Outcomes for sigmoid volvulus managed with and without early definitive surgery: 20-year experience in a tertiary referral centre

BACKGROUND

Sigmoid volvulus is rare in Western countries. Patients at risk of sigmoid volvulus are often older with significant co-morbidity. Without sigmoid colectomy there is a high recurrence rate, but indications for surgery are controversial.

METHODS

A retrospective observational study was conducted by reviewing clinical records of patients admitted to Waikato Hospital 1 January 2000 to 1 January 2020 with a diagnosis of sigmoid volvulus. Patient characteristics, clinical features, investigations, management, and outcomes were recorded.

RESULTS

One hundred and thirty-two patients (87 male) were included with 203 volvulus episodes. Median age 76 years, median Charlson co-morbidity index (CCI) 4. Median follow-up 11 years. 44/132 (33.3%) had surgery during the index admission, two had elective surgery and the remainder had planned non-operative management. 73/132 (55.3%) had surgery at any stage. 42/86 (48.8%) patients managed non-operatively recurred; 66.7% of recurrences were within 6 months. Forty-three (32.6%) died within 12 months of index admission; 28 (21.2%) died during an admission for volvulus. On univariate analysis higher age and abnormal vital signs were associated with inpatient and 12-month mortality; higher CCI was associated with 12-month mortality. On multi-variate analysis increasing age in years was associated with increased risk of death (HR 1.089 [1.052-1.128, P < 0.001]). Normal vital signs at presentation were associated with decreased risk of death (HR 0.147 [0.065-0.334, P < 0.001]).

CONCLUSION

Sigmoid colectomy should be considered at index presentation with sigmoid volvulus. Half of patients managed non-operatively recurred, with two-thirds recurring within 6 months. The mortality rate remains high for subsequent volvulus episodes.

Eosinophilic Myenteric Ganglionitis Presenting as Sigmoid Volvulus: A Brief Report

Eosinophilic myenteric ganglionitis (EMG) is a rare pathologic finding within the Auerbach myenteric plexus characterized by eosinophilic infiltration on light microscopy. The plexus's ultimate obliteration results in chronic intestinal pseudo-obstruction (CIPO). EMG is almost exclusively seen in the pediatric population. The diagnosis of EMG is made through full-thickness rectal biopsy and EMG is not detectable through routine screening measures such as imaging or colonoscopy. The current treatment modality for this disorder is not standardized, and has often been treated with systemic steroids given its eosinophilic involvement. This case presents a 73-year-old male with chronic constipation presenting with new obstipation in the setting of recent orthopedic intervention requiring outpatient opioids. Admission radiographs were consistent with sigmoid volvulus. Following endoscopic detorsion, exploratory laparotomy revealed diffuse colonic dilation and distal ischemia requiring a Hartmann's procedure. Surgical pathology revealed EMG, increasing the complexity of subsequent surgical decision-making after his urgent operation.

Sigmoid volvulus: Evaluating identification strategies and contemporary multicenter outcomes

BACKGROUND

There is limited epidemiologic data on sigmoid volvulus (SV) from non-endemic regions. Therefore, we performed a multicenter study to report contemporary outcomes and appraise literature-based methods that pair diagnostic and procedural codes to identify SV.

METHOD

Using an automated search for patients with 'volvulus' in our system from 2011 to 2021, we reviewed electronic charts to clarify the diagnosis, automatically replicate three strategies to identify SV, and retrieved 6-month outcomes.

RESULTS

Of 895 patients, 109 had SV. Literature-based strategies poorly identified SV. At the index admission, patients underwent endoscopic reduction alone (33%), emergent (16.5%), semi-elective (34%), or elective (16.5%) surgery. Endoscopic reduction alone had high recurrence rates and delayed surgery was associated with worse outcomes.

CONCLUSION

Literature-based strategies to identify SV suffer from misclassification bias which affects patient counseling. In this large series, one-third of patients do not undergo during their index admission despite improved outcomes with earlier surgery.

Factors precipitating volvulus formation in sigmoid volvulus

BACKGROUND

Sigmoid volvulus (SV), the wrapping of the sigmoid colon around itself, is a rare intestinal obstruction form world-wide. For this reason, the physiopathology of SV, particularly the precipitating factors, are not clearly identified. The aim of this study is to evaluate the precipitating factors in SV.

METHODS

The clinical records of consecutive 416 patients with SV were reviewed prospectively from January 1986 to July 2020. As a control, the records of consecutive 100 patients with non-volvulus intestinal obstruction were reviewed prospectively in the past 24 months. The premorbid symptoms including acute diarrhea, sudden and excessive body motions, overeating after a prolonged starvation, coughing spell, and labor was evaluated.

RESULTS

Among the premorbid symptoms, 1-5-day interval of diarrhea (42 patients, 10.1%, p<0.05), harvesting activation (35 patients, 8.4%, p<0.05), and overeating after Ramadan fasting (31 patients, 7.5%, p<0.05) were found to be statistically significant precipitating factors in SV.

CONCLUSION

Although there are few studies about the precipitating factors of SV in the literature, increased bowel motility, excessive body motions, and overeating following a prolonged starvation look like the precipitating factors in the development of SV.

Ileo-sigmoid knotting: the Parirenyatwa hospital experience

BACKGROUND

Ileo-sigmoid knotting is a rare cause of intestinal obstruction with a rapidly progressive course, for which expedient surgical intervention is required to prevent mortality. The aim of this study was to determine the characteristics, presentation, morbidity and mortality associated with ileo-sigmoid knotting at Parirenyatwa Group of Hospitals (PGH). To determine the preoperative diagnostic precision and management patterns of ileo-sigmoid knotting cases at PGH.

METHODS

A retrospective analysis was performed on patients operated on at Parirenyatwa Hospital with a diagnosis of ileo-sigmoid knotting between April 2011 and April 2018. Data inclusive of demographics, time to presentation and surgery, preoperative diagnosis, complications and in-hospital mortality was collected. The relationship between the duration of symptoms prior to surgery and incidence of both septic shock and transfusion were analysed.

RESULTS

Twenty-one cases of ileo-sigmoid knotting were identified for analysis. The median age was 37 years (range 18-65 years) with a 6:1 male to female ratio. Two of the three females included were pregnant. Twenty patients (95.2%) described an acute onset abdominal pain, with 83.3% experiencing the pain nocturnally, while asleep. The median duration of symptoms at presentation was 12.5 hours (range 2-39 hours). At admission, leucocytosis (WCC > 11x10³/dl) was noted in eleven patients (52.4%). Seventy-three per cent of patients were noted to have electrolyte derangements at presentation. Seven patients (33.3%) had recorded episodes of severe hypotension (SBP < 90) prior to surgery. The most common preoperative diagnosis, based on both clinical assessment and plain x-ray evaluation, was sigmoid volvulus (52.4%), with no preoperative diagnosis of ileo-sigmoid knotting being made. All patients had gangrenous small bowel, with 81% having a gangrenous sigmoid colon. All cases underwent small bowel resection and primary anastomosis plus Hartmann's procedure. Postoperatively, eleven patients (52.4%) developed septic shock, while 62% required blood transfusion. There was one (4.8%) early postoperative mortality.

CONCLUSION

To avoid mortality, the diagnosis of ileo-sigmoid knotting should be entertained and the imperative of emergency surgery recognised in the young male or pregnant female patient with acute nocturnal onset abdominal pain, a rapidly deteriorating small bowel obstruction clinical picture and with radiological features suggestive of both small and large bowel obstruction.

Crohn’s-like acute severe colitis associated with Hermansky-Pudlak syndrome: A case report

BACKGROUND

Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive disorder characterized by oculocutaneous albinism, platelet storage pool deficiency and systemic complications associated with ceroid deposition in the reticuloendothelial system. HPS types 1 and 4 are associated with Crohn’s disease (CD)-like gastrointestinal disorders, such as granulomatous enterocolitis or perianal disease. Cases of colitis can be particularly severe and, before the use of anti-tumor necrosis factor alpha (TNFα) therapy had become common, were reported as showing poor responsiveness to medical treatment.

CASE SUMMARY

We present the case of a 51-year-old albino woman who presented with acute severe colitis that led to the diagnosis of HPS. Histologic findings of biopsy samples showed chronic inflammation with deep ulcerations, and granulomas without caseous necrosis. Molecular genetic analysis confirmed HPS type 1, with a homozygous 27 base-pair deletion in exon 20 of the HPS1 gene. Once the patient’s bleeding diathesis was corrected by platelet transfusion, the granulomatous colitis responded dramatically to a medical treatment regimen that included corticosteroids, azathioprine and infliximab; this regimen is similar to that used in CD treatment. Although it remains unclear if the granulomatous enterocolitis in HPS is due to ceroid deposition or reflects the co-existence of CD and HPS, the fact that this case of HPS-related granulomatous colitis responded to the same therapeutic approach used in CD suggests that this type of colitis may result from HPS patients’ genetic susceptibility to CD.

CONCLUSION

We report a case of severe colitis that led to the diagnosis of HPS, which was responsive to azathioprine and infliximab.

Microvillus inclusion disease, a diagnosis to consider when abnormal stools and neurological impairments run together due to a rare syntaxin 3 gene mutation

BACKGROUND

Microvillus Inclusion Disease (MVID) was first described in the literature in 1978 with presentation of severe watery diarrhea, failure to thrive, and metabolic acidosis. Mutations in the myosin Vb (MYO5B) gene have been identified as causative for MVID, but other clinical manifestations and associations with novel mutations are lacking.

METHODS

We report a full-term infant admitted to the neonatal intensive care unit (NICU) with abdominal distension and inability to sustain full enteral feeds. A retrospective chart review and review of the literature was performed.

RESULTS

An infant with abnormal, mucoid-like stringy stools was incidentally found to have severe metabolic acidosis on routine lab monitoring. Acidosis corrected with total parenteral nutrition (TPN), but the infant experienced recurrent episodes of acidosis with enteral feeds. He was also noted to have abnormal ocular movements, fluctuating tonicity, and staring spells. He underwent an extensive workup and the diagnosis of microvillus inclusion disease was made by findings on electron microscopy. The diagnosis was confirmed with whole exome sequencing, showing a rare homozygous mutation in the syntaxin 3 (STX3) gene. This is the fifth reported patient with microvillus inclusion disease with a mutation in this gene, and the first with abnormal neurologic findings.

CONCLUSION

It is important to consider MVID in the differential diagnosis of a neonate or infant with abnormal stools, metabolic acidosis, with and without neurologic symptoms for prompt referral and treatment.

Malakoplakia of the large intestine: an incidental extremely rare finding

Malakoplakia is a rare inflammatory disease, most commonly found in the urinary tract. It appears be related to a functional deficiency of macrophages, resulting in an inability to destroy digested bacteria and it is associated with various conditions that cause immunodeficiency. A rare case of malakoplakia of the colon in a healthy 68-year old male is presented. The patient underwent emergency surgery with colon resection and an end stoma with closure of the distal bowel (Hartmann's procedure), due to incarcerated ventral hernia and sigmoid-colon rupture. He underwent reversal of the Hartmann's procedure four months after the initial operation. The histological examination from the anastomotic rings revealed Michaelis-Gutmann bodies that are pathognomonic of malakoplakia. He received per os ciprofloxacin, bethanecol and ascorbic acid for 12 months. Follow-up endoscopy did not exhibit any signs of the disease. A case of a healthy patient presenting with malakoplakia without any underlying disease that causes immunodeficiency is extremely rare. Treatment of malakoplakia involves the eradication of microorganisms. Cholinergic agonists, such as bethanechol and ascorbic acid, as well as antimicrobial treatment with trimpethoprim/sulphamethoxazol and rifampicin are most commonly being used. Long-term antimicrobial treatment has been reported (6 months to 3 years).

[Sigmoid colon diverticulitis : Treatment modalities 2011-2013]

INTRODUCTION

Diverticulosis is a relevant disease in Germany with a prevalence of over 60 % in patients aged ≥70 years. The S2k guidelines for the treatment of diverticulosis were recently published. Systematic epidemiological data on treatment modalities do not exist.

METHODS

Analysis of in-hospital treatment modalities for diverticulosis based on data from the Federal Office of Statistics.

RESULTS

Approximately 130,000 inpatient cases of diverticulosis are treated in Germany per year. Approximately 25 % undergo surgery and of these slightly under 50 % (12,000 procedures) are carried out by laparoscopy. The complication rates are 18 % in a best case scenario and up to 85 % in a worst case scenario. A stage-adjusted classification of treatment modalities based on data from the Federal Office of Statistics is currently practically impossible.

CONCLUSION

To enable stage-adjusted epidemiological analysis of diverticulosis, a standardized and transparent documentation system enabling systematic analysis is necessary, which does not currently exist (e. g. ICD 10 coding); moreover, information on conservative and interventional treatment options are not included in the operations and procedures key (OPS) coding system.

[How I EXPLORE ... SIGMOID VOLVULUS]

Sigmoid volvulus is a significant cause of bowel obstruction and will become a major cause in the future given its prevalence in the elderly and/or institutionalized patients. Furthermore that's the first cause of bowel obstruction in pregnant women. Given it's a non specific clinical presentation, the clinician has to do complementary exams, above all the x ray examinations. So, the role of radiologist is primordial in diagnostic, sometimes in the treatment given important morbidity and mortality of this pathology. We bring you here a typical case of sigmoid volvulus in 60 years old patient seen in emergency department for bloating and vomiting since several days.

[Coincidence of colonic lymphoma and gallstone ileus - case report]

INTRODUCTION

Primary colonic lymphoma is a very rare malignant disease of the gastrointestinal tract, accounting for 14% of all malignant diseases in this location. It is classified in the group of extranodal lymphomas; its long-term asymptomatic progression makes it different from common colorectal carcinomas making its diagnosis very difficult, more often accidental. Gallstone ileus is quite an uncommon complication of cholecystolithiasis diagnosed with difficulty. Up to 50% of cases are diagnosed during surgery. The obturated location depends on the size of the stone, location of the conjunction between the biliary and gastrointestinal tracts, and also on any preexisting stenosis due to another unknown pathology.

CASE REPORT

We present a case of an 86-year-old man treated for acute diverticulitis with typical clinical symptoms. Following further examination (colonoscopy, computed tomography) revealed a tumour-like infiltration in the sigmoid colon wall and a voluminous polyp was suspected according to the colonoscopy. Computed tomography described an obstruction by a biliary stone tumbling through the cholecystocolonic fistula. Subsequent biopsy supported the suspected malignant etiology. The patient underwent resection of the sigmoid colon sec. Hartmann; an infiltration was found in the subhepatic space, which corresponded to the described fistulisation between the biliary tract and the colon. A large 40 mm gallstone was found in the resected sigmoid colon over the stenosis and the bowel wall showed diffuse thickening with several polyps; final histopathological assessment confirmed malignant lymphoma of the plasmocytoma type. No serious complications occurred in the postoperative period; after healing, the patient was transferred to hematooncology care.

CONCLUSION

The article describes the presence of two rare diseases - colonic lymphoma and gallstone ileus. Clearly, without the biliary stone obstruction in the preexisting tumorous stenosis in the sigmoid colon, the malignant hematooncology disease would not have been diagnosed.

KEY WORDS

primary colonic lymphoma - gallstone ileus - complication of the cholecystolithiasis - extranodal lymphoma - acute diverticulitis.

[Acute sigmoid diverticulitis: toward a more and more conservative treatment]

Acute diverticulitis of the colon is a frequent pathology especially among elderly people and people of Caucasian origin. The prevalence is higher among sedentary people and in people with low-fiber diet. Its diagnosis is mainly based on computed tomography (CT) that allows guiding the therapeutic management. Over the last few years the treatment of acute diverticulitis has passably changed with in particular an evolution toward a restriction of the elective and emergency surgery indications and a reduction of the antiobiotherapy and hospitalization number. This article reviews the epidemiology, the diagnostic tools, and the management of this frequent digestive pathology.

Single-port laparoscopic surgery for sigmoid volvulus

AIM: To report our experience with single-port laparoscopic surgery (SPLS) for sigmoid volvulus (SV).

METHODS: Between October 2009 and April 2013, 10 patients underwent SPLS for SV. SPLS was performed transumbilically or through a predetermined stoma site. Conventional straight and rigid-type laparoscopic instruments were used. After intracorporeal, segmental resection of the affected sigmoid colon, the specimen was extracted through the single-incision site. Patient demographics and perioperative data were analyzed.

RESULTS: SPLS for SV was successful in all 10 patients (4, resection and primary anastomosis; 6, Hartmann’s procedure). The median operative time and postoperative hospitalization period were 168 (range, 85-315) min and 6.5 (range, 4-29) d, respectively. No intraoperative complications were noted; there were 2 postoperative complications, including 1 anastomotic leak.

CONCLUSION: SPLS was a safe and feasible therapeutic approach for SV, when performed by a surgeon experienced in conventional laparoscopic surgery.

Acute sigmoid diverticulitis within a nonincarcerated hernia

Separately, diverticulitis and inguinal hernias are both common findings in emergency medicine. However, diverticulitis within a reducible hernia has not been previously reported.We present a case of sigmoid diverticulitis within a non incarcerated easily reducible hernia treated with conservative management. Our review of literature did not reveal any previously documented cases of this type of presentation.

[Swimming pool suction injury: etiology, profylaxis and management]

Swimming pool suction injuries are unique and rare with a substantive risk of fatal consequences. Little children under the age of 8 are the most frequent victims with serious injuries. Drownings of different seriousness are also a usual part of accidents. The case of a 19 year old man trapped in the gluteal area by a unsecured suction drainage hole illustrates the uniqueness of this problem in an interesting way. Prophylactic arrangements are well known but the problem is with their strict application. Fatal causes excluding drowning include hypovolemic shock from the sudden redistribution of intersticial fluid and blood and also the evisceration of the bowel and other abdominal organs. Localised often bizarre and large swellings and sufusions can be treated nonoperatively in the vast majority of cases. For the prevention of these injuries it is important to inform the public and increase their awareness to these injuries. It is also crucial for the correct management of these injuries a deeper awareness of this issue and a sharing of experiences and solutions with other experts.Key words: vacuum - accident - entrapment - compartment syndrome.

[Megacolon and sigmoid volvulus: incidence and physiopathology]

The etiology of Megacolon is multiple. One of these causes and the most frequent is Chagas disease. Its complication: sigmoid volvulus was de main diagnosis in the admitted patients at the Bolivian and Japanese Gastroenterological Institute of Cochabamba Bolivia. It usually affects people of a low economic income. In this Gastroenterological Hospital a transversal and prospective study has been done, in order to know the real incidence and the physiopathology of this disease. In a six year period, from 2000 to 2006, 8.954 patients were admitted to the Hospital: of these, 814 (9.09%), where diagnosticated as lower intestinal obstruction. In 608 (74.7%) the final diagnosis was sigmoid torsion. Radiological diagnosis was made in 84% of the patients and endoscopic decompression was successful in 88.7%. As reported in the medical literature, the main cause of megacolon in this part of the world is Chagas disease. In our investigation 22% (98 patients), were serology positive to Chagas disease, and another 21.44% (95 patients) were serology negative. They were coca leaf chewers. One of coca leaf compounds is cocaine which blocks the adrenaline and noradrenaline degradation by mean of monoamine oxidase inactivation. These two hormones stay a long term of time in the target organ: the large bowel. By this mean chronic and persistent vessel constriction develops intestinal wall atrophy and lower resistance to the intraintestinal pressure.

[TREATMENT OF COLORECTAL CANCER COMPLICATED BY INTESTINAL OBSTRUCTION USING THE METHOD OF <<FAST-TRACK>> RECOVERY]

A medical trend which is currently gaining strength includes the complex treatment based on the concept of "fast-track" recovery in oncology. An application of modem high-tech approaches allowed minimizing the terms of treatment, shortening economic costs and getting the highest final results. It provides a high quality treatment. Given method could exclude an interim treatment stages, sufficiently reduces terms of general treatment and rehabilitation of patients and could succeed in high quality of life for the patients in short- and long-term period. The authors present the results of successful clinical surgery of 78 patients using this method in public health.

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.

[Patients with diagnostic challenging intestinal involvement of the endometriosis]

A considerable proportion of women with endometriosis have intestinal involvement of the endometriosis. Intestinal endometriosis (IE) often results in abdominal pain and thus mimics the symptoms of other bowel diseases, including colon cancer. As a consequence, some women with IE are initially referred to general surgery and treated under suspicion of colon cancer. This case report demonstrates the diagnostic challenges and describes the key symptoms of IE. Women with key symptoms should be referred to a gynaecological department for transvaginal ultrasonography. The optimal surgical treatment for IE is laparoscopically assisted bowel resection.

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.

[Intestinal endometriosis - a case report]

Endometriosis is defined as the presence of functional endometrial tissue outside the uterine cavity. The most common clinical symptoms of endometriosis are infertility and chronic pelvic pain. Endometriosis affects 8-10% of women of reproductive age and the condition is highly associated with infertility. Ectopic endometrial tissue is usually found in the small pelvis and the peritoneum, but endometrial tissue deposits have also been reported in other anatomical locations in the human body. We describe the case of a young patient with persistent abdominal pain and bleeding via the rectum during menstrual periods, hospitalised at the Second Department of Surgery, Pavol Jozef Šafárik University, Faculty of Medicine and Louis Pasteur University Hospital Košice.

Die Aktinomykose des Sigma als obstruierende Raumforderung im kleinen Becken Eine Falldarstellung

Abdominal actinomycosis is a rare chronic infectious disease, which may mimic abdominal cancer, inflammatory bowel disease or diverticulitis. We report the case of a 46-year-old women with a large bowel obstruction caused by extensive abdominal actinomycosis. Colon contrast examination revealed a stenosis in the sigmoid colon, while abdominal ultrasound showed a stenosis of the left ureter with left hydronephrosis. Preoperative presumptive diagnosis was a carcinoma of the sigmoid colon. She required emergency surgery, which involved both resection and colostomy. As in most cases reported in the literature, diagnosis was made postoperatively. Pathological examination following the sigmoid colon resection surprisingly revealed an actinomycosis. This case illustrates that consideration of actinomycosis in women with bowel obstruction and prolonged use of an intrauterine device could help to improve the preoperative diagnosis of this rare disease.

Endometriotic stricture of the sigmoid colon presenting with intestinal obstruction

Endometriosis, a relatively common condition, rarely involves the bowel; even more rarely does it present as a large-bowel stricture with intestinal obstruction. We report the case of a young woman who presented to an emergency department with intestinal obstruction secondary to an endometriotic stricture of the sigmoid colon, without evidence of disease elsewhere in the peritoneal cavity. Although large-bowel obstruction is usually caused by a malignant tumour, it can sometimes result from rare causes such as endometriosis. Symptoms of a cyclical nature may remind the clinician of this possibility.

Sigmoid volvulus in pregnancy: early diagnosis and intervention are important

Bowel obstruction is rare in pregnancy, and delay in recognition can lead to serious maternal and fetal complications. Most reported causes of bowel obstruction in pregnancy (adhesions, intussusception, hernia, and carcinoma) require surgical intervention. Sigmoid volvulus is an acute surgical cause that can now be managed successfully without surgery. We report the case of 33-year-old lady who presented with a sigmoid volvulus that was successfully managed with urgent endoscopic decompression.

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. CT was 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 diverticulitis in adolescent. Case report]

BACKGROUND

Few cases have been reported in children and adolescents of sigmoid diverticulitis. Most of the case reports in medical literature are associated with true congenital diverticula and genetic diseases of collagen synthesis.

CLINICAL CASE

13 year-old female who was admitted to General and Endoscopic Surgery service with diagnosis of complicated appendicitis. Laparotomy was performed finding complicated sigmoid diverticular disease. Lavage, sigmoidectomy and primary anastomosis were performed. The histopathological findings reported a perforated pseudo-diverticulum of the sigmoid colon with peritonitis. The patient was discharged 72 hours after surgery and no complications were reported.

CONCLUSION

There are only case reports about colonic diverticulitis in children and adolescents, and its etiology has not yet been well established. This patient had sigmoid pseudo-diverticula and did not present genetic concomitant disease. This case is an exception to data reported on literature about diverticular disease in this population.

Appropriate treatment of acute sigmoid volvulus in the emergency setting

AIM: To investigate an appropriate strategy for the treatment of patients with acute sigmoid volvulus in the emergency setting.

METHODS: A retrospective review of 28 patients with acute sigmoid volvulus treated in the Department of Colorectal Surgery, Changhai Hospital, Shanghai from January 2001 to July 2012 was performed. Following the diagnosis of acute sigmoid volvulus, an initial colonoscopic approach was adopted if there was no evidence of diffuse peritonitis.

RESULTS: Of the 28 patients with acute sigmoid volvulus, 19 (67.9%) were male and 9 (32.1%) were female. Their mean age was 63.1 ± 22.9 years (range, 21-93 years). Six (21.4%) patients had a history of abdominal surgery, and 17 (60.7%) patients had a history of constipation. Abdominal radiography or computed tomography was performed in all patients. Colonoscopic detorsion was performed in all 28 patients with a success rate of 92.8% (26/28). Emergency surgery was required in the other two patients. Of the 26 successfully treated patients, seven (26.9%) had recurrent volvulus.

CONCLUSION: Colonoscopy is the primary emergency treatment of choice in uncomplicated acute sigmoid volvulus. Emergency surgery is only for patients in whom nonoperative treatment is unsuccessful, or in those with peritonitis.