Volvulus (GI)

Question 1

Define volvulus.

Answer 1

Twisting of a loop of bowel on its mesentery –> compromised blood flow and closed loop obstruction

Question 2

What is volvulus one of the most common causes of?

Answer 2

Intestinal obstruction

Question 3

What are the two most common sites of volvulus in adults?

Answer 3

• sigmoid volvulus (65-80%) - LBO by sigmoid colon twisting around sigmoid mesocolon
• caecal volvulus (20-30%) - developmental failure of peritoneal fixation of proximal bowel (in majority, caecum is retroperitoneal so not at risk of twisting)

Question 4

What are the risk factors for sigmoid volvulus? (5)

Answer 4

• older patients
• chronic constipation
• Chagas disease
• neurological conditions e.g. Parkinson’s
• psychiatric conditions e.g. schizophrenia

Question 5

What are the risk factors for caecal volvulus? (3)

Answer 5

• all ages (vs older patients in sigmoid volvulus)
• adhesions
• pregnancy

Question 6

How does volvulus present in neonates or infants?

Answer 6

Midgut volvulus secondary to intestinal malrotation

Question 7

What are some general clinical features of volvulus? (3)

Answer 7

• abdominal pain - steady, may have colicky characteristics, varies from vague discomfort –> excruciating
  
  • severe unremitting pain = gangrenous bowel
  • pain decreases after explosive passage of stool/gas
  • periumbilical/hypogastric pain
• slowly progressive symptoms of bowel obstruction - abdominal pain, distension, N&V (bilious), constipation/diarrhoea
• constipation

Question 8

What might you see on examination of volvulus? (8)

Answer 8

• diffuse abdominal distension and tenderness
• faint/no bowel sounds
• rigid abdomen
• guarding
• rebound tenderness (peritonitis)
• fever
• haematochezia (passing fresh blood through anus)
• tachycardia/hypotension in bowel ischaemia

Question 9

What are the signs of bowel ischaemia? (3)

Answer 9

• tachycardia
• hypotension
• rebound tenderness (peritonitis)

Question 10

What are signs of caecal volvulus?

Answer 10

Features of SBO and recurrent episodes of RLQ abdominal pain

Question 11

What are the features of gastric volvulus? (3)

Answer 11

• failure to pass NG tube
• epigastric pain
• vomiting

Question 12

What are the signs of midgut volvulus (secondary to intestinal malrotation) in infants? (5)

Answer 12

• bilious vomiting
• haematemesis
• haematochezia (fresh blood through anus)
• hypotension
• tachycardia

Question 13

What is the first-line investigation for volvulus?

Answer 13

Abdominal x-ray

Question 14

What scans can we do in volvulus? (3)

Answer 14

• abdominal XR - dilated bowel loops, abdominal free air with perforation
• CT scan - whirl sign
• barium enema - bird’s beak sign

Question 15

What do we see on abdominal XR in sigmoid volvulus? (3)

Answer 15

• large bowel obstruction (large, dilated loop of colon often with air-fluid levels)
• coffee-bean sign (two dilated loops with no haustration)
• LUQ–>RLQ

Question 16

What do we see on abdominal XR in caecal volvulus? (3)

Answer 16

• may see small bowel obstruction
• kidney bean/embryo sign (marked dilation of 1 loop with haustration)
• RLQ–>LUQ

Question 17

What sign might you see in CT in volvulus?

Answer 17

Whirl sign

Question 18

What sign might you see in barium enema in volvulus?

Answer 18

Bird’s beak sign

Question 19

What might ABG show in volvulus?

Answer 19

May be normal or metabolic acidosis, elevated lactate

Question 20

What are some differential diagnoses for volvulus? (4)

Answer 20

• other forms of LBO (especially carcinoma of sigmoid colon)
• pseudo-obstruction (reduced colonic motility and dilatation)
• giant sigmoid diverticulum
• severe constipation

Question 21

What initial management is needed for bowel obstruction (volvulus)? (3)

Answer 21

Initial resuscitation:

• IV fluids
• NBM
• placement of NGT

Question 22

How do we manage sigmoid volvulus?

Answer 22

• rigid sigmoidoscopy with rectal tube insertion (detorsion)
• surgery - if signs of peritonism or decompression not working:
  
  • sigmoid colectomy (haemodynamically stable patient with viable bowel)
  • Hartmann procedure (haemodynamically unstable patient/ischaemic bowel)

Question 23

How do we manage caecal volvulus?

Answer 23

Operative management - right hemicolectomy often needed

Question 24

How do we manage midgut volvulus secondary to intestinal malrotation (neonates/infants)?

Answer 24

Ladd procedure (emergency surgery)

Question 25

What are some complications of volvulus? (3)

Answer 25

- recurrence - bowel obstruction - perforation and faecal peritonitis