The Pathogenesis and Etiology of Colonic Volvulus

Metachronous descending colon volvulus after sigmoidectomy: a case report

Volvulus is the rotation or twisting of the intestine around its vascular pedicle. The occurrence of descending volvulus after sigmoidectomy is extremely rare. We report a case of a 35-year-old male who presented with abdominal distention, cramping, and no passage of feces or gas for three days. He had a history of recurrent sigmoid volvulus, previously treated with sigmoidectomy. On this occasion, clinical examination and imaging revealed a distended bowel with air-fluid levels. During exploratory laparotomy, descending colon volvulus, a rare finding, was confirmed. The patient underwent a left hemicolectomy and transverse stoma and recovered well postoperatively. Descending colon volvulus is a rare but serious complication after sigmoidectomy, and early diagnosis is essential. In volvulus-endemic regions, awareness of this condition is critical to prevent delayed diagnosis and complications.

Recurrent splenic flexure colonic volvulus: A case report

INTRODUCTION AND IMPORTANCE

Large-bowel obstruction (LBO) is an emergency condition that requires early identification and intervention. Among all causes of LBO colonic volvulus is the third leading cause worldwide. Colonic volvulus is an axial rotation of the colon around a fixed point. Splenic flexure volvulus is the least common location for colonic volvulus, accounting for <1 % of cases.

CASE PRESENTATION

A 41-year-old male patient presented to the emergency department with a history of crampy abdominal pain, abdominal distension and failure to pass feces and flatus of three days duration. He had a history of laparotomy 1 year back, at which time de-rotation of the splenic flexure was done. This time, while preparing the patient for emergency laparotomy, he passed both feces and flatus. On the same admission, he was operated and left hemicolectomy and end to end anastomosis was done.

CLINICAL DISCUSSION

Due to splenic flexure attachments to the left upper quadrant via Splenic ligament splenic flexure colonic volvulus is very rare. Risk factors include congenitally absent ligaments, congenital bands, acquired adhesions, previous colonic surgery. With the appropriate clinical setting radiographic diagnosis is suggested when there is a markedly dilated, air-filled colon with an abrupt termination at the anatomic splenic flexure, two widely separated air- fluid levels, and an empty descending and sigmoid colon.

CONCLUSION

Following adequate resuscitation urgent exploratory laparotomy is recommended in splenic flexure volvulus. If the clinical condition of the patient allows colonic resection with continuity restoration is the preferred conventional approach.

WSES consensus guidelines on sigmoid volvulus management

Sigmoid volvulus is a common surgical emergency, especially in elderly patients. Patients can present with a wide range of clinical states: from asymptomatic, to frank peritonitis secondary to colonic perforation. These patients generally need urgent treatment, be it endoscopic decompression of the colon or an upfront colectomy. The World Society of Emergency Surgery united a worldwide group of international experts to review the current evidence and propose a consensus guidelines on the management of sigmoid volvulus.

Cecal bascule in pregnancy: a case report and review of the literature

A 36-year-old female at 36 weeks' gestation presented with right upper quadrant abdominal pain. She had no prior surgeries. Her pregnancy had been uncomplicated up until her presentation. Abdominal ultrasound was negative for cholecystitis or cholelithiasis, and the appendix was not visualized. During the second day of her hospital course, an abdominal magnetic resonance imaging (MRI) was performed revealing dilated small intestine with air-fluid levels and an inverted-appearing, prominent cecum. She was urgently taken to the operating room for cesarean section followed by abdominal exploration. After delivery of the child, a cecal bascule was found, with a severely distended cecum. To our knowledge, this is the first report of a cecal bascule diagnosed by MRI, and the first diagnosis of cecal bascule in a pregnant patient requiring surgical intervention. We discuss the pathophysiology, diagnosis and treatment of cecal bascule and review the current literature of reported cases.

Total colonic volvulus with a 720° twist of freely mobile colon

Segmental colonic volvulus involving the sigmoid or ileocaecal region is an important cause of large bowel obstruction and a well-established surgical emergency. Volvulus of the entire colon however is hazardously rare, in which case the diagnosis is likely to be made intraoperatively. The surgeon is then faced with the conundrum of the best surgical management, especially in the case of early intervention with viable bowel. To our knowledge this has never been reported.

Pseudovolvulus of the sigmoid colon after percutaneous endoscopic gastrostomy tube placement: A case report

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Percutaneous endoscopic gastrostomy (EPG) is a safe procedure, but complications may occur.

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Major complications of PEG may present with volvulus-like conditions.

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The need for percutaneous endoscopic gastrostomy should be carefully evaluated.

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Laparoscopic gastrostomy and laparoscopic-assisted PEG have been proposed.

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Risk of complications should be timely recognized to enable proper treatment.

Introduction

Percutaneous endoscopic gastrostomy (PEG) provides long-term enteral nutritional access for patients with inability to eat. Although considered safe, PEG tube placement is associated with complications. We report a rare case of PEG-related sigmoid colon pseudovolvulus.

Presentation of case

A 78-year-old man with a history of Parkinson’s disease developed severe abdominal pain and vomited continuously 50 days after PEG tube placement. Contrast-enhanced computed tomography revealed internal herniation of the sigmoid colon between the abdominal wall and the stomach at the gastrostomy site. Intraoperatively, the gastrostomy tube penetrated the sigmoid mesentery, which rotated around the tube, and the sigmoid colon was herniated towards the upper abdomen. The herniated colon was reduced and Hartmann’s procedure was performed. Subsequently, gastrostomy was reinforced with anterior gastropexy. The postoperative course was uneventful.

Discussion

This case highlights the need for caution when placing a PEG tube because of a mobile sigmoid mesocolon, raising the awareness of potential major complications. Complications can be avoided by directly visualising the intraabdominal organs using laparoscopic gastrostomy or laparoscopic-assisted PEG. However, these methods require general anaesthesia. Thus, the presence of redundant colons should be determined in advance to assess the risk of sigmoid mesocolon perforation. We should also assess the patients’ swallowing function and estimate whether it may recover with rehabilitation before deciding to place a PEG tube.

Conclusion

PEG tube should be considered after careful patient evaluation. If PEG is required, clinicians should recognise the patient-specific risks and consider other surgical procedures to avoid complications.

Management of the colonic volvulus in 2016

Colonic volvulus is the third leading cause of colonic obstruction worldwide, occurring at two principal locations: the sigmoid colon and cecum. In Western countries, sigmoid volvulus preferentially affects elderly men whereas cecal volvulus affects younger women. Some risk factors, such as chronic constipation, high-fiber diet, frequent use of laxatives, personal past history of laparotomy and anatomic predispositions, are common to both locations. Clinical symptomatology is non-specific, including a combination of abdominal pain, gaseous distention, and bowel obstruction. Abdominopelvic computerized tomography is currently the gold standard examination, allowing positive diagnosis as well as detection of complications. Specific management depends on the location, patient comorbidities and colonic wall viability, but treatment is an emergency in every case. If clinical or radiological signs of gravity are present, emergency surgery is mandatory, but is associated with high morbidity and mortality rates. For sigmoid volvulus without criteria of gravity, the ideal strategy is an endoscopic detorsion procedure followed, within 2 to 5 days, by surgery that includes a sigmoid colectomy with primary anastomosis. Exclusively endoscopic therapy must be reserved for patients who are at excessive risk for surgical intervention. In cecal volvulus, endoscopy has no role and surgery is the rule.

Cecal bascule after spinal cord injury: A case series report

Introduction

Cecal bascule is a rare cause of intestinal obstruction associated with upward and anterior folding of the ascending colon. We report three patients who presented with spinal cord injury complicated with a cecal bascule. Diagnosis and management of cecal bascule is discussed.

Presentation of cases

Patient 1: 59-year-old male sustained a traumatic brain injury and cervical spinal cord injury after a motorcycle crash. He had abdominal distension and the diagnosis of cecal bascule was made. Cecopexy was performed.

Patient 2: 51-year-old male sustained an unstable C7 vertebral fracture with a cord contusion and quadriplegia after a diving incident. After an unsuccessful medical management of the colonic distension, the patient was taken for a laparotomy and cecal bascule was found. A cecostomy and a cecopexy were performed.

Patient 3: 63-year-old male was transferred after a fall. He had diffuse degenerative changes in the thoracic and lumbar spine. He was found to have a perforated cecal bascule. He had a right hemicolectomy with an ileocolic anastomosis.

Discussion

We suggest the possibility of spinal cord injury being a risk factor for cecal bascule. Currently, right hemicolectomy is recommended for the treatment of cecal bascule. Cecopexy is also acceptable treatment option for a case in which the patient will be undergoing an operation with an insertion of hardware.

Conclusion

The diagnosis of cecal bascule should be considered for trauma patients with cecal distention without delay in order to prevent disastrous complications.

Colon cancer presented with sigmoid volvulus: A case report

INTRODUCTION

Sigmoid volvulus is the most prevalent type of colonic volvulus. Colon cancer is seen less where sigmoid volvulus is common, so it is rare to see that colon cancer is synchronous with sigmoid volvulus.

PRESENTATION OF CASE

We would like to present a case of sigmoid volvulus caused by colon cancer in a male patient aged 80 who was referred to the hospital with toxaemic shock presentation.

DISCUSSION

Sigmoid cancer can be presented as sigmoid volvulus to the emergency department. In intestinal obstruction early diagnosis is of crucial importance. Computarized tomography is a diagnosis tool that should be preferred both in the diagnosis of obstruction and in detecting its cause, localisation, degree and complications.

CONCLUSION

When surgery is performed due to the urgent colonic obstruction in colonic volvulus diagnosed patients, a colon tumour should be considered in the same column loops or in the distal colon. We believe that CT is the method that should be preferred in large-bowel obstruction suspected patients.

More patients should undergo surgery after sigmoid volvulus

AIM: To assess the outcome of patients treated conservatively vs surgically during their first admission for sigmoid volvulus.

METHODS: We conducted a retrospective study of 61 patients admitted to Aarhus University Hospital in Denmark between 1996 and 2011 for their first incidence of sigmoid volvulus. The condition was diagnosed by radiography, sigmoidoscopy or surgery. Patients treated with surgery underwent either a sigmoid resection or a percutaneous endoscopic colostomy (PEC). Conservatively treated patients were managed without surgery. Data was recorded into a Microsoft Access database and calculations were performed with Microsoft Excel. Kaplan-Meier plotting and Mantel-Cox (log-rank) testing were performed using GraphPad Prism software. Mortality was defined as death within 30 d after intervention or surgery.

RESULTS: Among the total 61 patients, 4 underwent emergency surgery, 55 underwent endoscopy, 1 experienced resolution of the volvulus after contrast enema, and 1 died without treatment because of large bowel perforation. Following emergency treatment, 28 patients underwent sigmoid resection (semi-elective n = 18; elective n = 10). Two patients who were unfit for surgery underwent PEC and both died, 1 after 36 d and the other after 9 mo, respectively. The remaining 26 patients were managed conservatively without sigmoid resection. Patients treated conservatively on their first admission had a poorer survival rate than patients treated surgically on their first admission (95%CI: 3.67-14.37, P = 0.036). Sixty-three percent of the 26 conservatively treated patients had not experienced a recurrence 3 mo after treatment, but that number dropped to 24% 2 years after treatment. Eight of the 14 patients with recurrence after conservative treatment had surgery with no 30-d mortality.

CONCLUSION: Surgically-treated sigmoid volvulus patients had a higher long-term survival rate than conservatively managed patients, indicating a benefit of surgical resection or PEC insertion if feasible.

[Colonic volvulus and recurrence of volvulus: what should we do?]

INTRODUCTION

Colonic volvulus (CV) is an uncommon disease in our country, which may present clinically as an intestinal obstruction or occlusion. Its diagnosis and therapeutic management remains controversial. The objective of this article is to present our series, analyse the results and establish a therapeutic approach to decrease the recurrence of the volvulus.

MATERIAL AND METHODS

A retrospective, descriptive study of patients diagnosed with CV between January 1997 and December 2009.

RESULTS

The study included 54 patients, with a mean age of 74 years, who had a total of 89 CV episodes. There was associated disease in 70% of the cases, which included 44% with constipation and 53% with neurological diseases. The volvulus was located in the sigmoid in 87% of cases and in the right colon in 13%. The large majority (92%) of cases had intestinal obstruction. Endoscopic treatment was effective in 61% and urgent surgery was performed in 31% of the cases, and in 40% of the first episodes of CV. There was recurrence of volvulus in 62% of cases treated with surgery, and surgery was performed in 72% of these. In the whole series, surgery was performed in 35 cases (64%), with sigmoidectomy with primary anastomosis being the technique most employed. The overall mortality of the series was 7 cases (12%), with 16% being in cases of surgery due to recurrence.

CONCLUSIONS

The diagnostic technique and initial treatment of CV is endoscopic decompression. Early elective surgery prevents the high recurrence rate associated with higher mortality.