Splenic Flexure Colonic Volvulus: A Pediatric Case Report

Splenic flexure volvulus: a rare case report

Colonic volvulus, where the colon twists around its mesentery, commonly occurs in the sigmoid and cecum. However, colonic volvulus of the splenic flexure is quite rare. Reported cases are limited but suggest that prolonged constipation in patients with either congenital anomalies, history of prior abdominal surgery, and or psychiatric history are described as common risk factors for large bowel volvulus. Here, we discuss a case of a 56-year-old man with a history of chronic constipation and no previous abdominal surgeries who presented to the emergency department with abdominal pain and distention. Further workup including a computed tomography imaging and decompressive via limited colonoscopy confirmed diagnosis of colonic volvulus of the splenic flexure. Surgical management of colonic volvulus is patient specific but invariably involves partial colectomy, as was performed in this case.

Splenic flexure volvulus, a rare etiology of colonic obstruction: Case report

Introduction

Splenic flexure volvulus (SFV) occurs as a result of twisting or torsion of a redundant colon around its mesentery. The SFV can be divided into primary and secondary types.

Presentation of case

An 82-year-old woman with a previous history of Parkinson's disease, diabetes mellitus and hypertension presented with a primary complaimt of obstipation and progressive abdominal pain. Abdomen was grossly distended and tympanic with generalized tenderness. The rectum was empty on digital rectal examination. Complete blood count showed leuckocytosis and neutrophlia. Plain abdominal X-rays showed distented cecum and ascending colon without any air in the gut distal to the splenic flexure. Regarding her unstable condition even aftre fluid resuscitation, she was transferred to the operating room. SFV was found and the standard left hemicolectomy was performed and bowel continiuity was established with primary anastomis of remained colonic ends. Postoperative period was uneventfull.

Discussion

The splenic flexure is strictly attached to the adjacent organs so its volvulus is rare. Most cases of adult SFV have an underlying disease associated with chronic constipation. Diagnosis of volvulus is suspected based on the history, clinical exam, and imaging. The initial and urgent treatment of SFV, if there are no signs of ischemia or perforation, may be conservative with endoscopic detorsion. Gangrenous bowel should not be detorted and should be resected with primary anastomosis or a diverting stoma.

Conclusion

SFV should be considered as a possible diagnosis of chronic constipation which might be diagnosed with plain abdominal Xray in non emergent condition. Special attention should be given to the medication history of the patient as the anticholinergic agents propagate normal pristaltis.

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Splenic flexure volvulus (SFV) is a rare condition of colonic obstruction

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An 82-year-old bedridden woman with a previous history of parkinson’s disease presented to the emergency department.

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SFV was seen due to the absence of leno-colic and phreno-colic ligaments and the proximal descending colon was intraperitoneal.

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An interesting finding about psychological profile of patients with SFV is that nearly all of these patients have a history of taking antipsychotic medication.

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The medication history of drugs interfering with gastrointestinal motility can be a guide for timely diagnosis.

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.

Transverse colonic volvulus in a child: successful management with decompression and delayed laparoscopic colopexy

We report a case of colonic volvulus in a 7-year-old child with normal development. Operative findings at laparotomy showed a 270-degree transverse colonic volvulus (TCV), with colonic ligamentous attachment abnormalities. A loop ileostomy was formed following detorsion, with delayed laparoscopic colopexy. This is the first case to describe decompression by diversion ileostomy as acute management of TCV with delayed laparoscopic colopexy, so avoiding unnecessary bowel resection.

Laparoscopic detorsion and colopexy for splenic flexure volvulus in an infant

Primary splenic flexure volvulus is a rare entity. We describe the first case of splenic flexure volvulus managed by a laparoscopic approach. A previously healthy 32-month-old girl presented with constipation, appetite loss, and nonbilious vomiting of 15 days of duration. Contrast enema and 3-dimensional computed tomography revealed a "bird's beak" sign at the splenic flexure, consistent with the diagnosis of splenic flexure volvulus. Attempted detorsion during colonoscopy was unsuccessful, and a laparoscopic procedure was performed, and 180° torsion of the splenic flexure with a distal caliber change was observed. After detorsion of the volvulus, the splenic flexure and descending colon were fixed to the peritoneum. The postoperative course was uneventful, and there was no recurrence during the subsequent 16 months of follow-up. Laparoscopic colopexy is a minimally invasive and effective method of managing splenic flexure volvulus, especially in patients without an underlying disease that causes constipation.