Volvulus

Article Author:
Carol Le
Article Editor:
Wantzy Cooper
Updated:
2/5/2020 11:11:16 AM
PubMed Link:
Volvulus

Introduction

Volvulus occurs when a loop of intestine twists around itself and the mesentery that supports it, causing a bowel obstruction. Symptoms include abdominal bloating, pain, vomiting, constipation, and bloody stools. The onset of symptoms may be gradual or rapid. The mesentery becomes so tightly twisted that blood supply is cut off, resulting in an ischemic bowel. Pain may be significant and fever may develop. 

Risk factors for volvulus include a birth defect known as intestinal malrotation, Hirschsprung disease, an enlarged colon, pregnancy, and abdominal adhesions. A high fiber diet and chronic constipation also increase the risk. In adults, the sigmoid colon and cecum are most affected.  In children, the small intestine and stomach are more commonly involved. Diagnosis is typically made with medical imaging such as plain X-rays, CT scan, or a GI series.  [1]

Initial treatment for sigmoid volvulus maybe with sigmoidoscopy or a barium enema. Due to the high risk of recurrence, a bowel resection within two days is generally recommended. If the bowel is severely twisted or the blood supply is cut off, emergent surgery is required. In a cecal volvulus, part of the bowel is usually removed. If the cecum is still healthy, it may be returned and sutured in place. However, conservative treatment in both cases is associated with high rates of recurrence.

Etiology

Volvulus is associated with intestinal malrotation, an enlarged colon, a long mesentery, Hirschsprung disease, pregnancy, abdominal adhesions, and chronic constipation. In adults, the sigmoid colon is most affected, with the cecum being second most affected. In children, the small intestine is more commonly involved.  [2]

Sigmoid volvulus is more common in individuals with neuropsychiatric disorders, multiple sclerosis, and Parkinson disease. Neuroleptic drugs can also interfere with colonic motility and may trigger volvulus. Nursing home patients who are bedridden and have chronic constipation can also experience sigmoid volvulus. In developing countries, consumption of high fiber diets leads to overloading of the sigmoid colon,  causing it to twist around the mesentery. Similarly, Chagas disease or megacolon can also predispose to sigmoid volvulus. In most cases, sigmoid volvulus is an acquired disorder. Cecal volvulus, on the other hand, may occur due to incomplete dorsal mesenteric fixation of the right colon or cecum or an elongated mesentery.

Rarely, appendicitis or surgery may lead to excessive adhesions leading to volvulus

Epidemiology

Sigmoid and cecal volvulus most often occurs between the ages of 30 and 70.

  • Volvulus occurs more frequently in middle-aged and elderly men.
  • Volvulus arises as a rare complication in patients with a redundant colon, a normal anatomic variation resulting in extra-colonic loops.
  • Sigmoid volvulus is a very common form of volvulus and is responsible for 8% of all intestinal obstructions. Sigmoid volvulus is particularly common in constipated and elderly persons. Patients experience pain, distension, and constipation.
  • Cecal volvulus is less common than sigmoid volvulus and is associated with pain and small bowel obstruction.
  • Midgut volvulus typically occurs in babies that are predisposed because of congenital intestinal malrotation. 
  • Segmental volvulus occurs in people of any age, usually with a predisposition because of abnormal intestinal contents or adhesions. 
  • Volvulus of the cecum, transverse colon, or sigmoid colon usually occurs in adults with minor predisposing factors such as redundant intestinal tissue and constipation.

Cases of volvulus were first described in ancient Egypt in 1550 BC. It occurs commonly in Africa, the Middle East, and India, presumably because of a high-fiber diet. Rates of volvulus in the United States are about 2 to 3 per 100,000 people per year. Outcomes are related to whether bowel tissue is ischemic or necrotic. The term volvulus is Latin for "volvere," which means "to roll."  [3]

Pathophysiology

Volvulus is typically caused by two mechanisms: chronic constipation and a high-fiber diet

In both instances, the sigmoid colon becomes dilated and heavy making it susceptible to torsion. With repeated attacks of torsion, the mesentery shortens. The chronic inflammation leads to the formation of adhesions which then entrap the sigmoid colon into fixed twisted position.

In cecal volvulus, the predominant symptom is small bowel obstruction (nausea, vomiting, and lack of flatus), because the obstructing point is close to the ileocecal valve and small intestine. Cecal volvulus may be organoaxial (cecocolic or true cecal volvulus) or mesentericoaxial (cecal bascule). In the former cases, the ascending colon and distal ileum twist around each other. However, unlike sigmoid volvulus where the torsion is counterclockwise, in cecal volvulus the torsion is clockwise. With cecal bascule, there are malfixed folds of cecum located anteriorly over the ascending colon at a right angle to the mesentery. since no torsion of the ileocolic mesentery occurs, vascular compromise of the cecum is rare. However, vascular compromise can occur if the cecum is severely distended and unable to return to its normal anatomic position.

In sigmoid volvulus, although pain may be present, constipation may be more prominent.  [4]

Volvulus causes severe pain with an accumulation of gas and fluid in the portion of the bowel obstructed resulting in necrosis of the affected intestinal wall, acidosis, and death. This is known as a closed-loop obstruction. Acute volvulus requires immediate surgical intervention to untwist the affected segment of bowel.

Volvulus may occur in patients with Duchenne muscular dystrophy due to smooth muscle dysfunction.

History and Physical

Patients with volvulus are usually debilitated and bedridden. Many of these individuals have a history of neuropsychiatry dysfunction, and thus, a medical history is usually unavailable.

Signs and symptoms of volvulus include pain, bloating, vomiting, constipation, bloody stool, fever, and significant pain when the abdomen is palpated. Depending on the duration of the condition, there may be signs of peritonitis and bleeding per rectum. The severe abdominal distension can also compromise respiration in some patients.  [5]

In the presence of severe abdominal distension, patients often develop hemodynamic instability and respiratory compromise.

Evaluation

Diagnosis usually is made by taking a thorough history and performing a physical examination; it is confirmed by radiographic studies. The diagnosis of colonic volvulus usually is included in the differential diagnosis which also includes bowel obstruction, mesenteric ischemia, and malignancy. 

Abdominal plain x-rays may be confirmatory for a volvulus, especially if a "bent inner tube" or a "coffee bean" sign are seen. These refer to the appearance of the air-filled closed loop of the colon which forms the volvulus. A barium enema is used to demonstrate a "bird's beak" at the point where the segment of the proximal bowel and distal bowel rotate to form the obstructing volvulus. This area will show an acute and sharp tapering that has the appearance of a bird's beak. If a perforation is suspected, barium should be avoided due to its potentially lethal effects when distributed throughout the free intraperitoneal cavity. Gastrografin, which is safer, can be substituted for barium.

In approximately 80% of colonic obstructions, a carcinoma invading the wall of the intestine is found to be the cause of the obstruction. This is usually easily diagnosed with CT scan and endoscopic biopsies. [6]

Blood work may reveal an elevated WBC with a leftward shift. Bowel obstruction may also lead to prerenal failure and alteration in electrolyte levels.

Treatment / Management

Initial treatment for sigmoid volvulus is sigmoidoscopy or insertion of a tube in the rectum to decompress the colon. Due to a high recurrence rate, a bowel resection within two days is recommended. In a cecal volvulus, part of the bowel often needs to be removed. Overall, the treatment depends on the acuteness of the condition.

Treatment for sigmoid volvulus includes sigmoidoscopy. If the mucosa of the sigmoid looks normal, place a rectal tube for decompression, correct electrolytes, ensure adequate fluids, and optimize cardiac, renal and pulmonary abnormalities. The patient should then be taken for surgical repair. If surgery is not performed, there is a high rate of recurrence of volvulus and obstruction. For patients with signs of sepsis or an acute abdominal catastrophe, immediate surgery and resection are advised.Bowel resection is recommended over conservative surgery (sigmoidopexy or mesentric plication). If the abdomen is not contaminated, a primary resection can be done. If there is bowel perforation, then a hartman procedure is performed.

Over the years many surgical techniques have been developed to treat cecal and sigmoid volvulus. In general, conservative procedures where the bowel is adhered with sutures are often associated with higher recurrence rates compared to procedures that involve resection of the bowel. Whether to do the surgery via an open or laparoscopic method depends on surgeon preference and experience. Elderly patients may benefit from minimally invasive procedures.  [7]

In a cecal volvulus, the cecum may be returned to a normal position and then sutured in place via a procedure known as cecopexy. If the bowel is obviously necrotic, then resection with an ileostomy or a colostomy is necessary. Endoscopic decompression for cecal voluvlus has low success rates and is also associated with high recurrence rates. The ideal procedure for cecal volvulus right hemicolectomy.

In all cases, patients need to be resuscitated prior to surgery. Broad spectrum antibiotics should be administered and a foley catheter should be inserted to measure the urine output. Because the volvulus can compromise venous return, patients should be placed in the left lateral position.

Prognosis

Any delay in diagnosis of cecal or sigmoid volvulus can be associated with high morbidity and mortality. Mortality rates appear to be much higher for cecal volvulus compared to sigmoid volvulus. When volvulus is treated non-surgically rates of recurrence are very high approaching 40-60%. When surgery is done in unstable patients, mortality rates of 12-25% have been reported.

Complications

Most complications are related to surgery and include the following:

  • Anastomotic leak
  • Wound infection
  • Abscess- abdominal or pelvic
  • Sepsis
  • Colocutaneous fistula

Pearls and Other Issues

Complications of volvulus include gangrene, strangulation, perforation fecal peritonitis, and recurrent volvulus.

Prognosis

Delay in diagnosis and treatment of volvulus is associated with a high morbidity and mortality. The mortality is 30% to 40% in patients in whom treatment of cecal volvulus is delayed. [8]

The recommended interval between endoscopic decompression and surgical intervention is 48 to 72 hours. This allows time for investigation, resuscitation, and intervention to reduce surgical risk.

  • Even when volvulus is successfully treated with endoscopic decompression and surgical resection, mortality is still 12% to 15%. 
  • 50% of patients who undergo endoscopic decompression alone experience recurrence. 
  • Endoscopic decompression alone for sigmoid volvulus carries a recurrence rate of 40% to 50% and a mortality of 25% to 30% after surgical treatment of the recurrence.

Enhancing Healthcare Team Outcomes

Patients with volvulus often present to the emergency department. While the diagnosis is not difficult, the management is not always straight forward. Thus it is important to involve an interprofessional team that includes the emergency department physician, nurse practitioner, general surgeon, gastroenterologist, and the internist. It is vital to involve the radiologist early so that a diagnosis can be made ASAP. Clinicians should immediately consult with a surgeon when volvulus has been diagnosed. While the patient is being prepared for surgery, aggressive resuscitation is necessary. Monitoring of the patient is vital both before and after surgery.

Sigmoid volvulus is initially treated with decompression but because of high recurrence rates, surgery is recommended. Cecal volvulus is usually treated with surgery. 

Over the years many surgical techniques have been developed to treat cecal and sigmoid volvulus. In general, conservative procedures where the bowel has adhered with sutures are often associated with higher recurrence rates compared to procedures that involve resection of the bowel. Whether to do the surgery via an open or laparoscopic method depends on surgeon preference and experience. Elderly patients may benefit from minimally invasive procedures.  [7] 

In the postoperative period, nurses should provide prophylaxis against DVT, pressure ulcers and gastritis. Open communication between the team is vital in order to achieve good outcomes.



  • Contributed by Scott Dulebohn, MD
    (Move Mouse on Image to Enlarge)
    • Image 1679 Not availableImage 1679 Not available
      Contributed by Scott Dulebohn, MD

  • image courtesy O.Chaigasame
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      image courtesy O.Chaigasame

References

[1] Yasui Y,Shironomae T,Kuwahara T, Target and whirl signs: volvulus of intussuscepted colon in an infant. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association. 2019 Jan 30;     [PubMed PMID: 30710705]
[2] DUTRA RM, [Upon a case of megacolon (syndrome of Hirshprung)]. Hospital (Rio de Janeiro, Brazil). 1948 Oct;     [PubMed PMID: 18890431]
[3] Tam A,Phong J,Yong C, Primary small bowel volvulus: surgical treatment dilemma. ANZ journal of surgery. 2018 Dec 18;     [PubMed PMID: 30562836]
[4] Hancerliogullari O,Senocak R,Kaymak S,Lapsekili E,Sinan H, An uncommon cause of acute abdomen in an acromegalic patient: colonic volvulus. Annali italiani di chirurgia. 2018;     [PubMed PMID: 30665214]
[5] Atamanalp SS, Comments on Contemporary Management of Sigmoid Volvulus. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2018 Nov 21;     [PubMed PMID: 30465185]
[6] Bailey KS,Lundstrom E,Borgstrom D, Cecal Volvulus: An Evolving Disease. The American surgeon. 2018 Sep 1;     [PubMed PMID: 30454520]
[7] Carmo L,Amaral M,Trindade E,Henriques-Coelho T,Pinho-Sousa J, Sigmoid Volvulus in Children: Diagnosis and Therapeutic Challenge. GE Portuguese journal of gastroenterology. 2018 Sep;     [PubMed PMID: 30320166]
[8] Korkut E,Aksungur N, Comments on a new classification, treatment algorithm and prognosis-estimating system for sigmoid volvulus: factors affecting recurrence. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland. 2018 Sep;     [PubMed PMID: 29904994]