmoid colon Narrow base of sigmoid mesocolon A heavily loaded sigmoid (as a result of chronic constipation) Adhesion at the apex of the sigmoid loop which facilitate the twisting of the loop

Types

Volvulus neonatorum

Due to arrest gut rotation & narrow mesentery of small bowel & caecum Repeated vomiting, rapid dehydration & abdominal distension Occurs primarily or secondarily; usually in lower ileum Occur spontaneously or secondary Treatment: reduction of the twist & directed to the underlying cause s Occurring primarily or as a part of volvulus neonatorum A clockwise twist Female > Male 25% has tympanic swelling at the midline or left side of abdomen An anti-clockwise twist Occurring spontaneously in adult (most common) Chronic constipation is a predisposing factors

Volvulus of small intestine

Caecal volvulus

Sigmoid volvulus

Clinical pictures

Features of that acute colonic obstruction Cardinal symptoms but not necessarily present in all cases: 1. Pain: colicky, caused by hyperperistalsis 2. Distension:

Mainly in flanks Marked in sigmoid volvulus, less in high obstruction Central abdominal distention in low small bowel obstruction

3. Absolute constipation: Early in colon obstruction , late in high obstruction. 4. Vomiting:

Early in high obstruction, late or absent in colon obstruction In neglected cases: vomiting become greenish, then later become brown & offensive

5. Neglected cases of sigmoid volvulus shows evidence of peritonitis Investigation 1. Plain X-ray: huge gas-filled sigmoid loop (omega loop) 2. Urea, electrolyte & blood picture Treatment Conservative:

Indicated in early cases with no evidence of gangrene A rectal tube is passed thru a sigmoidoscope to untwist the sigmoid loop gush of gases & fluid stools The tube is left in place & patient is prepared for later elective resection of the long sigmoid (to prevent recurrence) Indicated in 1) Failure of conservative management 2) Late presentation The gangrenous bowel is resected The proximal colon end is brought out to the skin as a terminal colostomy & the distal end is closed by sutures ( Hartmanns procedure) for later elective anastomosis Viable sigmoid is untwisted & either fixed to the posterior abdominal wall or resected as for gangrenous case

Surgery:

Muhammad Fuad Jaafar

24052012