Volvulus

Article Author:
Carol Le
Article Editor:
Wantzy Cooper
Updated:
3/13/2019 6:56:28 PM
PubMed Link:
Volvulus

Introduction

Volvulus occurs when a loop of intestine twists around itself and the mesentery that supports it, causing a bowel obstruction. Symptoms include abdominal bloating, pain, vomiting, constipation, and bloody stools. The onset of symptoms may be gradual or rapid. The mesentery becomes so tightly twisted that blood supply is cut off, resulting in an ischemic bowel. Pain may be significant and fever may develop. 

Risk factors for volvulus include a birth defect known as intestinal malrotation, Hirschsprung disease, an enlarged colon, pregnancy, and abdominal adhesions. A high fiber diet and chronic constipation also increase the risk. In adults, the sigmoid colon and cecum are most affected.  In children, the small intestine and stomach are more commonly involved. Diagnosis is typically made with medical imaging such as plain X-rays, CT scan, or a GI series.  [1]

Initial treatment for sigmoid volvulus may be with sigmoidoscopy or a barium enema. Due to the high risk of recurrence, a bowel resection within two days is generally recommended. If the bowel is severely twisted or the blood supply is cut off, emergent surgery is required. In a cecal volvulus, part of the bowel is usually removed. If the cecum is still healthy, it may be returned and sutured in place. 

Etiology

Volvulus is associated with intestinal malrotation, an enlarged colon, a long mesentery, Hirschsprung disease, pregnancy, abdominal adhesions, and chronic constipation. In adults, the sigmoid colon is most affected, with the cecum being second most affected. In children, the small intestine is more commonly involved.  [2]

Epidemiology

Sigmoid and cecal volvulus most often occurs between the ages of 30 and 70.

  • Volvulus occurs more frequently in middle-aged and elderly men.
  • Volvulus arises as a rare complication in patients with a redundant colon, a normal anatomic variation resulting in extra-colonic loops.
  • Sigmoid volvulus is a very common form of volvulus and is responsible for 8% of all intestinal obstructions. Sigmoid volvulus is particularly common in constipated and elderly persons. Patients experience pain, distension, and constipation.
  • Cecal volvulus is less common than sigmoid volvulus and is associated with pain and small bowel obstruction.
  • Midgut volvulus typically occurs in babies that are predisposed because of congenital intestinal malrotation. 
  • Segmental volvulus occurs in people of any age, usually with a predisposition because of abnormal intestinal contents or adhesions. 
  • Volvulus of the cecum, transverse colon, or sigmoid colon usually occurs in adults with minor predisposing factors such as redundant intestinal tissue and constipation.

Cases of volvulus were first described in ancient Egypt in 1550 BC. It occurs commonly in Africa, the Middle East, and India, presumably because of a high-fiber diet. Rates of volvulus in the United States are about 2 to 3 per 100,000 people per year. Outcomes are related to whether bowel tissue is ischemic or necrotic. The term volvulus is Latin for "volvere," which means "to roll."  [3]

Pathophysiology

Volvulus is typically caused by two mechanisms: chronic constipation and a high-fiber diet

In both the instances, the sigmoid colon becomes dilated and heavy making it susceptible to torsion. With repeated attacks of torsion, the mesentery shortens. The chronic inflammation leads to the formation of adhesions which then entrap the sigmoid colon into fixed twisted position.

In cecal volvulus, the predominant symptom is small bowel obstruction (nausea, vomiting, and lack of flatus), because the obstructing point is close to the ileocecal valve and small intestine.

In sigmoid volvulus, although pain may be present, constipation may be more prominent.  [4]

Volvulus causes severe pain with an accumulation of gas and fluid in the portion of the bowel obstructed resulting in necrosis of the affected intestinal wall, acidosis, and death. This is known as a closed loop obstruction. Acute volvulus requires immediate surgical intervention to untwist the affected segment of bowel.

Volvulus may occur in patients with Duchenne muscular dystrophy due to the smooth muscle dysfunction.

History and Physical

Patients with volvulus are usually debilitated and bedridden. Many of these individuals have a history of neuropsychiatry dysfunction, and thus, a medical history is usually unavailable.

Signs and symptoms of volvulus include pain, bloating, vomiting, constipation, bloody stool, fever, and significant pain when the abdomen is palpated. Depending on the duration of the condition, there may be signs of peritonitis and bleeding per rectum. The severe abdominal distension can also compromise respiration in some patients.  [5]

Evaluation

Diagnosis usually is made by taking a thorough history and performing a physical examination; it is confirmed by radiographic studies. The diagnosis of colonic volvulus usually is included in the differential diagnosis which also includes bowel obstruction, mesenteric ischemia, and malignancy. 

Abdominal plain x-rays may be confirmatory for a volvulus, especially if a "bent inner tube" or a "coffee bean" sign are seen. These refer to the appearance of the air-filled closed loop of the colon which forms the volvulus. A barium enema is used to demonstrate a "bird's beak" at the point where the segment of proximal bowel and distal bowel rotate to form the obstructing volvulus. This area will show an acute and sharp tapering that has the appearance of a bird's beak. If a perforation is suspected, barium should be avoided due to its potentially lethal effects when distributed throughout the free intraperitoneal cavity. Gastrografin, which is safer, can be substituted for barium.

In approximately 80% of colonic obstructions, a carcinoma invading the wall of the intestine is found to be the cause of the obstruction. This is usually easily diagnosed with CT scan and endoscopic biopsies. [6]

Treatment / Management

Initial treatment for sigmoid volvulus is sigmoidoscopy or a barium enema. Due to a high recurrence rate, a bowel resection within two days is recommended. In a cecal volvulus, part of the bowel often needs to be removed.

Treatment for sigmoid volvulus includes sigmoidoscopy. If the mucosa of the sigmoid looks normal, place a rectal tube for decompression, correct electrolytes, ensure adequate fluids, and optimize cardiac, renal and pulmonary abnormalities. The patient should then be taken for surgical repair. If surgery is not performed, there is a high rate of recurrence of volvulus and obstruction. For patients with signs of sepsis or an acute abdominal catastrophe, immediate surgery and resection are advised. In a cecal volvulus, the cecum may be returned to a normal position and then sutured in place via a procedure known as cecopexy. If the bowel is obviously necrotic, then resection with an ileostomy or a colostomy is necessary.

Over the years many surgical techniques have been developed to treat cecal and sigmoid volvulus. In general, conservative procedures where the bowel is adhered with sutures are often associated with higher recurrence rates compared to procedures that involve resection of the bowel. Whether to do the surgery via an open or laparoscopic method depends on surgeon preference and experience. Elderly patients may benefit from minimally invasive procedures.  [7]

Pearls and Other Issues

Complications of volvulus include gangrene, strangulation, perforation fecal peritonitis, and recurrent volvulus.

Prognosis

Delay in diagnosis and treatment of volvulus is associated with a high morbidity and mortality. The mortality is 30% to 40% in patients in whom treatment of cecal volvulus is delayed. [8]

The recommended interval between endoscopic decompression and surgical intervention is 48 to 72 hours. This allows time for investigation, resuscitation, and intervention to reduce surgical risk.

  • Even when volvulus is successfully treated with endoscopic decompression and surgical resection, mortality is still 12% to 15%. 
  • 50% of patients who undergo endoscopic decompression alone experience recurrence. 
  • Endoscopic decompression alone for sigmoid volvulus carries a recurrence rate of 40% to 50% and a mortality of 25% to 30% after surgical treatment of the recurrence.

Enhancing Healthcare Team Outcomes

Patients with volvulus often present to the emergency department. While the diagnosis is not difficult, the management is not always straight forward. Thus it is important to involve a multidisciplinary team that includes the emergency department physician, nurse practitioner, general surgeon, gastroenterologist, and the internist. Sigmoid volvulus is initially treated with decompression but because of high recurrence rates, surgery is recommended. Cecal volvulus is usually treated with surgery. 

Over the years many surgical techniques have been developed to treat cecal and sigmoid volvulus. In general, conservative procedures where the bowel has adhered with sutures are often associated with higher recurrence rates compared to procedures that involve resection of the bowel. Whether to do the surgery via an open or laparoscopic method depends on surgeon preference and experience. Elderly patients may benefit from minimally invasive procedures.  [7] 



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      Contributed by Scott Dulebohn, MD

References

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[2] DUTRA RM, [Upon a case of megacolon (syndrome of Hirshprung)]. Hospital (Rio de Janeiro, Brazil). 1948 Oct;     [PubMed PMID: 18890431]
[3] Tam A,Phong J,Yong C, Primary small bowel volvulus: surgical treatment dilemma. ANZ journal of surgery. 2018 Dec 18;     [PubMed PMID: 30562836]
[4] Hancerliogullari O,Senocak R,Kaymak S,Lapsekili E,Sinan H, An uncommon cause of acute abdomen in an acromegalic patient: colonic volvulus. Annali italiani di chirurgia. 2018;     [PubMed PMID: 30665214]
[5] Atamanalp SS, Comments on Contemporary Management of Sigmoid Volvulus. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2018 Nov 21;     [PubMed PMID: 30465185]
[6] Bailey KS,Lundstrom E,Borgstrom D, Cecal Volvulus: An Evolving Disease. The American surgeon. 2018 Sep 1;     [PubMed PMID: 30454520]
[7] Carmo L,Amaral M,Trindade E,Henriques-Coelho T,Pinho-Sousa J, Sigmoid Volvulus in Children: Diagnosis and Therapeutic Challenge. GE Portuguese journal of gastroenterology. 2018 Sep;     [PubMed PMID: 30320166]
[8] Korkut E,Aksungur N, Comments on a new classification, treatment algorithm and prognosis-estimating system for sigmoid volvulus: factors affecting recurrence. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2018 Sep;     [PubMed PMID: 29904994]