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A volvulus is a bowel obstruction resulting from a loop of intestine twisting around itself and its supporting mesentery. Symptoms include abdominal pain, bloating, vomiting, constipation, and bloody stool. Onset of symptoms may be rapid or more gradual. The mesentery may become so tightly twisted that blood flow to part of the intestine is cut off, resulting in ischemic bowel. In this situation there may be fever or peritonitis.
Risk factors include a birth defect known as intestinal malrotation, an enlarged Large intestine, Hirschsprung disease, pregnancy, and abdominal adhesions. Long term constipation and a high fiber diet may also increase the risk. The most commonly affected part of the intestines in adults is the sigmoid colon, with the cecum being the second most affected. In children the small intestine is more often involved.
The stomach can also be affected. Diagnosis is typically with medical imaging such as , a GI series, or CT scan.Initial treatment for sigmoid volvulus may occasionally occur via sigmoidoscopy or with a barium enema. Due to the high risk of recurrence, a bowel resection within the next two days is generally recommended. If the bowel is severely twisted or the blood supply is cut off, immediate surgery is required. In a cecal volvulus, often part of the bowel needs to be surgically removed. If the cecum is still healthy, it may occasionally be returned to a normal position and sutured in place.
Cases of volvulus were described in ancient Egypt as early as 1550 BC. It occurs most frequently in Africa, the Middle East, and India.
Rates of volvulus in the United States are about 2–3 per 100,000 people per year.
Volvulus causes severe pain and progressive injury to the intestinal wall, with accumulation of gas and fluid in the portion of the bowel obstructed.
Volvulus occurs most frequently in middle-aged and elderly men. Volvulus can also arise as a rare complication in persons with redundant colon, a normal anatomic variation resulting in extra colonic loops.
Sigmoid volvulus is the most common form of volvulus of the gastrointestinal tract. and is responsible for 8% of all intestinal obstructions. Sigmoid volvulus is particularly common in elderly persons and constipated patients. Patients experience abdominal pain, distension, and absolute constipation.
Cecal volvulus is slightly less common than sigmoid volvulus and is associated with symptoms of abdominal pain and small bowel obstruction.
Volvulus can also occur in patients with Duchenne muscular dystrophy due to smooth muscle dysfunction.
Gastric volvulus causes nausea, vomiting, and pain in the upper abdomen. The Borchardt triad is a group of symptoms that help doctors identify gastric volvulus. The symptoms are intractable retching, pain in the upper abdomen, and inability to pass a nasogastric tube into the stomach.
This area shows an acute and sharp tapering and looks like a bird's beak. If a perforation is suspected, barium should not be used due to its potentially lethal effects when distributed throughout the free intraperitoneal cavity. Gastrografin, which is safer, can be substituted for barium.
The differential diagnosis includes the much more common constricting or obstructing carcinoma. In approximately 80 percent of colonic obstructions, invasive carcinoma is found to be the cause. This is usually easily diagnosed with endoscopic biopsies.
Diverticulitis is a common condition with different presentations. Although diverticulitis may be the source of a colonic obstruction, it more commonly causes an ileus, which appears to be a colonic obstruction. Endoscopic means can be used to secure a diagnosis, although this may cause a perforation of the inflamed diverticular area. CT scanning is the more common method to diagnose diverticulitis. The scan will show mesenteric stranding in the involved segment of edematous colon, which is usually in the sigmoid region. Microperforations with free air may be seen.
Ulcerative colitis or Crohn's disease may cause colonic obstruction. The obstruction may be acute or chronic, and after years of uncontrolled disease, it leads to the formation of strictures and fistulas. The medical history is helpful in that most cases of inflammatory bowel disease are well known to both the patient and doctor.
Other rare syndromes, including Ogilvie's syndrome, chronic constipation, and impaction, may cause a pseudo-obstruction.
For people with signs of sepsis or an abdominal catastrophe, immediate surgery and resection are advised.
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