An Overview of Volvulus

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Volvulus is when a portion of the digestive system loops around and folds over itself. Volvulus can be very dangerous because the twisting of the intestines may cut off blood supply causing extreme pain, discomfort, bloody stool, cramps, bloating, an obstruction of the bowel making it difficult to have a bowel movement, or necrosis of the bowel, which is very dangerous and irreversible.

Symptoms

Usually there is a slow onset of symptoms with worsening over time. It may start with cramping, then the pain becomes worse with time until it becomes unbearable.

Common symptoms of volvulus that may also signal bowel obstruction include:

  • Abdominal distention
  • Abdominal tenderness
  • Vomiting
  • Blood in stools
  • Constipation

One may have constipation paired with the inability to pass gas. Abdominal distention occurs due to these factors and possibly even nausea and vomiting. Vomiting usually begins a few days after the onset of the pain.

For children, the main clinical findings are usually vomiting of a bilious-looking material, which is a yellow-green color. This is a strong sign of something going wrong in the bowel and requires an immediate workup. The vomit may also be nonbilious.

Both children and adults with volvulus may also develop hemodynamic instability from not having enough fluid intake or being in septic shock.

The most common location for volvulus to occur in adults is the sigmoid colon and cecum. The stomach may also be affected. In children, the small intestine is usually the location of its occurrence.

Causes

The cause of volvulus is not entirely known. It predominately occurs in older adults around age 70. Some studies have shown it to be more common in men, though other studies have found no link to gender. It is more common among those who are debilitated with neurologic or psychiatric conditions with associated constipation.

Where the cause is not exactly understood, there are several factors that may make volvulus more likely. These may be broken down into anatomic factors and colonic factors.

Some anatomic features that may predispose a person to sigmoid volvulus is a long, redundant, sigmoid colon, where there is more length to wrap around itself and a narrow mesenteric attachment. The mesentery is a fold in the peritoneum that helps to attach the intestines to the wall of the abdomen.

Colonic dysmotility may be a cause of volvulus. It is believed that if the colon is not moving as it does normally, it may predispose to torsion of the sigmoid colon. Therefore, the connection with constipation is thought to occur due to the chronic overload of fecal matter which elongates and dilates the sigmoid colon.

Other connections have been made between sigmoid volvulus and people who presented as children with Hirschsprung disease, where there is a portion of bowel that does not have the nerve cells it needs to create the regular movement of the colon. Missing these nerve cells in the colon paired with a freely mobile mesentery could predispose to the development of volvulus.

Causes in Children

In children, volvulus occurs as a result of an abnormality in the rotation of the gut when the baby is still in utero. This occurs in babies about one in 6,000 live births.

Many children who have volvulus will also have an associated congenital anomaly, such as atresia, which is a blocking of the bowel.

Intestinal Detorsion

While volvulus is caused by the torsion of the intestine, it is also possible for intestinal detorsion, where the intestines spontaneously unwrap themselves. This may happen over and over again so the vascular supply is not getting as compromised due to the moments the intestines are not twisted.

This is more likely to occur in younger people, where they will experience symptoms that come and go multiple times and have painful bouts that spontaneously resolve with time. This does not mean the issue goes away. It may just take more time to diagnose and treat.

Diagnosis

The first tip-off to the diagnosis of volvulus is a high suspicion based on the presenting symptoms, which includes abdominal pain, nausea, abdominal distention, constipation, and inability to pass gas.

Physical Exam

If the physical exam, performed by a doctor, is indicative of volvulus, the diagnosis is then usually made via imaging, with high importance placed on ruling out other causes for these findings. In order to rule out other causes for the pain, a thorough exam, including a possible pelvic exam for women, may be necessary.

Labs and Tests

Lab tests are usually done to check the electrolytes, other markers for infection and necrosis, and a urine test to rule out a urine pathology. Women of childbearing age should also have a pregnancy test performed.

If a patient presents as being sick with advanced disease possible, a more detailed laboratory workup is performed, which can include looking at liver markers, pancreatic function markers, and others.

CT Scan

For adults, an abdominal computed tomography, better known as a CT scan, is performed.

A CT scan usually will show a "whirl pattern" which is caused by the dilation of the sigmoid colon wrapped around the mesentery and vessels. A "bird-beak" appearance with the contrast may be seen where there is an obstruction and the contrast cannot pass through. These findings are not always seen, however, and the diagnosis can be made without them.

Another finding on imaging that helps to support the diagnosis is an absence of rectal gas. If the disease has progressed to bowel necrosis, it may be possible to see bubbles in the bowel wall, known as pneumatosis intestinalis, or portal venous gas.

Radiographs

Abdominal X-rays can help to make the diagnosis of sigmoid volvulus but usually need to be accompanied by other forms of imaging. (For children, an ultrasound can be performed initially to prevent radiation exposure.)

The characteristic findings are distended large bowel and air-fluid levels. These findings are seen in a general bowel obstruction or other pathologies so it is difficult to pinpoint the diagnosis of volvulus with just these X-rays alone.

Contrast Enema

A contrast enema demonstrates the pattern of a twisted taper or again, the appearance of a "bird's beak." This study should only be performed under fluoroscopy and with experts because it poses the risk of perforation. They should not be performed in patients with possible peritonitis.

Treatment

Once the diagnosis of volvulus is made, the goal of treatment is to relieve the twisting of the intestine and prevent future episodes of twisting.

The process of untwisting the intestines is called "reducing" the volvulus. In order to accomplish this, a flexible sigmoidoscopy is performed first. A sigmoidoscopy can reduce the sigmoid volvulus when it is advanced through the twisted segment of the colon. This allows it to unravel and the blood supply can be restored to the tissue.

The doctor performing the procedure is able to look at the colon through the scope to assess if there is tissue damage without putting the patient through surgery. Some doctors may leave a rectal tube in place to allow for less abdominal distention with a theoretical reduction in the risk for a recurrence.

There is debate on the best overall management of sigmoid volvulus because some suggest that endoscopy only be done for those patients who can not undergo surgery, while another group recommends performing surgery after the sigmoidoscopy to prevent further episodes after the initial presentation. The reason this debate occurs is that sometimes reduction of the volvulus is not accomplished by endoscopy, some patients may not be able to undergo the procedure due to advanced disease, and the reduction may be unsuccessful, with many experiencing a recurrence.

If a second recurrence occurs, the chance of subsequent recurrences is even higher. The time between these recurrences may vary from hours to months.

Surgical management of a sigmoid volvulus includes resection of a portion of the bowel with either a reconnecting of the bowel or colostomy formation. It depends on the extent of bowel injury to help determine which is the more appropriate approach. Usually, if the necrosis of the tissue is not extensive, there has been great success in reconnecting the bowel in that same procedure without the need for a colostomy.

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