Vólvulo

Descripción General

Definición

Un vólvulo es la torsión de un segmento de intestino en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum su mesenterio, lo que provoca una obstrucción intestinal.

Epidemiología

• 3ra causa más común de obstrucción del intestino grueso después del cáncer y la diverticulitis Diverticulitis Inflammation of a diverticulum or diverticula. Diverticular Disease
• Tipos de vólvulo colónico:
  • Sigmoide (~75%; más común)
  • Cecal (~20%)
  • Colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy transverso (3%)
  • Flexión esplénica (2%)
• Vólvulo sigmoide:
  • Hombres mayores (edad media de 70 años)
  • A veces afecta a pacientes jóvenes con dismotilidad colónica
• Vólvulo cecal: común en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum mujeres de mediana edad

Etiología

Vólvulo sigmoide:

• Mesenterio largo con una base estrecha que permite la torsión
• Colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy alargado redundante generalmente por estreñimiento crónico
• Factores de riesgo:
  • Edad (50% de los LOS Neisseria pacientes > 70 años)
  • Residentes en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum instituciones o residencias de ancianos
  • Trastornos neurológicos (e.g., enfermedad de Parkinson, esclerosis múltiple)
  • Antecedentes de vólvulo
  • Dieta rica en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum fibra
  • Estreñimiento crónico y abuso de laxantes
  • Megacolon Megacolon Megacolon is a severe, abnormal dilatation of the colon, and is classified as acute or chronic. There are many etiologies of megacolon, including neuropathic and dysmotility conditions, severe infections, ischemia, and inflammatory bowel disease. Megacolon (enfermedad de Hirschsprung, enfermedad de Chagas)
  • Embarazo

Vólvulo cecal:

• Generalmente congénito
• Fijación mesentérica posterior incompleta del ciego
• Mesenterio alargado

Fisiopatología

• La torsión del intestino sobre su eje conduce a la obstrucción mecánica del intestino en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum asa ASA Anterior Cord Syndrome cerrada.
• Acumulación de gas, agua y heces dentro del asa ASA Anterior Cord Syndrome → aumento de la presión intraluminal
• La fermentación bacteriana contribuye a la distensión; el aumento de la presión intraluminal perjudica la perfusión capilar.
• Deterioro de la perfusión capilar del intestino → estrangulamiento e isquemia
• Oclusión vascular en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum el mesenterio si la torsión es lo suficientemente fuerte (> 360° de torsión)
• Torsión del pedículo vascular mesentérico → oclusión/trombosis de los LOS Neisseria vasos mesentéricos → isquemia
• 3 tipos de vólvulo cecal:
  • Tipo 1: torsión del ciego en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum el sentido de las agujas del reloj a lo largo del eje largo (ciego en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum el cuadrante inferior derecho)
  • Tipo 2: torsión del ciego y del íleon terminal en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum sentido contrario a las agujas del reloj (ciego en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum el cuadrante superior izquierdo)
  • Tipo 3: basculación cecal (pliegue hacia arriba del ciego en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum lugar de torsión)

Presentación Clínica

Vólvulo sigmoide

• El inicio suele ser lento e insidioso.
• Dolor Dolor Inflammation abdominal con distensión gradual
• Dolor Dolor Inflammation constante con episodios de cólicos superpuestos
• Náuseas, estreñimiento
• Típicamente, vómitos unos días después de la aparición del dolor Dolor Inflammation

Vólvulo cecal

• La presentación es variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables:
  • Aparición insidiosa de dolores y cólicos abdominales intermitentes
  • Dolor Dolor Inflammation abdominal agudo y repentino
  • Los LOS Neisseria síntomas duran de horas a días
  • Un dolor Dolor Inflammation intenso y constante puede indicar isquemia o perforación.
• Síntomas acompañantes:
  • Náuseas y vómitos biliosos
  • Estreñimiento
  • Obstipación (incapacidad para expulsar el flato o las heces)

Diagnóstico

Antecedentes clínicos

• Estreñimiento crónico
• Uso prolongado de laxantes
• Trastornos neurológicos (e.g., enfermedad de Parkinson)
• Medicamentos que afectan a la motilidad intestinal (psicotrópicos, opiáceos)

Examen físico

• Abdomen timpánico distendido
• Puede estar asimétricamente distendido con vacío en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum el lado derecho o izquierdo
• Sensibilidad a la palpación
• Signos de isquemia o perforación:
  • Dolor Dolor Inflammation abdominal desproporcionado con respecto al AL Amyloidosis examen físico
  • Signos peritoneales (defensa, rigidez, sensibilidad de rebote)
  • Taquicardia
  • Hipotensión
  • Fiebre
  • Hematoquecia o sangre en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum el tacto rectal

Estudios de laboratorio

• Hemograma:
  • Frecuentemente normal
  • Una leucocitosis significativa puede indicar isquemia/perforación.
• Química:
  • Frecuentemente normal
  • Hipopotasemia/alcalosis metabólica por vómitos persistentes
  • Acidosis Acidosis A pathologic condition of acid accumulation or depletion of base in the body. The two main types are respiratory acidosis and metabolic acidosis, due to metabolic acid build up. Respiratory Acidosis metabólica/ácido láctico elevado por isquemia/perforación
• Prueba de embarazo: se obtiene en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum todas las mujeres en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum edad fértil

Imagenología

• Radiografía de abdomen de pie:
  • Vólvulo sigmoide: signo del grano de café ( colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy sigmoide dilatado que se proyecta hacia el cuadrante superior derecho)
  • Vólvulo cecal:
    • Signo de la habichuela ( asa ASA Anterior Cord Syndrome de colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy dilatada que se extiende desde el lado derecho hasta la mitad del abdomen)
    • Signos de obstrucción del intestino delgado: asas distendidas, niveles de aire-líquido
  • Neumoperitoneo: indica perforación
• TC abdominal:
  • Estudio de confirmación
  • Signo del remolino:
    • Patognomónico de vólvulo
    • Indica una torsión del mesenterio
  • Dilatación del intestino delgado (especialmente vólvulo cecal)
  • Dilatación significativa del colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy con descompresión distal y escasez de gas en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum el recto
  • Signos de isquemia:
    • Neumatosis intestinal (aire en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum la pared intestinal) y gas en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum la vena porta
    • Pared intestinal engrosada (debido a la pérdida de drenaje venoso/linfático)
    • Líquido libre intraperitoneal Intraperitoneal Peritoneum: Anatomy
    • Heterogeneidad de la grasa mesentérica
    • Realce diferencial de la pared (mala captación del contraste intravenoso en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum la pared del intestino afectado)
    • El aire libre indica una perforación.
• Enema de contraste:
  • Rara vez se necesita para el diagnóstico
  • Vólvulo sigmoide:
    • El signo del pico de pájaro se ve VE Ventilation: Mechanics of Breathing en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum el sigmoide.
    • El tinte no pasa el punto de torsión en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum el colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy sigmoide.
  • Vólvulo cecal: signo del pico de pájaro, el colorante no entra en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum el intestino delgado

Tratamiento

Tratamiento inicial de soporte

• Líquido intravenoso y corrección del desequilibrio electrolítico
• Nada por vía oral
• Descompresión con sonda nasogástrica si hay vómitos/signos de obstrucción del intestino delgado
• Antibióticos intravenosos por sospecha de isquemia/perforación/signos de sepsis Sepsis Systemic inflammatory response syndrome with a proven or suspected infectious etiology. When sepsis is associated with organ dysfunction distant from the site of infection, it is called severe sepsis. When sepsis is accompanied by hypotension despite adequate fluid infusion, it is called septic shock. Sepsis and Septic Shock

Vólvulo sigmoide

Sigmoidoscopia con detorsión:

• Para pacientes estables sin sospecha de isquemia o perforación
• Flexible o rígida
• La sonda rectal debe dejarse colocada para la descompresión y la prevención de la recidiva inmediata.
• Tasa de éxito: 75%–95%
• Recurrencia: hasta el 84%
• Se recomienda la cirugía definitiva a menos que se trate de un paciente de muy alto riesgo quirúrgico.
• Si es posible, se debe intentar la descompresión antes de la cirugía:
  • Convierte la cirugía de emergencia en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum electiva y permite la planificación preoperatoria
  • Permite una anastomosis primaria exitosa (ayuda a evitar la colostomía)

Cirugía:

• Indicaciones:
  • Peritonitis Peritonitis Inflammation of the peritoneum lining the abdominal cavity as the result of infectious, autoimmune, or chemical processes. Primary peritonitis is due to infection of the peritoneal cavity via hematogenous or lymphatic spread and without intra-abdominal source. Secondary peritonitis arises from the abdominal cavity itself through rupture or abscess of intra-abdominal organs. Penetrating Abdominal Injury, signos de isquemia/perforación
  • Detorsión endoscópica sin éxito
  • Detorsión exitosa en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum pacientes que son candidatos quirúrgicos aceptables
• Procedimientos:
  • Colectomía sigmoidea con anastomosis primaria: pacientes estables con colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy viable
  • Colectomía sigmoidea con colostomía terminal (procedimiento de Hartmann): pacientes inestables, perforación, isquemia

Vólvulo cecal

• Intervención quirúrgica directa tras la estabilización
• La descompresión colonoscópica aumenta el riesgo de perforación y no se realiza.
• Procedimientos:
  • Pacientes hemodinámicamente estables: resección ileocecal o colectomía derecha con anastomosis ileocólica
  • Pacientes inestables:
    • Detorsión y cecopexia (para intestino viable) +/- tubo de cecostomía para descompresión
    • Colectomía derecha con ileostomía (para intestino isquémico/necrótico)

Pronóstico

Mortalidad general:

• Vólvulo cecal: 6,64%.
• Vólvulo sigmoide: 9,44%.

Predictores de mortalidad:

• Gangrena intestinal/ peritonitis Peritonitis Inflammation of the peritoneum lining the abdominal cavity as the result of infectious, autoimmune, or chemical processes. Primary peritonitis is due to infection of the peritoneal cavity via hematogenous or lymphatic spread and without intra-abdominal source. Secondary peritonitis arises from the abdominal cavity itself through rupture or abscess of intra-abdominal organs. Penetrating Abdominal Injury
• Edad avanzada
• Coagulopatía
• Enfermedad renal crónica
• Creación de un estoma durante la cirugía

Diagnóstico Diferencial

• Megacolon Megacolon Megacolon is a severe, abnormal dilatation of the colon, and is classified as acute or chronic. There are many etiologies of megacolon, including neuropathic and dysmotility conditions, severe infections, ischemia, and inflammatory bowel disease. Megacolon agudo/pseudoobstrucción colónica: dilatación masiva de todo el colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy secundario a un problema funcional más que a una obstrucción mecánica; normalmente se diagnostica mediante una combinación de antecedentes clínicos e imagenología. El tratamiento suele ser médico y la cirugía se reserva para los LOS Neisseria casos avanzados asociados a isquemia y sepsis Sepsis Systemic inflammatory response syndrome with a proven or suspected infectious etiology. When sepsis is associated with organ dysfunction distant from the site of infection, it is called severe sepsis. When sepsis is accompanied by hypotension despite adequate fluid infusion, it is called septic shock. Sepsis and Septic Shock.
• Megacolon Megacolon Megacolon is a severe, abnormal dilatation of the colon, and is classified as acute or chronic. There are many etiologies of megacolon, including neuropathic and dysmotility conditions, severe infections, ischemia, and inflammatory bowel disease. Megacolon tóxico: una complicación de la colitis Colitis Inflammation of the colon section of the large intestine, usually with symptoms such as diarrhea (often with blood and mucus), abdominal pain, and fever. Pseudomembranous Colitis infecciosa o inflamatoria. La presentación incluye taquicardia, hipotensión y distensión abdominal masiva. El diagnóstico se basa en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum varios síntomas, como los LOS Neisseria antecedentes de diarrea sanguinolenta, la fiebre/infección y los LOS Neisseria hallazgos en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum la TC característicos del megacolon Megacolon Megacolon is a severe, abnormal dilatation of the colon, and is classified as acute or chronic. There are many etiologies of megacolon, including neuropathic and dysmotility conditions, severe infections, ischemia, and inflammatory bowel disease. Megacolon tóxico. El tratamiento depende de la causa subyacente y la cirugía se reserva para el fracaso del tratamiento médico.
• Obstrucción mecánica del intestino grueso: interrupción del flujo del contenido a través del colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy. La presentación es similar al AL Amyloidosis cuadro clínico y a los LOS Neisseria hallazgos radiográficos (dilatación del colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix: Anatomy) del vólvulo sigmoide. El diagnóstico definitivo se establece con una TC y a veces con una colonoscopia. El tratamiento suele consistir en EN Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum la resección quirúrgica para tratar la causa de la obstrucción.
• Obstrucción mecánica del intestino delgado: interrupción del flujo del contenido a través del intestino delgado. Presentación similar al AL Amyloidosis cuadro clínico y algunos hallazgos radiográficos (dilatación del intestino delgado) del vólvulo cecal. El diagnóstico definitivo se establece con una TC. El tratamiento no quirúrgico suele tener éxito. La cirugía se reserva para la presentación clínica grave y el fracaso del tratamiento médico.