Sigmoid volvulus in children and adolescents

Seeds of Discomfort: An Unusual Case of Pediatric Abdominal Pain

This case describes a seven-year-old healthy boy who presented with seven days of abdominal pain, small-volume liquid stools, tenesmus, fevers, and dehydration after consuming an unknown amount of shelled watermelon seeds. He was ultimately found to have a large rectal seed bezoar that caused irritation, resulting in stercoral colitis with rectal inflammation. He was additionally found to have sigmoid volvulus during one of his disimpactions, which was also likely secondary to his rectal seed bezoar. This case uniquely highlights the importance of maintaining an index of suspicion for rectal seed bezoars, discusses previously unreported pediatric complications of rectal seed bezoars, including stercoral colitis and sigmoid volvulus, and addresses the management of this rare presentation.

Management of Recurrent Sigmoid Volvulus in the Pediatric Population

Sigmoid volvulus is a rare etiology of bowel obstruction in the pediatric population that can be easily misdiagnosed, leading to delayed treatment and potential complications. Given that sigmoid volvulus is a common cause of bowel obstruction in the adult population and the significant lack of literature on its management in children, treatment strategies for pediatric patients often follow standardized protocols for adults. We report the case of a 15-year-old boy who presented with recurrent episodes of sigmoid volvulus over a 1-month period. Computed tomography demonstrated a sigmoid volvulus without evidence of ischemia or bowel infarction. Colonoscopy demonstrated a descending megacolon, and bowel transit studies demonstrated normal transit time. Acute episodes were managed conservatively with colonoscopic decompression. After a complete study, laparoscopic sigmoidectomy was performed. This work demonstrates the importance of early recognition and treatment of sigmoid volvulus in the pediatric population to limit recurrent episodes.

Sigmoid volvulus secondary to undescended testicle: Report of first case in the literatures

Sigmoid volvulus accounts for 20%-50% of colonic obstructions in Eastern countries. This occurs mostly in patients with a lack of mobility and a history of chronic constipation. There are some very known complications of a undescended intra-abdominal testicle such as cancer, ischemia, and infertility; But the rotation of the colon around the spermatic cord of one UDT is a very rare phenomenon that there is no similar report. A 67-year-old man came to the emergency department with a complaint of abdominal pain and obstipation. On examination, patient was febrile (T: 38.5) and had mild general tenderness. According to the appearance of coffee beans in the X-ray, the diagnosis of sigmoid volvulus was made. In the requested tests, leukocytosis was observed. Rectosigmoidoscopy was unsuccessful. The patient underwent laparotomy. After manual untwisting, a tubular structure at the base of the meso-sigmoid was noticed. With further exploration, the testis was observed intra-abdominally. Orchidectomy and sigmoidectomy were performed by Hartmann's method. Sigmoid volvulus is one of the common cases that surgeons frequently encounter. The case scenarios are often the same, and from experience, most cases result from a long meso and an elongated sigmoid secondary to prolonged constipation. Therefore, it is clear that a scrotal examination would not be part of the routine examination of a patient with sigmoid volvulus. In this article, by reporting a very rare etiology for a very common pathology, we tried to point out the importance of head-to-toe examination in all patients.

Recurrent Sigmoid Volvulus in Children-Our Experience and Systematic Review of the Current Literature

Sigmoid volvulus (SV) occurs rarely in children. After encountering two cases of recurrent SV, we reviewed the literature to define the recurrence risk, identify outcome predictors and to give treatment recommendations. We found 256 cases reported in children (mean age 10.2 years, gender ratio (m:f) 2.3:1). Associations exist with Hirschsprung disease (HD) in 10%, neurodevelopmental disorders in 10.9% and chronic constipation in 10.2%. Common symptoms and clinical signs were abdominal pain (85%), distension (85%), tenderness (54%) and vomiting (59%). Signs of peritonitis were present in 14% and indicated a gangrenous sigmoid (X2 = 45.33; p < 0.001). A total of 183 had abdominal radiographs, and 65% showed a positive 'coffee-bean-sign'. Contrast enemas were positive in 90%. A total of 124 patients underwent laparotomy; in 41 cases, the sigmoid was gangrenous and associated with more complications (X2 = 15.68; p < 0.001). Non-operative treatment (NOT) like endoscopic, fluoroscopic or rectal tube decompression was performed in 135 patients and successful in 79% with a 38-57% recurrence rate. A total of 73 patients subjected to elective surgery: 50 underwent sigmoid resection; 17 had surgery for HD. Clinicians should consider SV in all children with abdominal pain, distension and vomiting. Gangrene carries a higher morbidity. After successful NOT we recommend counselling about the recurrence risk and definitive surgery should be advised. HD is frequent in newborns but sometimes found in older children.

A Twist on Adolescent Abdominal Pain in the Emergency Department

Abdominal pain is a common complaint in pediatric patients in the emergency department (ED). Evolutions in clinical practice have shifted away from computed tomography (CT) to ultrasound (US) in assessing abdominal pain. However, ultrasound may not reliably rule out critical diagnoses. We present a 15-year-old male with intermittent suprapubic abdominal pain. Subsequent CT imaging showed swirling mesenteric vessels with a dilated sigmoid colon. In adolescent abdominal pain, sigmoid volvulus (SV), although rare, should be considered. Clinicians should avoid anchoring bias by maintaining a broad differential. Definitive care is surgical with resection to prevent recurrence.

Colonic Volvulus in Children: Surgical Management of a Challenging Condition

Colonic volvulus (CV) is a rare but potentially life-threatening condition with unclear etiopathogenesis. To date, less than 80 pediatric cases have been described. Hirschsprung’s disease (HD) is associated with CV in 17% of cases, representing a significant risk factor. Non-HD CV is an even more complex entity. The aim of this study is to describe a series of patients with CV to accentuate some peculiar aspects of this disease. We performed a retrospective study (period: 2012–2021) collecting information of patients with CV. Data analyzed included: demographics, medical history, presenting symptoms and radiological and surgical details. Eleven patients (12.5 ± 2.8 years; 7F/4M) had CV (eight sigmoid, two transverse colon, one total colon). Five patients had associated anomalies and three had HD. A two-step approach with volvulus endoscopic/radiological detorsion followed by intestinal resection was attempted in eight cases (one endoscopic approach failed). Three patients required surgery at admission. At follow-up, two patients developed recurrent intestinal obstruction, one of whom also had anastomotic stenosis. Colonic volvulus is a challenging condition that requires prompt patient care. A missed diagnosis could lead to severe complications. The evaluation of the patient should include a careful histological examination (searching for HD and alpha-actin deficiency), immunologic and metabolic screening, neurological tests and detection of chronic intestinal pseudo-obstruction (CIPO). Lifelong follow-up is mandatory for the early recognition and treatment of progressive diseases involving the proximal gastrointestinal tract.

Sigmoid volvulus in an adolescent female: A case report

INTRODUCTION AND IMPORTANCE

Sigmoid volvulus is a rare cause of intestinal obstruction in children and adolescent population. It's considered a disease of the elderly with a widely varying incidence worldwide. It is more common in areas referred to as "volvulus belt" (Middle East, Africa, the Indian subcontinent, Turkey, and South America).

CASE PRESENTATION

We report a 16-year-old female who underwent emergency laparotomy for intestinal obstruction. We found a twisted sigmoid volvulus in 3600 degree clockwise. The sigmoid colon was distended and edematous with no perforation or gangrene. Resection of the redundant colon was performed followed by primary anastomosis.

CLINICAL DISCUSSION

Sigmoid volvulus remains an uncommon cause of intestinal obstruction among the adolescent age group. A high index of suspicion is necessary to reach a diagnosis and manage accordingly. Delay in diagnosis can lead to complications such as necrosis and perforation of the twisted colon.

CONCLUSION

We present a rare cause of intestinal obstruction in a 16-year-old female due to sigmoid volvulus. Early diagnosis and management reduce morbidity and mortality.

Constipation in Pediatrics: A Clinical Review

Constipation is a common problem encountered in the pediatric setting. For many children, constipation is functional in nature-potentially stemming from a pattern of stool output that is infrequent or not fully productive (ie, incomplete stool evacuation)-and includes behavioral concerns like stool withholding. In many cases of functional constipation (FC), the pattern may have started in the toddler years during or before toilet training and may now be well established. Additional factors often include inadequate fluids and fiber, or excess dietary dairy or carbohydrates. In a small percentage of cases, constipation is a symptom of an underlying organic disease process. Laboratory tests and imaging may be helpful in determining most organic concerns. In the absence of an organic process, FC can be treated by properly educating families about the nature of FC as well as careful attention to dietary fiber and fluid intake, use of stool softeners, laxatives, and behavioral modifications. [Pediatr Ann. 2021;50(8):e320-e324.].

Endoscopic Reduction of Sigmoid Volvulus in a 15-Year-Old Male

Sigmoid volvulus is a well-recognized phenomenon in the elderly but rare in children. The proposed mechanism involves rotation of a redundant sigmoid loop around a narrow, elongated mesentery with subsequent vascular occlusion. The condition can be intermittent or may resolve spontaneously, complicating diagnosis. Early diagnosis is imperative to prevent ischemic complications including necrosis, perforation, and sepsis. Abdominal pain, abdominal distention, and vomiting are the most common presenting symptoms, however abdominal tenderness is uncommon. Colonic dilation is the most frequent finding on abdominal radiograph. Contrast enema reveals a "bird's beak" configuration of the twisted colon and moreover, is successful in reducing the majority of pediatric cases. If there is no evidence of bowel ischemia or perforation, endoscopic reduction has been proposed as first-line treatment for sigmoid volvulus, especially in children. We report the case of 15-year-old male in which endoscopic reduction of sigmoid volvulus was successful without complication.

Pediatric sigmoid volvulus of an extremely long sigmoid colon with hypoganglionosis: a case report

Sigmoid volvulus is an extremely rare cause of intestinal obstruction in pediatric patients. This condition occurs when a redundant sigmoid loop with a narrow mesenteric base of attachment to the posterior abdominal wall rotates around its mesenteric axis. This situation might result in vascular occlusion and large bowel obstruction. There are only a few predisposing factors of sigmoid volvulus, such as a long-term history of constipation or pseudo-obstruction with an excessive sigmoid colon. Underlying hypoganglionosis can also lead to large bowel obstruction. There have only been two reported cases of hypoganglionosis with sigmoid volvulus, and both were in adults. Sigmoid volvulus usually presents with abdominal pain, nausea, vomiting, constipation and abdominal distension, an absence of stool, or the presence of melenic stool in the rectum. Initial treatment options are non-surgical for stable patients, although surgical management might be necessary. If sigmoid volvulus is not recognized and resolved, it may lead to serious complications and death. Pediatric sigmoid volvulus is frequently the fulminant type, and therefore, a decision about treatment must be prompt. We present an unusual pediatric case of an extremely long sigmoid colon with hypoganglionosis, which twisted and caused obstruction. This condition was resolved with surgical resection.

Non-invasive treatment of the sigmoid volvulus. A pediatric case report

Sigmoid volvulus occurs when the sigmoid colic loop gets wrapped around its own mesocolon. While this condition is categorized as an extremely rare emergency in the pediatric population, diagnosis is often difficult due to the fact that its aspecific manifestations or sneaky symptoms are similar to other medical conditions. The available treatment options remain controversial up to this day, and the non-operative approach is more preferred in treating hemodynamic stable patients. This paper examines the case study of a 13-year-old girl suffering from sigmoid volvulus, who was treated with water-soluble contrast enema, in order to determine whether this method is efficient and effective in successfully treating the pathology of this condition.

Sigmoid volvulus in children

Sigmoid volvulus in paediatric patients is a rare but potentially life-threatening condition. Since 1940, only 100 cases have been reported. There are no consensual guidelines for juvenile sigmoid volvulus unlike in adults, where the condition and the treatment is well described. We report a case of a 12-year-old patient, who presented with uncharacteristic symptoms of mild abdominal discomfort and lack of passage of stool. A CT-scan showed a sigmoid volvulus and emergency resection was performed with placement of a colostomy. With this case, we want to emphasise juvenile sigmoid volvulus as a probable differential diagnosis when symptoms of abdominal distress and constipation occur.

Short bowel syndrome as a result of sigmoid volvulus in an 8-year-old child. The first reported case worldwide: A case report

INTRODUCTION

We present a case of a male child 8 years old presenting with a sigmoid volvulus causing ischemia of most of bowel loops resulting in a short bowel syndrome. It is the first reported case worldwide.

PRESENTATION

A male child presented with a picture of intestinal obstruction. After complete laboratory and radiological investigation, laparotomy was done revealing a sigmoid volvulus compessing most of the small bowel loops with gangrenous sigmoid colon for which sigmoidectomy with end colostomy, resection of gangrenous small bowel loops and primary anastomosis of the remaining healthy part.

DISCUSSION

There are few reported cases describing sigmoid volvulus in this age group. However, none of them resulted in short bowel syndrome. The median age was 7 years with a higher ratio in males than females (3.5:1).

CONCLUSION

Sigmoid volvulus is not a common problem in children and adolescents, and is rarely considered as a cause of intestinal obstruction and it was never reported as a cause of short bowel syndrome. Early diagnosis and prompt treatment confer an excellent prognosis.

A case report of Hirschsprung's disease presenting as sigmoid volvulus and literature review, Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

Background

Sigmoid volvulus is an uncommon problem in children and adolescents, and is rarely considered a diagnosis in this group. A high index of suspicion is necessary to reach a diagnosis and avoid morbidity and mortality. Sigmoid volvulus is a rare complication of Hirschsprung’s disease, which has been reported in neonates, children, and adults. Here we report a case of sigmoid volvulus accompanied by undiagnosed Hirschsprung's disease.

Case presentation

A 9 years old boy who presented with sudden onset of colicky abdominal pain of 4 h duration associated with gross abdominal distension and 2 episodes of non-bilious vomiting. A plain abdominal radiographs showed single hugely dilated bowel loops in the left lower quadrant with single air fluid level. Sigmoid volvulus was considered and rectal tube deflation was done and it was successful. Full thickness rectal biopsy was done and it was consistent with aganglionic megacolon. A primary trans-anal Soave endo-rectal pull through was done 3 weeks later, after biopsy result arrived, which yielded loss of symptoms and regular bowel movement.

Conclusions

Sigmoid volvulus should be considered in the differential for children presenting with acute onset of abdominal obstruction. It should be known that when its’s diagnosed in children, it is often associated with Hirschsprung's disease. Therefore, a proper diagnostic and treatment algorithm should be followed in order not to miss associated HD and to give optimum care to such patients.

Different clinicopathological features of non-elderly sigmoid volvulus patients

PURPOSE

Sigmoid volvulus is frequently seen in male patients over 60 years old. Here, we aimed to investigate the causes of sigmoid volvulus developing in patients under 60 years of age.

METHODS

Patients diagnosed with sigmoid volvulus between 2009 and 2018 were retrospectively analyzed. The patients were divided into two as under 60 years old and above. The co-morbidity, mortality, morbidity, complications, age, and gender data were analyzed.

RESULTS

A total of 134 patients were included. The median age was 70 (19-92), ≤ 59 age patients constituted 24% of all patients. Eighty-one percent (109/134) of the patients were male, and male/female ratio was lower in ≤ 59 age patients (2.0 vs 6.2, p = 0.01). Diseases that caused and underlying colon dilatation (mental retardation with hypomotility, pregnancy-puerperium, Hirschsprung's disease, etc.) were more common in ≤ 59 age patients, but no observed at 60≤ age patients (15.2% vs 0%, p = 0.0007). While there was no difference between the two groups in terms of mortality, it was proportionally higher in the 60≤ age group (3.0% vs. 13.9%, p = 0.12).

CONCLUSION

By decreasing age, male dominance disappears progressively, and it is likely to have an underlying colonic hypomotility in young sigmoid volvulus patients.

Hirschsprung's Disease Complicated by Sigmoid Volvulus: A Systematic Review

BACKGROUND

Hirschsprung's disease and sigmoid volvulus can sometimes be seen in the same patient.

AIMS

To investigate the presence of Hirschsprung's disease in patients with sigmoid volvulus and to discuss the diagnosis and treatment methods.

STUDY DESIGN

Systematic review.

METHODS

This systematic review has been reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the methodological quality of systematic reviews guidelines. The PubMed and Scopus databases were scanned using the keywords "Hirschsprung* volvulus*" and "congenital aganglionic megacolon volvulus*". The reference list of the selected studies was reviewed for cross-checking. Two reviewers independently screened the available literature. Only the Hirschsprung's disease cases involving sigmoid volvulus were included, and cases of patients with volvulus in other sites was excluded. There was no restriction with respect to the publication language and type of writing. The primary outcome was morbidity and mortality.

RESULTS

A total of 31 cases were analyzed in 22 articles; 97% of the patients were under the age of 40, 90% were male. There was a statistically significant difference in the necessity for relaparotomy between patients who were scheduled for sigmoid volvulus therapy with the suspicion of Hirschsprung's disease and patients who were treated without suspicion of Hirschsprung's disease (0% vs 37.5%, p=0.02). While there was no postoperative death in cases with suspected Hirschsprung disease, this mortality rate was 25% in cases without suspicion (p = 0.08).

CONCLUSION

Hirschsprung's disease should be excluded with rectal biopsy if a patient with sigmoid volvulus is under 40 years of age and has complaints of constipation from childhood.

Sigmoid Volvulus in 16-year-old Boy with an Associated Anomalous Congenital Band

Sigmoid volvulus, a condition generally seen in debilitated elderly patients, is extremely rare in the pediatric age group. Frequent predisposing conditions that accompany pediatric sigmoid volvulus include intestinal malrotation, omphalomesenteric abnormalities, Hirschsprung's disease, imperforate anus and chronic constipation. A 16-year-old previously healthy African American male presented with a 12 hour history of sudden onset abdominal pain and intractable vomiting. CTwas consistent with sigmoid volvulus. A contrast enema did not reduce the volvulus, but it was colonoscopically reduced. Patient condition initially improved after colonoscopy, but he again became distended with abdominal pain, so he was taken to the operating room. On exploratory laparotomy, a band was discovered where the mesenteries of the sigmoid and small bowel adhered and created a narrow fixation point around which the sigmoid twisted. A sigmoidectomy with primary anastomosis was performed. The diagnosis of sigmoid volvulus may be more difficult in children, with barium enema being the most consistently helpful. Seventy percent of cases do not involve an associated congenital problem, suggesting that some pediatric patients may have congenital redundancy of the sigmoid colon and elongation of its mesentery. The congenital band found in our patient was another potential anatomic factor that led to sigmoid volvulus. Pediatric surgeons, accustomed to unusual problems in children, may thus encounter a condition generally found in the debilitated elderly patient.

Sigmoid volvulus after CABG surgery

We report a case of a geriatric patient who underwent CABG and developed sigmoid volvulus (SV) with recurrence. SV is a rarely reported complication of CABG. Timely diagnosis, management, and follow-up are strictly advised, particularly in geriatric patients. Immediate surgical measures are required to prevent volvulus-associated ischemia.

Sigmoid volvulus in a 10-year-old male: A case report and review of the literature

Sigmoid volvulus in children is a potentially disastrous situation, still remaining rare in terms of occurrence. We hereby present a case report of a 10-year-old male, having admitted in our department complaining about abdominal pain, who finally proved to suffer from sigmoid volvulus.

Sigmoid volvulus: a rare but unique complication of enteric fever

We present a case of sigmoid volvulus in a young male patient with culture-proven Salmonella Typhi in the blood which was sensitive to Meropenem and Azithromycin only, presented with fever, vomiting, loose stools, hematochezia, abdominal distention and tenderness with no signs of perforation on erect chest x-ray. Further, radiological imaging showed signs of sigmoid volvulus. An urgent colonic decompression with untwisting of the mesentery was performed. In our case, it can be said that sigmoid volvulus was developed as a complication of multiple drug-resistant strains of Salmonella Typhi. The resistance is acquired by alteration in the genome sequence. Currently, it is important to control such an unknown outbreak of multiple drug-resistant strains of Salmonella Typhi as it is a serious health care issue of disease control and prevention in Pakistan.

American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of acute colonic pseudo-obstruction and colonic volvulus

Colonic volvulus and acute colonic pseudo-obstruction (ACPO) are 2 causes of benign large-bowel obstruction. Colonic volvulus occurs most commonly in the sigmoid colon as a result of bowel twisting along its mesenteric axis. In contrast, the exact pathophysiology of ACPO is poorly understood, with the prevailing hypothesis being altered regulation of colonic function by the autonomic nervous system resulting in colonic distention in the absence of mechanical blockage. Prompt diagnosis and intervention leads to improved outcomes for both diagnoses. Endoscopy may play a role in the evaluation and management of both entities. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on the evaluation and endoscopic management of sigmoid volvulus and ACPO.

Pediatric Sigmoid Volvulus

Sigmoid volvulus is an extremely rare cause of abdominal pain in children. More commonly seen in older adults, an SV occurs when a redundant loop of sigmoid wraps around its elongated, narrow mesentery causing obstruction and ischemia to the affected bowel segment. Children usually present with abdominal pain, nausea, and abdominal distension. Presentations may be acute or chronic with a history of episodic constipation or abdominal distension. The treatment plan includes an initial reduction of the volvulus via sigmoidoscopy with rectal biopsy to rule out Hirschsprung disease; however, operative management to remove the dilated sigmoid colon may be required in the setting of recurrence or confirmed Hirschsprung disease. Although rare, SV should be considered in a child presenting with abdominal pain as a missed diagnosis can have high potential morbidity and mortality.

Volvulus of sigmoid colon in a challenged adolescent: An unusual case report

Sigmoid volvulus is very uncommon cause of intestinal obstruction in pediatrics population withhigh rate of mortality. To date, few cases of sigmoid volvulus in children and association with several condition has been reported in literature, of them very few cases are with mental disability. We report a challenged (mentally disabled) 14-year old adolescent boy presented asan emergency with feature of complete bowel obstruction. Abdominal X-rays shows dilated loop of large bowel with inverted U shaped. Volvulus of sigmoid colon was found during laparotomy and successfully managed with resection of a redundant colon with colocolic end to end anastomosis. Sigmoid volvulus is relatively uncommon in children as compared to adults. Surgeons should be attentive of this rare entity, cause of large bowel obstruction to allow for early diagnosis and to enable better patient outcomes by reducing the morbidity and mortality.

Colonoscopic decompression of childhood sigmoid and cecal volvulus

Cases of colonic volvulus in children are infrequently described in the literature. Here we describe the case of three patients with colonic volvulus. The first patient was a 10-year-old girl with abdominal dilation and pain and no bowel movement for 48 h. Her abdominal X-ray showed the coffee bean sign adjacent to the diaphragm, which was compatible with a diagnosis of cecal volvulus. The second patient was a 4-year-old boy with a history of chronic constipation during the past year and with no bowel movement for 24 h. Clinical manifestations included severe nausea, vomiting, and abdominal distension. His abdominal X-ray demonstrated the coffee bean sign in the right upper quadrant with upward convexity corresponding to a diagnosis of sigmoid volvulus. The third patient was a 10-month-old male who presented with excessive crying, malnutrition, and no bowel movement for 36 h. His abdominal X-ray demonstrated the coffee bean sign in the left upper quadrant with upward convexity. The presence of gas was not observed in the distal obstructed region, corresponding to a diagnosis of sigmoid volvulus. All three patients successfully underwent colonoscopy for volvulus reduction. Volvulus did not reoccur in any of the patients within 6 months of follow-up. It is recommended to perform abdominal X-ray imaging in patients who present with abdominal pain and distension, diarrhea, or constipation for possibly diagnosing volvulus.

Sigmoid Volvulus in Children: Diagnosis and Therapeutic Challenge

Background

Sigmoid volvulus is a rare condition in children. Early diagnosis increases the success of nonsurgical treatment in the emergency department, but posterior elective surgery is important due to the risk of recurrence.

Methods/Conclusions

We present the case of a healthy 16-year-old girl with recurrent volvulus and successful endoscopic treatment followed by elective surgery.

A case report and literature review of sigmoid volvulus in children

RATIONALE

Sigmoid volvulus (SV) is an exceptionally rare but potentially life-threatening condition in children.

CHIEF COMPLAINT

Abdominal distention for 1 week.

DIAGNOSES

Sigmoid volvulus.

PATIENT CONCERNS

We present a case of a 12-year-old boy with mechanical ileus who was finally confirmed to have SV with the combination of abdominal plain film, sonography, and computed tomography (CT) with the finding of mesenteric artery rotation.

INTERVENTIONS

Because bowel obstruction was suspected, abdominal plain film, sonography, and CT were performed. The abdominal CT demonstrated whirlpool sign with torsion of the sigmoid vessels. In addition, lower gastrointestinal filling study showed that the contrast medium could only reach the upper descending colon. Therefore, he received laparotomy with mesosigmoidoplasty for detorsion of the sigmoid.

OUTCOMES

The postoperative recovery was smooth under empirical antibiotic treatment with cefazolin. A follow-up lower gastrointestinal series on the seventh day of admission showed no obstruction compared with the previous series. He was finally discharged in a stable condition 8 days after admission.

LESSONS

SV is a congenital anomaly and an uncommon diagnosis in children. Nevertheless, case series and case reports of SV are becoming more prevalent in the literature. Failure to recognize SV may result in life-threatening complications such as sigmoid gangrene/perforation, peritonitis, sepsis, and death. Thus, if the children have persistent and recurrent abdominal distention, abdominal pain, and vomiting, physicians should consider SV as a "do not miss diagnosis" in the differential diagnosis.

Sigmoid volvulus in children: a case report

BACKGROUND

Sigmoid volvulus is frequently reported in the "volvulus belt" (Middle East, Africa, the Indian subcontinent, Turkey, and South America) and is the third leading cause of large bowel obstruction in North America. It is an uncommon problem in children and adolescents, and is rarely considered a diagnosis in this group. A high index of suspicion is necessary to diagnose sigmoid volvulus in children.

CASE PRESENTATION

We present a 13-year-old Arabian girl who came with features suggestive of intestinal obstruction. Plain abdominal film revealed classic omega (coffee bean) sign of sigmoid volvulus. The volvulus was successfully decompressed by means of a rectal tube in our emergency department. The next day during the same admission the volvulus recurred and was successfully decompressed by endoscopy. She was discharged home on her parents' request; she presented again 1 month later. This time the volvulus could not be decompressed non-operatively, so she underwent sigmoidectomy with primary anastomosis. Postoperatively she developed paralytic ileus that resolved after 10 days. Following that she did well and was discharged home. She is still free of symptoms 1 year after the resection.

CONCLUSIONS

Sigmoid volvulus is an uncommon problem in children and adolescents, and is rarely considered a diagnosis in this group as a cause of intestinal obstruction. Pediatric surgeons should maintain a high index of suspicion, in order not to miss this important diagnosis, as any delay in instituting treatment has a devastating effect on morbidity as well as mortality. Early diagnosis and prompt treatment confer an excellent prognosis.

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.

Neonatal sigmoid volvulus

BACKGROUND

Neonatal sigmoid volvulus is a rare entity. It is associated with Hirschsprung's disease. Presentation is acute abdominal distention, vomiting and obstipation. Abdominal radiograph will show the "coffee bean" sign, but this is frequently missed and the diagnosis requires a high index of suspicion. Treatment options include contrast enema, colonoscopy or laparotomy, depending on the condition of the baby and local availability.

POPULATION AND RESULTS

During the last 6years, 6 infants with sigmoid volvulus were treated in our department. Four presented during the first 48h since birth, and 2 presented at the age of 2 and 7weeks of age. One child was operated and 5 had primary contrast enema with radiologic de-volvulus. Rectal biopsy was performed in all cases; three children had Hirschsprung's disease. Those with normal biopsies responded well to rectal washouts. Two patients had early one stage transanal pullthrough and one had 2 further occasions of sigmoid volvulus prior to definitive surgery. All three recovered with an uneventful course.

CONCLUSIONS

Neonatal sigmoid volvulus requires a high level of suspicion. Contrast enema is efficient for primary de-volvulus. Rectal biopsy should be performed and if positive for Hirschsprung's disease, surgery should be performed sooner rather than later.

Endoscopic management of sigmoid volvulus in children

Sigmoid volvulus (SV) is extremely uncommon in children and is usually associated with a long-standing history of constipation or pseudo-obstruction. An early diagnosis and management are crucial in order to prevent the appearance of hemorrhagic infarction of the twisted loop, avoiding further complications such as necrosis, perforation and sepsis. In patients with no evidence of peritonitis or ischemic bowel, treatment starts with resuscitation and detorsion of the SV, accomplished by means of sigmoidoscopy and concomitant rectal tube placement. The bowel is then prepared and surgery is undertaken electively during the same hospitalization. We report a detailed review of the literature focusing on technical details, risks and benefits of endoscopic management of SV in childhood.

The role of sigmoidoscopy in thediagnosis and treatment of sigmoid volvulus

Sigmoid volvulus (SV) is a rare form of acute intestinal obstruction in which the sigmoid colon wraps around itself. The disease generally presents as a mechanical bowel obstruction with clinical features that are not pathognomonic. Similarly, X-ray films are not diagnostic in most cases. It is difficult to establish the correct preoperative diagnosis when CT and MRI are not used.

The principal strategy in the treatment of SV in uncomplicated patients is emergency endoscopic detorsion followed by elective surgery; emergent surgery is required in patients with bowel gangrene, bowel perforation, peritonitis, or unsuccessful endoscopic treatment.

In this review, we have discussed the role of sigmoidoscopy in the diagnosis and treatment of SV. Additionally, we have retrospectively and prospectively evaluated our 49-year, 987-patient clinical experience, the largest single-center SV series ever reported.

The morphology of the foetal sigmoid colon in the African population: a possible predisposition to sigmoid volvulus

AIM

This study aimed to determine the morphological types of the foetal sigmoid colon and establish if the anatomical predisposition to sigmoid volvulus is present in Black African foetuses. Sigmoid volvulus affects Black Africans in our province more frequently than other ethnic groups, and males more than females. Its aetiology remains speculative, with factors being proposed that do not suggest the pathogenetic mechanisms or the gender bias. Previous anatomical studies have suggested that Black Africans have a predisposition to sigmoid volvulus due to an elongated sigmoid colon. We investigated whether this phenomenon occurred during foetal development.

METHOD

Foetuses were donated from local hospitals. Population groups were defined as Black African and non-African. After dissection, the anatomy of the sigmoid colon was described according to level of origin, classic or elongated type and shape (broad or narrow).

RESULTS

A total of 296 Black African foetuses and 37 non-African foetuses were donated. The sigmoid colon in the majority of foetuses in all gestational age groups had a low level of origin. An elongated colon was seen in 68% of Black African and 17% of non-African foetuses (P < 0.0001). Among Black Africans there was a higher proportion of elongated sigmoid colon among male (73%) than female foetuses (62%) (P = 0.044). In foetuses with an elongated sigmoid colon the broad shape was more common in females than males and the long-narrow shape was more common in males (P = 0.038).

CONCLUSION

The elongated sigmoid colon seen in Black Africans is present in utero and occurs more frequently in Black African males. A narrow shape is more common in male foetuses and the broad shape is more common in female foetuses. These anatomical features may be the cause of the predisposition to sigmoid volvulus in Black African adults.

Presentation and endoscopic management of sigmoid volvulus in children

The aim of the present study was to evaluate clinical presentation and management of sigmoid volvulus in children, focusing on endoscopic reduction. In this retrospective multicenter study, we reviewed the charts of 13 patients with sigmoid volvulus. We recorded clinical symptoms, diagnostic methods, endoscopic or surgical therapy, and outcome. The children (seven girls, six boys) had a median age of 12.8 years (range, 15 months to 17 years) at initial presentation. Eight patients had associated diseases (e.g., chronic constipation, mental retardation, or myopathy). The initial symptoms were abdominal pain (13/13), abdominal distension (11/13), and vomiting (7/13), which were associated with abdominal tenderness in all patients. Abdominal X-ray showed dilated sigmoid loops and air-fluid levels in all patients. Endoscopic reduction by exsufflation was successful without any complications in 12 patients, whereas the youngest patient underwent a first-line sigmoidectomy. Recurrence occurred in 7/12 patients after endoscopic exsufflation. Finally, 11 patients underwent a sigmoidectomy.

CONCLUSION

Although rare in children, sigmoid volvulus should be advocated when abdominal pain is associated with dilated sigmoid loops. Sigmoidoscopic exsufflation can be considered as the first-line management in the absence of perforation. However, sigmoidectomy is often required for prevention of recurrence.

WHAT IS KNOWN

• Sigmoid volvulus is uncommon in childhood. • Diagnosis is often missed or delayed. What is New: • This is the first pediatric series showing that endoscopic exsufflation is an efficient and safe treatment option. • Elective sigmoid resection with primary anastomosis is often required to prevent recurrence.

Role of the enteric nervous system in the elongated sigmoid colon of patients with sigmoid volvulus

To clarify the physiologic function of the enteric nervous system (ENS) in the elongated sigmoid colon (ESC) of patients with sigmoid volvulus (SV), we examined the enteric nerve responses in lesional and normal longitudinal muscle strips (LMS) derived from patients with ESC and patients who underwent colon resection for colonic cancers. Thirty preparations of LMS were taken from the lesional sigmoid colons of 10 ESC patients with SV (8 men and 2 women, aged 53 to 80 years, mean 66.2 years). Forty preparations of LMS were taken from the normal sigmoid colons (NSC) of 20 patients with colonic cancer (12 men and 8 women, aged 55 to 76 years, mean 62.3 years). A mechanographic technique was used to evaluate in vitro muscle responses to electrical field stimulation (EFS) before and after treatment with various autonomic nerve blockers. Response to EFS before blockade of the adrenergic and cholinergic nerves was as follows: NSC and ESC significantly demonstrated relaxation reaction rather than contraction reaction (P = 0.0253, P < 0.0001, respectively). ESC showed relaxation reaction more than NSC (P = 0.1138). Response to EFS after blockade of the adrenergic and cholinergic nerves was as follows: NSC and ESC significantly demonstrated relaxation reaction via nonadrenergic noncholinergic (NANC) inhibitory nerves rather than contraction reaction via NANC excitatory nerves (P < 0.0001, P < 0.0001, respectively). ESC with SV significantly showed relaxation reaction more than NSC (P = 0.0092). An increased response of relaxation mediated NANC inhibitory nerves may play a role in impaired motility in the ESC of patients with SV.

Sigmoid volvulus in an adolescent girl: staged management with emergency colonoscopic reduction and decompression followed by elective sigmoid colectomy

A case of acute sigmoid volvulus in a 14-year-old adolescent girl presenting with acute low large bowel obstruction with a background of chronic constipation has been presented. Abdominal radiograph and CT scan helped in diagnosis. She underwent emergency colonoscopic detorsion and decompression uneventfully. Lower gastrointestinal contrast study showed very redundant sigmoid colonic loop without any transition zone and she subsequently underwent elective sigmoid colectomy with good outcome. The sigmoid volvulus should be considered in the differential diagnosis of paediatric acute abdomen presenting with marked abdominal distention, absolute constipation and pain but without vomiting. Plain abdominal radiograph and the CT scan are helpful to confirm the diagnosis. Early colonoscopic detorsion and decompression allows direct visualisation of the vascular compromise, assessment of band width of the volvulus and can reduce complications and mortality. Associated Hirschsprung's disease should be suspected if clinical and radiological features are suggestive in which case a rectal biopsy before definitive surgery should be considered.

Treatment of sigmoid volvulus: a single-center experience of 952 patients over 46.5 years

BACKGROUND

Sigmoid volvulus describes the wrapping of the sigmoid colon around itself and its mesentery, causing an intestinal obstruction. The aim of this study was to assess the outcomes of 952 patients treated for sigmoid volvulus over a period of 46.5 years.

METHODS

Clinical records were reviewed retrospectively.

RESULTS

Nonsurgical detorsion was performed in 686 patients with 77.1 % success, 2.5 % morbidity, 0.7 % mortality, and 4.5 % early recurrence rates; emergency surgical procedures were performed in 447 patients with 35.3 % morbidity, 16.1 % mortality, 0.7 % early recurrence, and 7.4 % late recurrence rates, while elective surgical treatment was performed in 104 patients with 12.5 % morbidity, no mortality, and no recurrence.

CONCLUSIONS

The principal strategy in the treatment for sigmoid volvulus is early nonsurgical detorsion followed by elective surgery in uncomplicated patients, while emergency surgical treatment is performed for patients with bowel gangrene, perforation, or peritonitis, other difficulties with diagnosis, unsuccessful nonsurgical detorsion, and early recurrence.

Hirschsprung disease presenting as sigmoid volvulus: a case report and review of the literature

While sigmoid volvulus is commonly seen in older patients, it is rarely encountered in children and younger adults. Consequently, heightened awareness of this entity is required to avoid a delay in diagnosis. Among the pediatric and adult cases of colonic volvulus previously reported in the English literature, 23 of the affected individuals have also been diagnosed with Hirschsprung disease (HD). This report describes a 12-year-old male with a history of chronic constipation who presented with vomiting and abdominal distension and was found to have sigmoid volvulus with previously unrecognized HD. The case presentation is followed by a review of the literature describing colonic volvulus secondary to HD in children.

Sigmoid volvulus

In sigmoid volvulus (SV), the sigmoid colon wraps around itself and its mesentery. SV accounts for 2% to 50% of all colonic obstructions and has an interesting geographic dispersion. SV generally affects adults, and it is more common in males. The etiology of SV is multifactorial and controversial; the main symptoms are abdominal pain, distention, and constipation, while the main signs are abdominal distention and tenderness. Routine laboratory findings are not pathognomonic: Plain abdominal X-ray radiographs show a dilated sigmoid colon and multiple small or large intestinal air-fluid levels, and abdominal CT and MRI demonstrate a whirled sigmoid mesentery. Flexible endoscopy shows a spiral sphincter-like twist of the mucosa. The diagnosis of SV is established by clinical, radiological, endoscopic, and sometimes operative findings. Although flexible endoscopic detorsion is advocated as the primary treatment choice, emergency surgery is required for patients who present with peritonitis, bowel gangrene, or perforation or for patients whose non-operative treatment is unsuccessful. Although emergency surgery includes various non-definitive or definitive procedures, resection with primary anastomosis is the most commonly recommended procedure. After a successful non-operative detorsion, elective sigmoid resection and anastomosis is recommended. The overall mortality is 10% to 50%, while the overall morbidity is 6% to 24%.

Volvulus: small bowel and colon

Volvulus of the intestine is a surgical emergency. Volvulus of the small bowel is more common in children and is most often secondary to malrotation. Small bowel volvulus is an uncommon cause for small bowel obstruction in adults, and is more likely to be secondary to postoperative adhesive bands. Colonic volvulus is a rare cause of large bowel obstruction, but more common than small bowel volvulus. The sigmoid is most frequently involved, with redundant colon as the primary cause. Cecal volvulus most commonly is due to lack of fixation. Colonic volvulus has a specific radiographic appearance; however, small bowel volvulus is difficult to distinguish from other causes of small bowel obstruction by radiographic means. New surgical techniques with minimally invasive surgery are increasingly being applied to this old problem with good results in selected cases.

Colonic volvulus in children with intestinal motility disorders

BACKGROUND

Chronic intestinal pseudo-obstruction (CIP) is a condition characterized by symptoms of bowel obstruction in the absence of an anatomical cause. Patients with CIP and chronic intractable constipation (CIC) can also develop anatomical obstruction, and the presenting symptoms mimic those of underlying pseudo-obstruction.

OBJECTIVES

Our objectives were to evaluate the incidence, clinical presentation, and diagnostic investigations of colonic volvulus in children with intestinal motility disorders and to differentiate these episodes of colonic volvulus from the underlying motility disorder based on clinical presentation and imaging techniques.

MATERIALS AND METHODS

Patients records of children with colonic volvulus cared for at our institution over the previous 20 years were retrospectively reviewed. We identified 8 patients who were between 2 and 22 years of age at the time of diagnosis with colonic volvulus who also had CIP and CIC.

RESULTS

The mean age +/- SD at presentation with colonic volvulus was 13.2 +/- 5.05 years. All patients presented with worsening of abdominal distension and pain. The mean duration of symptoms of colonic volvulus before seeking medical help was 4.2 days (range 1-7 days). Water-soluble contrast enema was the single most useful investigation for confirming the diagnosis. All patients required surgery. There was no mortality associated with colonic volvulus.

CONCLUSIONS

Clinicians should be vigilant and include volvulus in the differential diagnosis of the acute onset of abdominal distension and pain in patients with CIP and CIC. Delay in diagnosis can result in bowel ischemia and perforation.

Management of sigmoid volvulus based on Ladd's procedure: a case report

Sigmoid volvulus is a rare but potentially life-threatening condition in childhood. Colectomy is usually required to prevent recurrent volvulus, which carries a high risk of morbidity and mortality. Here, we report a non-resection method based on the concept of Ladd's procedure to treat a sigmoid volvulus in a 15-year-old boy. After reduction of the volvulus, the distance between the sigmoid-rectal junction and the sigmoid-descending colon junction was widened by dissecting the meso-sigmoid colon along the course of the long axis. No colon resection was performed. The total operation time was less than an hour. The post-operative recovery was uneventful. There was no recurrent volvulus during a follow-up of 1 year. Widening the base of the mesosigmoid according to the concept of Ladd's procedure may be considered as a more simple and safe alternative treatment to prevent recurrent sigmoid volvulus in children.

An algorithm for the management of sigmoid colon volvulus and the safety of primary resection: experience with 827 cases

PURPOSE

This study was designed to review the outcomes of emergent treatment of sigmoid colon volvulus.

METHODS

The records of 827 patients were reviewed retrospectively.

RESULTS

The mean age was 57.9 years (range, 10 weeks to 98 years), and 688 patients (83.2 percent) were male. Nonoperative reduction was applied in 575 patients (barium enema in 13, rigid sigmoidoscopy in 351, and flexible sigmoidoscopy in 211, with rectal tube placement in all patients). The results were as follows: success of 78.1 percent, mortality of 0.9 percent, complication of 3 percent, and early recurrence of 3.3 percent. Surgical treatment was performed on 393 patients (detorsion in 46, mesosigmoidopexy in 56, exteriorization in 4, resection with Hartmann's procedure in 146, resection with Mikulicz procedure in 14, resection with primary anastomosis in 51, tube cecostomy and colonic cleansing with resection in 75, and laparotomy in 1). The results were as follows: mortality of 15.8 percent, complication of 37.2 percent, early recurrence of 0.8 percent, and late recurrence of 6.7 percent.

CONCLUSIONS

Nonoperative reduction is the initial treatment of sigmoid colon volvulus, and flexible sigmoidoscopy with rectal tube placement can be used successfully. Patients in whom bowel gangrene or peritonitis is present or nonoperative treatment is unsuccessful need emergency surgery. In surgical treatment, resection and primary anastomosis is the first choice, and it can be performed with acceptable mortality and morbidity rates if the patient is stable and a tension-free anastomosis is possible. Nondefinitive procedures have high recurrence rates; thus, definitive surgical techniques must be preferred.

A Surprising Twist to an Old Problem: Sigmoid Volvulus in a 19-Year-Old Man

Sigmoid volvulus classically presents in the seventh or eighth decade, therefore, diagnosis of sigmoid volvulus in an adolescent may be delayed or missed. This life-threatening diagnosis should be considered in young patients presenting with abdominal pain, nausea, vomiting, and constipation. Intraoperative findings in a 19-year-old man with a sigmoid volvulus highlight the importance of considering further studies, such as an abdominal CT scan, which goes beyond the typical obstruction evaluation in the adolescent patient. When nonoperative management fails to decompress the volvulus, complicating factors should be considered, and laparotomy is indicated to provide definitive treatment for this condition.