Colonic Volvulus: a New Twist on an Old Story

Introduction: in Hippocrates’ Affections, treatment of volvulus involved injecting air into colon through anus and inserting suppository 10 digits (22 cm)-long; variations on these treatments still in use today Colonic volvulus: incidence — third most common cause of colonic obstruction worldwide; accounts for 2% to 4% of cases of colonic obstruction in United States but ≤50% of cases in “volvulus belt” (ie, Africa, Middle East, India, and Russia) Sigmoid volvulus: most common type; counterclockwise twist of redundant sigmoid colon; according to Treves (1884), volvulus occurs due to long loop, with long narrow mesocolon at its parietal attachment, which results in 2 ends of loop being in close proximity; chronic constipation most common cause; characteristics of typical patient — male, elderly, constipated, in nursing facility, taking psychotropic medication, with excessive fecal burden Cecal volvulus: second most common type, characterized by mesoaxial clockwise rotation or cecal bascule (large floppy long cecum that folds upon itself); incidence increasing but still less common than sigmoid volvulus; only small series of studies conducted (but no randomized controlled trials) because of low incidence; patient characteristics — often young, female (possibly during pregnancy), with previous history of surgery involving mobilization of right colon; may relate to developmental abnormality (eg, incomplete fixation of cecum to retroperitoneum) Transverse colon and splenic flexure: 2% to 4% of volvulus cases; typically occurs in young women; risk factors include pregnancy, chronic constipation, distal colonic obstruction, previous surgery, and lack of ligamentous fixation Ileosigmoid knotting: extremely rare; ie, “compound volvulus” or “double volvulus”; most common in Middle East, Asia, and Africa, and in men in 40 to 50 yr of age Case 1 (typical sigmoid volvulus): 84-yr-old man transferred from nursing facility with no bowel movement for 4 days and vomiting; had dementia, hypertension, and chronic constipation; taking several medications; osmotic laxative no longer providing benefit; had history of abdominal operations; on physical examination (PE), patient distended, tympanitic, and nontoxic, with no indication of masses; abdominal x-ray showed gas-filled abdomen and loop that extended into right upper quadrant (RUQ); hospital course involved colonoscopic detorsion of sigmoid volvulus, which resulted in passage of large quantity of stool and gas; patient then underwent placement of rectal tube, bowel preparation, and laparoscopically assisted sigmoidectomy plus end-to-end anastomosis Case 2 (typical cecal volvulus): 32-yr-old woman, with history of cerebral palsy, type 1 diabetes, chronic aspiration, and gastrostomy for venting and feeding, brought to emergency department for acute abdominal pain, distension, and vomiting; had dental procedure 2 days prior under general anesthesia, plus postoperative analgesia; on PE, abdomen distended, tympanitic, and tender in left upper quadrant (LUQ); white blood cell (WBC) count highly elevated; abdominal x-ray suspicious for pseudoobstruction; computed tomography (CT) suggested cecal volvulus, which prompted immediate surgery; ischemic cecum found in LUQ; cecum resected and anastomosis performed Diagnosing colonic volvulus: abdominal pain, constipation, and abdominal distension common to all volvuli; differential diagnosis — includes impaction, carcinoma, diverticulitis, and pseudoobstruction; rectal examination often helpful for distinguishing condition; imaging — plain radiographs often difficult to interpret (if volvulus present, ideally show “bent inner tube,” with convexity in RUQ in sigmoid cases, and in LUQ in cecal cases); CT usually performed, which may show “whirl sign” in left abdomen in sigmoid, and in right abdomen in cecal volvulus (location sometimes unclear) Treatment of sigmoid volvulus: operate emergently if patient has pneumoperitoneum, peritonitis, elevated WBC, and/or appears toxic; otherwise, if patient reasonable surgical candidate, perform endoscopic detorsion, bowel preparation, and urgent colectomy; colostomy and Hartmann pouch usually performed; anastomosis avoided in most emergency operations; if no signs of gangrene or perforation present, colonoscopy or sigmoidoscopy warranted to allow detorsion of bowel, bowel preparation, decompression of proximal colon, evaluation of colonic mucosa to rule out ischemia and necrosis, and insertion of rectal tube to prevent recurrence; detorsion successful in majority of patients, and allows semielective surgery for operative candidates, including laparoscopic colectomy or anastomosis; nonoperative management — associated with rates of recurrence of 25% to 90% (average 48%); poor surgical candidates may accept palliative care and high recurrence rate; endoscopically assisted placement of T-fasteners may function as sigmoidopexy for some high-risk patients Treatment of cecal volvulus: presentation varies widely; some associated with early vascular compromise that requires immediate resection, while other cases indolent, progressive, and intermittent (symptoms may resolve without treatment); diagnosis of latter type challenging (may be due to cecal bascule);