Volvulus

A volvulus is the twisting or axial rotation of a portion of the bowel around its mesentery. The most common site of volvulus in adults is the colon; most frequently the sigmoid volvulus. Patients typically present with symptoms of bowel obstruction such as abdominal pain, distension, vomiting, and constipation/obstipation. In severe cases, signs of bowel ischemia and gangrene (tachycardia, hypotension, hematochezia, and peritonitis) may also be present. Clinical suspicion prompts imaging to confirm the diagnosis and surgery is the definitive treatment. For stable patients with sigmoid volvulus, surgery may be preceded by endoscopic detorsion. However, immediate surgery is required for colon perforation or ischemia.

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Overview

Definition

A volvulus is the twisting of a segment of bowel on its mesentery, which results in bowel obstruction.

Epidemiology

  • 3rd most common cause of large bowel obstruction after cancer and diverticulitis
  • Types of colonic volvulus:
    • Sigmoid (80%; most common)
    • Cecal (15%)
    • Transverse colon (3%)
    • Splenic flexure (2%)
  • Sigmoid volvulus: 
    • Older men (mean age 70-years-old)
    • Sometimes affects younger patients with colonic dysmotility
  • Cecal volvulus: common in middle-aged women

Etiology

Sigmoid volvulus:

  • Long mesentery with a narrow base to allow twisting
  • Redundant elongated colon usually from chronic constipation
  • Risk factors:
    • Age (50% of patients > 70-years-old)
    • Institutionalized/nursing home residents
    • Neurologic disorders (e.g., Parkinson’s disease, multiple sclerosis)
    • Previous history of volvulus
    • High-fiber diet 
    • Chronic constipation and laxative abuse
    • Megacolon (Hirschsprung’s disease, Chagas disease)
    • Pregnancy

Cecal volvulus:

  • Usually congenital
  • Incomplete dorsal mesenteric fixation of the cecum 
  • Elongated mesentery

Pathophysiology

  • Torsion of bowel on its axis leads to closed-loop mechanical bowel obstruction.
  • Accumulation of gas, water, and feces within the loop → increased intraluminal pressure
  • Bacterial fermentation contributes to distention; increased intraluminal pressure impairs capillary perfusion.
  • Impaired capillary perfusion of bowel → strangulation and ischemia
  • Vascular occlusion in the mesentery if torsion is tight enough (> 360° torsion)
  • Torsion of the mesenteric vascular pedicle → occlusion/thrombosis of mesenteric vessels → ischemia
  • 3 types of cecal volvulus:
    • Type 1: clockwise twisting of the cecum along the long axis (cecum in right lower quadrant)
    • Type 2: counterclockwise twisting of the cecum and terminal ileum (cecum in left upper quadrant)
    • Type 3: cecal bascule (upward folding of cecum rather than twisting)

Clinical Presentation

Sigmoid volvulus

  • Onset is usually slow and insidious.
  • Abdominal pain with gradual distention
  • Constant pain with superimposed colicky episodes
  • Nausea, constipation
  • Typically vomiting a few days after the onset of pain

Cecal volvulus

  • Presentation is variable:
    • Insidious onset of intermittent abdominal pain and cramping
    • Acute sudden onset of abdominal pain
    • Symptoms last from hours to days
    • Severe, constant pain may indicate ischemia or perforation.
  • Accompanying symptoms:
    • Nausea and bilious vomiting
    • Constipation
    • Obstipation (inability to pass flatus or stool)

Diagnosis

History

  • Chronic constipation
  • Long-term laxative use
  • Neurologic disorders (e.g., Parkinson’s disease)
  • Medications affecting bowel motility (psychotropics, opiates)

Physical exam

  • Distended tympanitic abdomen
  • Can be asymmetrically distended with emptiness on the right or left side
  • Tenderness to palpation
  • Signs of ischemia or perforation: 
    • Abdominal pain out of proportion to physical exam
    • Peritoneal signs (guarding, rigidity, rebound tenderness)
    • Tachycardia
    • Hypotension
    • Fever
    • Hematochezia or blood on a digital rectal exam

Laboratory studies

  • Complete blood cell count:
    • Frequently normal
    • Significant leukocytosis may indicate ischemia/perforation.
  • Chemistry:
    • Frequently normal
    • Hypokalemia/metabolic alkalosis with protracted vomiting
    • Metabolic acidosis/elevated lactic acid with ischemia/perforation
  • Pregnancy test: obtained in all women of child-bearing age

Imaging

  • Upright abdominal X-ray:
    • Sigmoid volvulus: coffee bean sign (dilated sigmoid colon projecting to the right upper quadrant)
    • Cecal volvulus: 
      • Kidney bean sign (dilated colon loop extending from right side to mid-abdomen)
      • Signs of small bowel obstruction (SBO): distended loops, air-fluid levels
    • Pneumoperitoneum: indicates perforation
  • Abdominal CT scan:
    • Confirmatory test
    • Whirl sign: 
      • Pathognomonic for volvulus 
      • Indicates twisting of the mesentery
    • Small bowel dilatation (especially cecal volvulus)
    • Significant colon dilatation with distal decompression and paucity of gas in the rectum
    • Signs of ischemia: 
      • Pneumatosis intestinalis (air in the bowel wall) and portal venous gas
      • Thickened bowel wall (due to loss of venous/lymphatic drainage)
      • Free intraperitoneal fluid 
      • Mesenteric fat stranding
      • Differential wall enhancements (poor uptake of intravenous (IV) contrast into the wall of the affected bowel)
      • Free air indicates perforation.
  • Contrast enema: 
    • Rarely needed for diagnosis
    • Sigmoid volvulus: 
      • Bird’s beak sign is seen at the sigmoid.
      • Dye does not pass the twist point in the sigmoid colon.
    • Cecal volvulus: bird’s beak sign, dye does not enter the small bowel

Management

Initial supportive management

  • IV fluid and correction of electrolyte imbalance
  • Nil per os (NPO) 
  • Nasogastric decompression if vomiting/signs of SBO
  • IV antibiotics for suspected ischemia/perforation/signs of sepsis

Sigmoid volvulus

Sigmoidoscopy with detorsion:

  • For stable patients with no suspicion of ischemia or perforation
  • Flexible or rigid
  • Rectal tube should be left in place for decompression and prevention of immediate recurrence.
  • Success rate: 75%–95%
  • Recurrence: up to 84%
  • Definitive surgery is recommended unless a very high surgical risk patient.
  • Decompression should be attempted if feasible prior to surgery:
    • Converts emergent surgery into elective surgery and allows preoperative planning
    • Allows for successful primary anastomosis (helps avoid colostomy)

Surgery:

  • Indications:
    • Peritonitis, signs of ischemia/perforation
    • Unsuccessful endoscopic detorsion
    • Successful detorsion in patients who are acceptable surgical candidates
  • Procedures:
    • Sigmoid colectomy with primary anastomosis: stable patients with viable colon
    • Sigmoid colectomy with end colostomy (Hartmann’s procedure): unstable patients, perforation, ischemia
Sigmoid volvulus during surgery

Sigmoid volvulus (intraoperative view)

Image: “Sigmoid volvulus during surgery” by General Surgery Department, Aga Khan University Hospital, Stadium Road, Karachi 74800, Pakistan. License: CC BY 2.0

Cecal volvulus

  • Direct surgical intervention after stabilization
  • Colonoscopic decompression increases the risk of perforation and is not performed.
  • Procedures:
    • Hemodynamically stable patients: ileocecal resection or right colectomy with ileocolic anastomosis 
    • Unstable patients: 
      • Detorsion and cecopexy (for viable bowel) +/- cecostomy tube for decompression
      • Right colectomy with ileostomy (for ischemic/necrotic bowel)

Prognosis

Overall mortality:

  • Cecal volvulus: 6.64%
  • Sigmoid volvulus: 9.44%

Predictors of mortality:

  • Bowel gangrene/peritonitis
  • Advanced age
  • Coagulopathy
  • Chronic kidney disease
  • Stoma creation during surgery

Differential Diagnosis

  • Acute megacolon/colonic pseudo-obstruction: massive dilation of the entire colon secondary to a functional problem rather than a mechanical obstruction; usually diagnosed by a combination of clinical history and imaging. Treatment is typically medical management with surgery reserved for advanced cases associated with ischemia and sepsis.
  • Toxic megacolon: a complication of infectious or inflammatory colitis. Presentation includes tachycardia, hypotension, and massive abdominal distention. Diagnosis is based on several symptoms such as a history of bloody diarrhea, fever/infection, and CT findings characteristic of toxic megacolon. Management depends on the underlying cause with surgery reserved for failure of medical management.
  • Mechanical large bowel obstruction (LBO): interruption of the flow of contents through the colon. Presentation is similar to the clinical picture and X-ray findings (dilation of the colon) of sigmoid volvulus. Definitive diagnosis is established with a CT scan and sometimes colonoscopy. Management usually involves surgical resection to address the cause of the obstruction.
  • Mechanical small bowel obstruction (SBO): interruption of the flow of contents through the small bowel. Presentation similar to the clinical picture and some X-ray findings (small bowel dilation) of cecal volvulus. A definitive diagnosis is established with a CT scan. Nonoperative management is frequently successful. Surgery is reserved for severe clinical presentation and failure of medical management.

References

  1. Halabi W.J., Jafari M.D., Kang C.Y., Nguyen V.Q., Carmichael J.C., Mills S., et al. (2014). Colonic volvulus in the United States: trends, outcomes, and predictors of mortality. Ann Surg.
  2. Hodin R.A. (2020). Cecal Volvulus. Retrieved February 15, 2021, from https://www.uptodate.com/contents/cecal-volvulus
  3. Hodin R.A. (2020). Sigmoid Volvulus. Retrieved February 15, 2021, from https://www.uptodate.com/contents/sigmoid-volvulus
  4. Thornton S.C. (2020). Sigmoid and Cecal Volvulus. Retrieved February 16, 2021, from https://emedicine.medscape.com/article/2048554-overview
  5. Williams N., Bulstrode Ch. (2013). Bailey and Love’s Short Practice of Surgery 26th ed. (pg 1181–1198).

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