Acute intestinal volvulus. A report of 238 cases

A Case Report of Appendicitis Causing Cecal Volvulus: A Rare Occurrence

This case report presents a fascinating scenario involving a 60-year-old female who was diagnosed with cecal volvulus secondary to appendicitis. The patient's initial presentation included a three-day history of periumbilical pain accompanied by reduced oral intake and an inability to pass stool. Through a systematic approach involving detailed history-taking, comprehensive physical examinations, and pertinent imaging studies, a precise diagnosis of cecal volvulus induced by appendicitis was established. Subsequently, the patient underwent a timely operation, leading to a successful resolution of her condition and a remarkably swift recovery post-surgery. This unique case prompts a deeper exploration into the incidence and management of this rare phenomenon, where the seemingly unrelated condition of appendicitis precipitated a cecal volvulus. Given the unusual nature of this presentation, it underscores the importance of considering atypical etiologies in patients presenting with signs and symptoms of bowel obstruction. This discussion aims to shed light on the diagnostic challenges, treatment strategies, and outcomes associated with this intriguing interplay of pathologies, offering valuable insights for clinicians encountering similar cases in their practice.

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.

Small and large bowel volvulus: Clues to early recognition and complications

Small and large bowel volvulus are uncommon causes of bowel obstruction with nonspecific clinical manifestations which may delay the diagnosis and increase morbidity. Therefore, radiologists play an important role in promptly establishing the diagnosis, recognizing underlying congenital or acquired risk factors and detecting potentially life-threatening complications. Multidetector CT performed with intravenous contrast is currently the preferred modality for the evaluation of volvulus, which is best appreciated when imaging is perpendicular to the axis of bowel rotation, hence the benefit of multiplanar reformations. In this pictorial essay we review the pathophysiology of the different types of intestinal volvulus, discuss diagnostic criteria for prompt diagnosis of volvulus and emphasize early recognition of the complications.

Operative therapy for cecal volvulus combining resection with colopexy

BACKGROUND

Cecal volvulus is an uncommon clinical event. The literature contains many recommended treatments with varied results.

STUDY DESIGN

A series of 10 consecutive patients treated by the author was reviewed. Each patient had complete clinical follow-up. The cecal volvulus was resected without detorsion and reperfusion of the volvulus. The intestine was resected using a surgical stapling device, transection of the mesentery at the axial twist, and a stapled anastomosis of the terminal ileum to the remnant of the right colon. Permanent sutures between the colonic tenia and the peritoneum of the right paracolic gutter fixed the remainder of the right colon to prevent recurrence of the volvulus.

RESULTS

The author in clinical practice surgically treated a series of 10 consecutive patients with complete follow-up between 1981 to 2004. All patients survived the surgical procedure and were discharged from the hospital. The diagnosis was determined preoperatively in 5 of the 10 patients. Five patients had gangrene of the colon, and two of these patients had perforation. All patients required postoperative intensive care from 2 to 9 days. Five of the 10 patients required ventilator support for 1 to 3 days. Postoperative complications included intraperitoneal bleeding, pneumonia, and surgical incision infection with a subcutaneous abscess. There has been no recurrence of the volvulus in any of these patients.

CONCLUSIONS

Ten consecutive cases of cecal volvulus were surgically treated by a uniform resection procedure. The cecal volvulus was not reperfused by detorsion. Reperfusion of ischemic or gangrenous bowel can possibly produce reperfusion injury, metabolic acidosis, intestinal bacterial, and toxin translocation with possible irreversible septic shock. Recurrence of the cecal volvulus was prevented by colopexy of the right colon remnant. Avoidance of reperfusion of the cecal volvulus with resection, primary anastomosis, and colopexy resulted in successful results in a small series in clinical practice.

Ileosigmoid knotting

Intestinal obstruction is a common cause of emergency surgical admission. The most frequent causes are well known and may often be safely treated conservatively in the first instance. The rarer causes of intestinal obstruction require prompt diagnosis and surgery if they are not to progress rapidly to strangulation and gangrene. One such cause is the ileosigmoid knotting, which is associated with a high morbidity and mortality. With increasing travel activity and population migration this condition is now being seen outside its original geographical sites of origin. This article focuses on the aetiology, pathophysiology, clinical features, investigations and the various surgical options for the management of the ileosigmoid knotting. Studies and case reports in English literature were identified by PubMed, ISIS, Embase and CAS searches between the years 1966-2004 using the following free text keywords: ileo- sigmoid knotting, ileosigmoid knot(ting), intestinal knot(ting), compound volvulus and double volvulus. All the reference lists were reviewed to retrieve additional articles. Aggressive resuscitation, prompt surgical relief of obstruction, appropriate antibiotics, accurate intra-operative assessment of the viability of the involved loops of intestine and the use of modern postoperative intensive care will help reduce the mortality and morbidity associated with this life threatening condition.

Ileosigmoid knotting in Turkey. Review of 68 cases

PURPOSE

The high mortality associated with ileosigmoid knotting prompted us to review the collected experiences of three university hospitals in order to establish a more rational approach to the problem.

METHOD

The clinical records of 68 patients with ileosigmoid knotting from 1970 to 1990 were reviewed with respect to incidence, etiopathogenesis, clinical features, treatment, and clinical outcome.

RESULTS

The most common type of ileosigmoid knotting was Type IA (48.5 percent), in which the active ileum encircled the passive sigmoid in a clockwise manner. Fifty (73.5 percent) patients developed a gangrenous bowel whereas 18 patients did not show any definite evidence of impairment of bowel viability. En bloc removal of gangrenous knot and reestablishment of intestinal continuity by enteroenteric or enterocolic anastomosis combined with the Hartmann procedure, which was employed in 20 (42.6 percent) cases, constituted the most frequently preferred operation. The mortality rate in this series was 30.9 percent (21/68) and toxic shock, which ultimately resulted in multiple organ failure, was the major cause of death. It was remarkable to note that there was an inverse correlation between the duration of symptoms and the mortality rate reflecting the dramatic rapidity and severity of symptoms due to tightness of the knot which led to early and extensive gangrene, thus inevitably urged the patients to seek medical help without delay.

CONCLUSION

The performance of prompt, individualized surgical treatment in conjunction with the use of advanced measures of critical care to combat the disastrous consequences of multiple organ failure would contribute greatly to improve survival rate in victims of this dreadful entity.

Cecal volvulus

A review of 561 cases of cecal volvulus that were published between 1959 and 1989 along with 7 new cases, was performed to characterize the clinical and laboratory profile and to evaluate the various surgical options in treating this life-threatening condition. The age and sex distribution of these patients have changed over the years and shifted toward older patients (mean, 53 years) and female predominance (female:male ratio, 1.4:1). The clinical presentation was usually of distal closed-loop small bowel obstruction. Forty-six percent of the plain abdominal radiographs were suspected for cecal volvulus, but only 17 percent were diagnostic. Barium enema had a high rate of accuracy (88 percent) and was associated with minimal complications. True volvulus was 6 times more common than bascule, and gangrenous cecum was found in 20 percent of cases. Detorsion alone and cecopexy had almost similar complications, mortality, and recurrence rates (15, 10, and 13 percent, respectively), whereas, resection, which was performed primarily for gangrenous cecum, had higher rates. However, the highest rates of complications (52 percent), mortality (22 percent), and recurrence (14 percent) were noticed after cecostomy. These data suggest that resection should be reserved for patients with necrotic cecum and that detorsion is sufficient for patients with viable cecum. Cecostomy should be abandoned.

Volvulus of the cecum. Report of 26 cases and review of the literature

The management of cecal volvulus is controversial. From 1971 to 1986, 26 patients with cecal volvulus were treated at Malmö General Hospital. Treatment and patient follow-up are presented, together with a review of 350 patients reported in the literature during the past 15 years. Anatomic background and types of volvulus are described. Simple detorsion is an alternative in high-risk patients without gangrene, but resection is the method of choice also when there is no gangrene present.

Cecal volvulus. Low mortality at a city hospital

The case records of 12 patients with cecal volvulus over a 20-year period were reviewed. The patients averaged 46.7 years old; 75 per cent were white and 67 per cent were male. Patients presented with signs and symptoms of intestinal obstruction. Pain and distention were present in more than half of the patients. X-rays assisted in making the diagnosis of cecal volvulus in only five of the patients. Diagnosis was made in the remainder at the time of surgical exploration. At operation, one cecum was necrotic and required resection. Five patients underwent cecostomy, two cecopexy, and four simple detorsion. Post-operatively, one patient developed a wound infection. There were no deaths. Follow-up for seven patients averaged 75 months each. One patient who had undergone simple detorsion developed another cecal volvulus. All who were contacted were alive and well. At St. Luke's Hospital, cecal volvulus generally occurs in middle-aged white males. Cecostomy or cecopexy adequately treats cecal volvulus when the cecum remains viable. This study demonstrates that prompt surgical intervention, before strangulation of the colon occurs, results in low mortality even in city hospital patients.

Cecal volvulus: A diagnostic and therapeutic challenge

Cecal volvulus is a malrotational abnormality of the intestine that causes obstruction. Diagnosis is difficult and, if delayed, the results may be intestinal ischemia, perforation, sepsis, and even death. Cecal ischemia or gangrene cannot always be determined from physical and laboratory findings. Although not always conclusive, contrast radiography may be helpful; however, laparotomy is often required for definitive diagnosis and therapy. If vascular compromise of the cecum is found, right hemicolectomy is the treatment of choice. In the absence of ischemia, decompressive tube cecostomy, simple detorsion, and cecopexy have all been recommended, but the optimal treatment is a matter of controversy.

Volvulus of the transverse colon

Volvulus of the transverse colon is rare. Seven cases, 6 acute, are presented. Early diagnosis and prompt surgical management prevented complications. At laparatomy, extended right hemicolectomy or end colostomy and distal mucous fistula are the procedures of choice. Non-resection was associated with recurrence in three cases.

Volvulus of the sigmoid colon: a ten-year study

A ten-year study of volvulus of the sigmoid colon is presented. Although the results of treatment of volvulus of the sigmoid colon are generally improving, the challenge for further improvement remains.

Volvulus of the transverse colon in an Australian aboriginal

A case of volvulus of the transverse colon in an elderly female Australian Aboriginal is reported. The rarity of the condition is stressed and the radiological features are discussed. Reference is also made to the geographical distribution of all types of volulus of the colon, and to the apparently high incidence of the condition in Aboriginal patients admitted to the Darwin Hospital.