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Volvulus

It is the twisting of air filled segment of bowel about its narrow mesentery causing obstruction which leads to gangrene and strangulation. Volvulus occurs when colon is filled wit solid stools. Many cases are observed with volvulus of cecum, sigmoid and transverse colon. Volvulus causes less than 10% of bowel obstruction in USA, 55% in Iran and Russia.

Redundant sigmoid colon with a narrow based mesentery or mesocolon is the factor necessary for sigmoid colon volvulus.

Pathogenesis:
  • When a solid mass obstruction occurs, the colon becomes distended and loaded causing redundant loop.
  • This hangs down into the pelvis causing elongation of pelvic mesocolon. This elongation is possible because peritonium from the superior abdominal wall is raised and becomes part of the mesocolon. This attachment of the pelvic mesocolon becomes narrow.
  • As a result two ends of the pelvic colon are approximated to each other and twist can easily follow.
  • A horizontal attachment of mesocolon (pelvic) to the anterior abdominal wall may be additional predisposing factor.
  • A band of adhesion stretching from antimesenteric border at the summit of pelvic colonic loop may also be an aiding factor. The gut rotates between two fixed points.
Clinical Features:
  • Nausea and vomiting
  • Diffused pain
  • Inability to discharge stool and gas
  • Abdominal distension without Blumberg’s sign
  • Per rectal examination reveals blood on the tip of finger
If the complication is peritonitis then fever, increase in WBC count and evidence of peritoneal irritation suggest strangulated and gangrenous bowel.

Diagnosis:
Plain abdominal radiograph has great diagnostic value in intestinal obstruction. We can see “U” shaped (sausage like) distended intestine. Barium enema show beak like narrowing of the contrast.

Treatment:
Any type of attempt in repositioning sigmoid volvulus covers the dangerous complication. Scientists noticed that repositioning with fibroelastic colonoscope has perforation rate of about 40% (perforation). Surgical intervention is indicated if the nearby loops of strangulated bowel are visible then creation of anastomosis could be done but if the picture of peritonitis occurs and in the case of spread bowel necrosis, Hartmann’s pouch type of operation is indicated.

Cecal Volvulus

Generally occurs in younger patients and accounts for 20% of the colon volvulus. It is thought to be due to anomalies of fixation of the right colon to the retroperitoneum which leaves free and mobile cecum.

Signs and Symptoms:
Severe pain, distension, cramps, nausea and vomiting, opstiption and diarrhoea are common symptoms.

Treatment:
Operative and surgical distortion in association with cecoplasty and cecostomy are done.

Cecoplasty: Fixation peritoneum of cecum with sphincters.
Right ileocolomy: in this case there is no evidence of gangrene
Ileotransversotomy: Removal of whole cecum and anastomosis of ileum with transverse colon directly, but if the gangrene develops then right hemiileocolectomy with ileostomy is indicated.

In addition to the surgical interventions, in all cases of obstructions it is necessary to transfuse great amount of fluids due to the sequestration of the fluid in so called third space occurs.

First space: blood stream
Second space: intra and extra cellular space
Third space: intraluminal space


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This article has been written by Dr. M. Javed Abbas.
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21:04 21/12/2002