Transverse colon volvulus in children: A case series and a review of the literature

From the Cecum to the Sigmoid: Twisted Colon in the Pediatric Population

Colonic volvulus (CV) is the third leading cause of colonic obstruction in adults. In infants and children, this is exceedingly rare, with only sporadic cases reported so far. We present two cases of CV to highlight the differences in etiology, presentation, diagnosis, and treatment of this condition. The first patient is a 12-year-old boy with no previous surgeries who presented with four days of abdominal pain. Imaging showed a sigmoid volvulus that was decompressed endoscopically, and he was discharged. He had a contrast enema showing an abnormal rectosigmoid ratio. At the time of the rectal biopsy four weeks later, he was found to have a recurrence, at which point definitive operative treatment was pursued. The second patient is a 17-year-old boy who presented with five days of abdominal pain and CT findings concerning for ischemic volvulus. This prompted emergent operative intervention, where a cecal volvulus was discovered as the result of a congenital band. The band was divided without complication.  Pediatric CV is a rare condition that might be severe in some cases. High suspicion, prompt diagnosis, and treatment are essential to prevent early and long-term morbidity.

Volvulus of the Transverse Colon

BACKGROUND

In the United States, the third leading cause of a large bowel obstruction (LBO) is colonic volvulus with torsion occurring most commonly in the sigmoid and the cecum. Transverse colonic volvulus (TCV) is exceedingly rare and specific involvement of the splenic flexure (SFV) is even less common. The present analysis was undertaken to interrogate current trends in presentation, management, and outcomes of TCV.

METHODS

In the present report, the world literature was reviewed for the past 90 years (1932 to 2021). We conducted a systematic review to identify all cases of TCV following the PRISMA guidelines.

RESULTS

We identified 317 cases of TCV. This included SFV (n = 75), TCV in pediatric patients (n = 63), TCV in pregnant patients (n = 8), and TCV associated with other pathology such as Chilaiditi's syndrome (n = 11). Compared to sigmoid and cecal volvulus, TCV was rare (.94%). It affected slightly more women (54%) than men, commonly in their third decade of life (37.7 ± 23.8). The clinical presentation and diagnostic imaging were consistent with LBO. Compared to sigmoid volvulus, there was a limited role for conservative management and colonoscopic decompression was less effective. The most common operation was segmental resection (25%). Mortality was (20%) commonly because of cardiopulmonary complications and affected more women (63%). The average age of this cohort was 55.7±24.6 years old.

DISCUSSION

Our review showed that TCV is an uncommon surgical entity. The diagnosis is likely to be made at laparotomy. Prompt recognition is paramount in preventing ischemia necrosis and perforation. Compared to sigmoid and cecal volvulus, the mortality for TCV remains high.

Rare case of rectosigmoid stricture causing transverse colon volvulus

A 60-year-old woman with remote history of sleeve gastrectomy presented with altered mental status after an unwitnessed fall. She was found to be hypothermic with lactic acidaemia, leucocytosis, positive urinalysis, and dilated ascending and transverse colon on cross-sectional imaging, initially thought to be secondary to faecal loading. She was admitted to the medical intensive care unit for resuscitation and broad-spectrum antibiotics for presumed urinary sepsis. She became acutely altered and underwent urgent flexible sigmoidoscopy by gastroenterology to evaluate for ischaemic colitis. During the procedure, there was concern for iatrogenic colon injury given the friability of the colonic mucosa, so the patient was taken urgently for exploratory laparotomy. Intraoperatively, she was found to have a transverse colon volvulus with large areas of patchy, gangrenous bowel without evidence of gross perforation. A rectosigmoid stricture with associated serosal tear, but no full-thickness injury was identified. An extended left hemicolectomy and end transverse colostomy was performed resulting in improvement in the patient's clinical status and eventual discharge to subacute rehab.

Pediatric colonic volvulus: A single-institution experience and review

BACKGROUND/PURPOSE

Pediatric colonic volvulus is both rare and underreported. Existing literature consists only of case reports and small series. We present an analysis of cases (n=11) over 15 years at a single institution, focusing on workup and diagnosis.

METHODS

This was an institutional review board approved single-institution retrospective chart review of 11 cases of large bowel volvulus occurring over 15 years (2000-2015).

RESULTS

In our series, the most common presenting symptoms were abdominal pain and distention. Afflicted patients often had prior abdominal surgery, a neurodevelopmental disorder or chronic constipation. Of the imaging modalities utilized in the 11 patients studied, colonic volvulus was correctly diagnosed by barium enema in 100% of both cases, CT in 55.6% of cases and by plain radiography of the abdomen in only 22.2%of cases. Colonic volvulus was confirmed by laparotomy in all cases. The cecum (n=5) was the most often affected colonic segment, followed by the sigmoid (n=3). Operative treatment mainly consisted of resection (63.6%) and ostomy creation (36.4%). Colopexy was performed in 18.2% of cases.

CONCLUSIONS

Plain abdominal radiography may be performed as an initial diagnostic study, however, it should be followed CT or air or contrast enema in children where there is high clinical suspicion and who do not have indications for immediate laparotomy. CT may be the most specific and useful test in diagnosis of colonic volvulus and has the added advantage of detection of complications including bowel ischemia. We demonstrate a range of diagnostic and therapeutic modalities for pediatric colonic volvulus. This underscores the need for further study to draft standard best practices for this life-threatening condition.

LEVEL OF EVIDENCE

Prognosis Study: Level IV. Study of a Diagnostic Test: Level III.