Volvulus

Question 1

What is a volvulus?

Answer 1

• Twisting of a loop of bowel
• Around its mesenteric attachment

Question 2

Why is a volvulus bad?

Answer 2

• Surgical emergency
• Closed loop bowel obstruction forms within affected segment
• Compromise of blood supply due to twisting
• Rapidly leads to bowel necrosis and perforation

Question 3

Where do most volvulus occur and why?

Answer 3

• Sigmoid colon due to its long mesentery
• = prone to twist
• Other sites inc stomach, caecum, small intestine and transverse colon

Question 4

RF for volvulus

Answer 4

• Advanced age
• Neurological disorders eg Parkinsons or vascular dementia
• Psychiatric disease - on antipsychotics esp
• Reduced mobility
• Male

Question 5

Why are all these risk factors increasing the risk?

Answer 5

• Increase chance of chronic constipation and slow transit time
• = redundant sigmoid colon (longer than space to fit)
• = prone to twist

Question 6

Symptoms of sigmoid volvulus

Answer 6

• Abdominal distension
• Absolute constipation
• Varying degrees of abdominal pain
• Then vomitting secondary to obstruction later

Question 7

Compared to other causes of bowel obstruction, how do symptoms differ?

Answer 7

• Rapid onset - over a few hours
• Degree of abdominal distension - very

Question 8

Examination of volvulus

Answer 8

• Distended abdomen
• Tympanic to percussion
• Localised tenderness
• Peritonism = ?bowel ischaemia developing

Question 9

Sigmoid volvulus x-ray

Answer 9

Often done first line even though less sensitive than CT

Coffee bean sign

Question 10

Management of all patients with volvulus

Answer 10

• IV fluids - resuscitation
• NG tibe esp if vomitting
• Urinary cathter for fluid balance
• Analgesia
• Correct electrolytes

Question 11

Bedside and bloods for ?volvulus

Answer 11

• FBC
• U&E
• CRP
• Clotting screen
• VBG - pH and lactate - bowel ischaemia?

Question 12

Imaging for volvulus sigmoid

Answer 12

• CT abdomen pelvis + IV contrast
• = very dilated sigmoid colon with whirl sign
• Also allows to check for bowel ischaemia, if ileocaecal valve is incompetent = signs of SBO

Question 13

Conservative management sigmoid volvulus

Answer 13

• Decompression via sigmoidoscope and insertion of flatus tube

Question 14

How is sigmoidoscope decompression done?

Answer 14

• Patient placed in left lateral position
• Lubricated sigmoidoscope into rectum - often need to use flexible one instead of rigid as difficult
• Manoeuvered to locate the twisted bowel
• Gentle pressure to untwist the volvulus
• When in correct position - rush of air and liquid faeces as obstruction is relieved

Question 15

What is the flatus tube for?

Answer 15

• Left in situ for up to 24hrs after initial decompression
• Allows for continued passage of contents and aid recovery of affected area

Question 16

When is surgery for volvulus needed?

Answer 16

• Evidence of bowel ischaemia
• Perforation
• Repeated failed endoscopic decompression

Question 17

Surgery for sigmoid volvulus

Answer 17

• Sigmoid colectomy - often as Hartmanns procedure via laparotomy
• Primary anastomosis not advised as co-morbid and frail

Question 18

What happens if patients get recurrent volvulus?

Answer 18

• May choose to have elective surgery
• Sigmoid colectomy with primary anastomosis or end colostomy
• Balance risk of recurrence with risk of surgery

Question 19

Complications of volvulus

Answer 19

• Bowel ischaemia
• Bowel perforation

Question 20

Ages that caecal volvulus affects

Answer 20

• Bimodal
• 10-29 - may have intestinal malformation or sometimes excessive exercise
• 60-79

Question 21

Managament caecal volvulus

Answer 21

• Right hemicolectomy

Question 22

Imaging for caecal volvulus

Answer 22

• CT abdomen pelvis
• Distended caecum, mesenteric whirl and SBO