Primary small bowel volvulus: cause and management

Primary small bowel volvulus: A case report and literature review

Background

Small bowel volvulus (SBV) is an aberrant rotation of the small bowel segment along the axis of its mesentery.

Secondary SBV is the most frequent situation. Postoperative adhesions represent the main cause. On the other hand, primary SBV is an extremely rare situation. There are no predisposing anatomical abnormalities.

Herein, we present a case of a 73-year-old-patient, with no surgical history, presenting primary SBV.

Case presentation

A 73-year-old-patient presented to the emergency department with a one-day history of acute abdominal pain and vomiting. He had no medical comorbidities and no previous abdominal surgery.

On examination, he was agitated and afebrile.

Urgent computed tomography (CT) scan showed dilated small bowel loops with a “whirl sign”.

A laparotomy was performed. It revealed a 320° SBV of the distal jejunum and the proximal ileum. The small bowel was ischemic. There were no congenital malformations, no adhesions, and no internal hernia.

We performed a detorsion of the small bowel. It regained good vitality. To avoid recurrence, we performed enteropexy of the terminal ileum, and the caecum to widen the mesenteric base.

We noted no recurrence of the pathology after three months of follow-up.

Conclusion

Primary SBV is an extremely rare situation. Physiopathology is still misunderstood. The clinical presentation is not specific. Diagnosis can be evoked by CT scan but can only be confirmed intraoperatively. The surgical treatment should be performed timely. Different techniques have been described to avoid recurrence. None of those techniques is consensual.

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Primary small bowel obstruction is an extremely rare situation.

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The physiopathology is still unclear.

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The diagnosis is difficult due to the non-specificity of the symptoms.

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The surgical treatment should be performed timely.

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Enteropexy is an option to avoid recurrence but it's not consensual.

Seasonality of Primary Small Bowel Volvulus and Its Variations Based on Sex and Place of Residence, North Western Ethiopia

Background

Primary small bowel volvulus is a common surgical emergency in some parts of the globe. Its seasonal nature has not been widely researched. The main objective of this study was to assess its underlying patterns among different gender and geographical location.

Materials and methods

A hospital-based retrospective cross-sectional study was conducted from November 2020 to February 2021 at two comprehensive specialized hospitals in North West Ethiopia. The monthly count of primary small bowel volvulus was analyzed for patterns using Minitab 18. Graphical techniques such as run sequence plots, multiple box plots, and correlogram were used. Additive decomposition was also done. The degree of seasonal variation was measured in terms of seasonal indices generated for each month. A chi-square goodness-of-fit test at p < 0.05 was applied to determine statistical significance.

Results

A total of 235 patients were found to have surgically confirmed diagnosis of primary small bowel volvulus over six years. Most were males (77.4%) and from rural residence (73.2%). The mean age in years was 40.5 (±16.7). Overall, 179 (76.2%) of the total cases, 148 (81.3%) of males, and 138 (80.2%) of rural cases were admitted during June through November.

Conclusion

Seasonal variation was found to be a feature of primary small bowel volvulus. Knowing its seasonal nature helps raise the threshold of suspicion among health care providers to pass timely clinical decisions particularly in resource-limited setups.

Small bowel knots

INTRODUCTION

Intertwining of bowel loops to form a knot is very rare cause of intestinal obstruction. Among intestinal knots, ileoileal knotting is the most rare, with only a handful of cases reported in literature. We present a rare case of ileoileal knotting and review of small bowel knots. The aim of this review was to summarise the existing evidence on small bowel knots and to postulate the possible mechanisms for knotting.

METHODS

A systematic search was conducted for literature published up to December 2019 using MEDLINE, PubMed and Google Scholar databases, together with the references of the full-text articles retrieved. Papers with case reports of small bowel knots were considered to be eligible for inclusion in the review.

FINDINGS

A total of 14 case reports were evaluated. There was no clear predilection for age or sex. Mostly cases were from Asia and Africa with no cases from the West. The presenting complaints were abdominal pain (93%), vomiting (64%), abdominal distention (57 %) and obstipation (43%). The bowel was gangrenous in 78% of cases. All underwent exploration, with the majority requiring resection and anastomosis of the involved segment.

CONCLUSION

Ileoileal knotting is a very rare cause of intestinal obstruction. Possible mechanisms include loaded bowel with longer mesentery, vigorous peristalsis, single bulky meal, pregnancy and intussusception. The condition is extremely difficult to diagnose preoperatively and it is usually diagnosed intraoperatively. The standard of treatment is resection of gangrenous part and anastomosis.

Primary Small Bowel Volvulus: An Unusual Cause of Small Bowel Obstruction

We present the case of a 78-year-old female who presented to the emergency department with small bowel obstruction in a virgin abdomen. Although the patient did not have peritonism and biochemical investigations did not reveal alarming features of ischemia, an abdominal computed tomography (CT) scan was suggestive of small bowel volvulus (SBV), and operative exploration was pursued. No obvious cause was identified aside from hard stools throughout the colon and a diagnosis of primary SBV was determined. She was subsequently discharged symptom-free on day seven post-operatively. She re-presented on day 10 post-operatively with a similar history, examination, and abdominal CT findings suggestive of SBV recurrence. Her volvulus slowly resolved post administration of rectal enemas and did not require any further operative intervention; she was discharged on day eight of re-admission (day 19 post-operatively) with no recurrence of her symptoms on a regular diet. In this article, we discuss the management of SBV.

Small bowel volvulus versus adhesive small bowel obstruction: a diagnostic dilemma in a 19-year-old woman

Small bowel volvulus (SBV) is often challenging to diagnose. Research suggests that the clinical presentation of this disease is often very similar to other more common causes of small bowel obstruction (SBO) such as intraabdominal adhesions and no single preoperative diagnostic study is sensitive or specific enough to identify this rare cause of mechanical SBO. This report describes a case of a 19-year-old woman who presented with irretractable vomiting and abdominal pain secondary to SBV. This case is unusual as her history of recurrent adhesive SBO presented a diagnostic dilemma that required a higher degree of clinical suspicion to tease these differential diagnoses apart. She underwent laparoscopy which facilitated successful detorsion and resection of the floppy tongue of jejunum. This report aims to increase the awareness among surgeons.

Primary small intestinal volvulus after laparoscopic rectopexy for rectal prolapse

Primary small intestinal volvulus is defined as torsion in the absence of congenital malrotation, band, or postoperative adhesions. Its occurrence as an early postoperative complication is rare. A 40-year-old woman presented with rectal prolapse, and laparoscopic rectopexy was uneventfully performed. She could not have food on the day after surgery. She started oral intake on postoperative day 3 but developed abdominal pain after the meal. Contrast-enhanced CT revealed torsion of the small intestinal mesentery. An emergent laparotomy showed small intestinal volvulus, without congenital malformation or intestinal adhesions. We diagnosed it as primary small intestinal volvulus. The strangulated intestine was resected, and reconstruction was performed. The patient recovered uneventfully after the second surgery. To the best of our knowledge, this is the first report of primary small intestinal volvulus occurring after rectopexy for rectal prolapse. Primary small intestinal volvulus could be a postoperative complication after laparoscopy.

Small Bowel Volvulus: A Case Report

Small bowel volvulus is a rare clinical entity which presents as recurrent intermittent abdominal pain after consumption of food. Although the entity is well described in the literature, diagnosis is often difficult due to its clinical presentation being similar to mesenteric ischemia. Herein we present the case of a 44-year-old male who presented to us with this condition.

Diagnosis, treatment and prognosis of small bowel volvulus in adults: A monocentric summary of a rare small intestinal obstruction

Objectives

Small bowel volvulus is a rare disease, which is also challenging to diagnose. The aims of this study were to characterize the clinical and radiological features associated with small bowel volvulus and treatment and to identify risk factors for associated small bowel necrosis.

Methods

Patients with small bowel volvulus who underwent operations from January 2001 to December 2015 at the First Affiliated Hospital of China Medical University (Shenyang, China) were reviewed. Clinical, surgical and postsurgical data were registered and analyzed.

Results

Thirty-one patients were included for analysis. Fifteen patients were female (48.4%), with an average age of 47.7 years (18–79 years). The clinical signs and symptoms were unspecific and resembled intestinal obstruction. Clinical examination revealed abdominal distension and/or diffuse tenderness with or without signs of peritonitis. The use of CT scans, X-rays or ultrasound did not differ significantly between patients. In 9 of 20 patients that received abdominal CT scans, “whirlpool sign” on the CT scan was present. Secondary small bowel volvulus was present in 58.1% of patients, and causes included bands (3), adhesion (7), congenital anomalies (7) and stromal tumor (1). Out of the 31 patients, 15 with gangrenous small bowel had to undergo intestinal resection. Intestinal gangrene was present with higher neutrophils count (p<0.0001) and the presence of bloody ascites (p = 0.004). Three patients died of septic shock (9.68%), and the recurrence rate was 3.23%.

Conclusions

To complete an early and accurate diagnosis, a CT scan plus physical exam seems to be the best plan. After diagnosis, an urgent laparotomy must be performed to avoid intestinal necrosis and perforation. After surgery, more than 90% of the patients can expect to have a favorable prognosis.

Risk factors for intestinal gangrene in children with small-bowel volvulus

OBJECTIVES

Pediatric small-bowel volvulus (SBV) is a surgical emergency, and early diagnosis is difficult. We analyzed the clinical manifestations, imaging findings, and laboratory parameters in children with SBV and attempted to determine the risk factors for bowel gangrene.

PATIENTS AND METHODS

Forty-nine children (35 boys and 14 girls) with SBV who were admitted to the hospital for a period of 13 years were enrolled. Clinical and laboratory parameters and evaluation measures included fever, abdominal pain, vomiting, bloody stool, peritoneal signs, severe dehydration, disease duration, white blood cell counts, sugar, C-reactive protein (CRP), sodium, potassium, metabolic acidosis, blood urea nitrogen, and creatinine. These parameters were statistically compared between patients with and without bowel gangrene.

RESULTS

Thirty-six patients (73.5%) were 5 years old or younger, and nearly half were younger than 1 year old. Abdominal pain and vomiting were 2 major symptoms. Malrotation was the most common cause of SBV. In univariate analysis, nonbilious vomiting, peritoneal signs, severe dehydration, leukocytosis (WBC count >18,000 cells/mm3), elevated CRP (>50 mg/dL), and hyponatremia (<130 mmol/L) were significantly associated with bowel gangrene (P < 0.05). In multivariate analysis, nonbilious vomiting, leukocytosis, and elevated CRP were significantly (P < 0.05) associated with bowel gangrene. The resection rate for bowel gangrene was 44.9%, and no mortality was found. Seven (14.3%) patients had postoperative complications, including short-bowel syndrome (n = 2), adhesion ileus (n = 3), and intraabdominal abscess (n = 3). Seven experienced failure to thrive in later follow-up.

CONCLUSIONS

Specific clinical manifestations and laboratory parameters are helpful in the identification of bowel gangrene in children with SBV.

Ileo-anal pouch necrosis secondary to small bowel volvulus: A case report

INTRODUCTION

Small bowel volvulus is a rare occurrence in the Western world and its occurrence after ileo-anal ouch formation is even rarer.

CASE PRESENTATION

We report a case of a 26 year old lady who presented with small bowel volvulus and subsequent ischaemia and necrosis of her ileo-anal pouch created 5 years previously.

CONCLUSION

This case illustrates a rare but potentially devastating complication of ileo-anal pouch formation and as such the diagnosis should be borne in mind when a patient with a pouch presents with an acute abdomen.

Laparoscopic management of a primary small bowel volvulus: a case report

Primary small bowel volvulus in adults is a very rare condition, and it is defined as torsion of all or a large segment of the small intestine and its mesentery in the absence of any preexisting etiologic factors. Proper management of the patients suffering from a strangulated obstruction depends on making an early and accurate diagnosis. Timely treatment is crucial to prevent gangrene. A 49-year-old man who had a history of previous abdominal surgery was admitted to our hospital with complaints of acute abdominal pain. Simple abdominal x-ray showed multiple dilated loops of small intestine in the mid-abdomen. Enhanced abdominal computed tomography showed the distended small bowel loops and longitudinal tapering of the collapsed bowel loops. We carried out diagnostic laparoscopy to confirm the cause of suspected mechanical ileus. It revealed strangulation of the small bowel at the terminal ileum due to clockwise torsion of the bowel loop. There were no adhesions or congenital anomalies in the peritoneal cavity. The torsional segment was spontaneously reduced with minimal handling, and the strangulated portion was resected. The patient was discharged from hospital on postoperative day 6. Primary small bowel volvulus in adults is a very rare malady; if the diagnosis is uncertain, then diagnostic laparoscopy is a valuable tool for making the definitive diagnosis and administering prompt treatment.

Small bowel volvulus among adults

BACKGROUND

To elucidate clinical experience associated with rare cases of small bowel volvulus among adults, we conducted a retrospective study.

METHODS

From January 1993 to March 2003 inclusively, we reviewed the presentation and management of 19 patients featuring small bowel volvulus. All study-included patients underwent surgical treatment to confirm their diagnosis. We also analyzed their signs, symptoms, radiological examination details, clinical course and surgical results.

RESULTS

The mean age of the study-included 19 patients (13 males, six females) was 61.3 years (range = 16-83 years). All patients suffering from small bowel volvulus were categorized as displaying either primary (no obvious predisposing factors) or secondary volvulus (specific predisposing anatomical abnormalities present). Among them, nine patients were categorized as having primary volvulus, and the remaining 10 were patients with secondary volvulus; this comprised one pregnancy, two malignant stromal tumors of the jejunum, six jejunal diverticula, and one adhesion band. Nine examples of volvulus occurred in the jejunum, four in the ileum, and six in both jejunum and ileum. There were five examples of a counter clockwise rotation of small bowel volvulus. Two patients exhibited bowel wall gangrene, both of whom died subsequent to surgery. The overall mortality rate was 11%.

CONCLUSIONS

Although small bowel volvulus is rarely seen among adults, when a patient presents with intestinal obstruction, the possibility of small bowel volvulus must be considered. Early surgical intervention should be undertaken in order to prevent vascular compromise.

An intestinal volvulus caused by multiple magnet ingestion: an unexpected risk in children

It has been reported that ingested magnets can cause intestinal fistula formation or perforation, leading to intestinal obstruction. However, there are no previous case reports that magnet ingestion additionally caused an intestinal volvulus. We report herein the case of a 1-year-old boy in whom the ingested magnets caused a volvulus of part of the small intestine leading to the resection of the necrotic portion. We think that if more than one magnet is found as a foreign body in the intestine, they should be removed immediately by laparotomy. Clinicians who care for children should be aware of this unexpected risk.

Primary small bowel volvulus in Nepal

Small bowel volvulus is a rare cause of intestinal obstruction. Primary small bowel volvulus occurs without any predisposing cause. It is rare in Western countries but common in Africa and Asia. It is the most common cause of bowel obstruction in Nepal (excluding incarcerated external hernias). Early diagnosis and management is essential to avoid infarction of bowel. Persistent central abdominal pain is characteristic. There is no single specific diagnostic clinical sign or abnormality in laboratory or radiological findings. There is no role of conservative management and, in suspected cases, early laparotomy should be done to avoid bowel infarction. In follow-up patients may present with stricture formation or recurrence of bowel volvulus.

Computed tomography features of small bowel volvulus

A case of small bowel volvulus in an adult is presented. The established CT signs of small bowel volvulus are discussed. These include an abnormal orientation of the superior mesenteric artery to the superior mesenteric vein; the whirl sign, the triangle sign and the beak sign.

Primary small bowel volvulus in rural Nepal

Primary small bowel volvulus is the commonest cause of intestinal obstruction in the Gorkha district of Nepal resulting in laparotomy. Yet, this problem is mentioned only briefly, if at all, in many standard textbooks of surgery. This paper presents details of the presentation, clinical findings, and surgical management of 18 cases of primary small bowel volvulus. Small bowel volvulus occurred in adults only, with an overwhelming male predominance and a low mortality despite late presentation in the majority of cases. Attention is drawn to the common finding of localized ischaemia of several centimetres of terminal ileum.

Management of small intestinal volvulus in a district hospital

Primary small intestinal volvulus is one of the common causes of intestinal obstruction in various localities of the developing world. Although the general principles of management of intestinal obstruction apply to it, its diagnosis is dependent on a clinical exclusion of other causes of intestinal obstruction with overt features, and awareness of patterns of obstruction in a given locality. Moreover, in nearly all the cases early operation is recommended for a confirmation of the diagnosis and relief of the obstruction. However, lacking the necessary precautions on operation, sometimes a relief of the obstruction without a diagnostic confirmation may be the result.

Acute small bowel volvulus in adults. A sporadic form of strangulating intestinal obstruction

Small bowel volvulus is an uncommon but important cause of small intestinal obstruction. It often results in ischemia or even infarction. Delay in diagnosis and surgical intervention increases morbidity and mortality rates. Based on cause, small bowel volvulus can be divided into primary and secondary type. Goals for treatment of small bowel volvulus should include physician awareness of this uncommon diagnosis, accurate workup, and advanced surgical intervention. The presentation and subsequent management of 35 patients with small bowel volvulus confirmed by laparotomy are reviewed and discussed. The incidence of small bowel volvulus in the adult European and North American is low. The resultant mortality rate, however, makes diagnosis critically important. The cardinal presenting symptom is abdominal pain. There is no single specific diagnostic clinical sign or abnormality in laboratory or radiologic finding. In practice, the diagnosis can only be made by laparotomy. The failure to perform an exploratory laparotomy cannot be justified. Early diagnosis and early surgery are the keys for successful management of strangulation obstruction of the small bowel.

The ileosigmoid knot

The ileosigmoid knot (ISK) is a rare cause of intestinal obstruction. Unfamiliarity with the condition could have disastrous consequence at surgery. Over the past 20 years, we have encountered seven cases. Analyzing the data gathered from these, and on reviewing the literature, we found it possible to arrive at a preoperative diagnosis in two patients. Four patients were women, two of whom developed the obstruction in the postpartum period. One of the males was found to have an inflamed Meckel's diverticulum included in the knotting. The symptoms and the clinical findings were nonspecific. The characteristic x-ray findings of a double closed loop obstruction, was seen in only three patients. Resection of gangrenous bowel with anastomoses was feasible in four. Unlike in other series, primary anastomosis of the large gut was undertaken. There were two deaths early in the series. Guidelines to the management have been suggested.

Volvulus of the small intestine

At the Mayo Clinic, six patients with primary volvulus and 51 with secondary volvulus were treated during a 10-year period. Volvulus of the small intestine must be considered when a patient presents with small-bowel obstruction, and early operative intervention should be undertaken to prevent vascular compromise.

Intestinal volvulus: a new concept

A concept of the aetiology of intestinal volvulus is presented based on the fact that bowel when distended becomes elongated. The antimesenteric border of the bowel elongates more than the mesenteric border and this provides the driving force which initiates and sustains the volvulus. It is, therefore, a secondary event resulting from distention.

Patterns of mechanical obstruction of the small bowel in Nigeria

One hundred sixty-one patients with mechanical small bowel obstruction were treated within 2 years at the University of Nigeria Teaching Hospital, Enugu, Nigeria. The various causes of obstruction fairly typify the patterns of mechanical small bowel obstruction in Nigeria, except for slight differences in some parts of the country. The fairly high mortality rate reflects the difficulties encountered in management of the patients. Measures to reduce mortality are suggested.