Edit concept Create issue ticket

Volvulus

Intestinal Volvulus

Volvulus is defined as a torsion of a portion of the gastrointestinal tract. The disorder is characterized by twisting of intestine that obstructs the blood supply. Such a type of condition can gradually lead to tissue death.


Presentation

Infants, who have developed volvulus due to intestinal malrotation, suffer from signs and symptoms similar to those of bowel obstruction. Symptoms tend to get so severe, that the infant needs immediate hospitalization. Affected infants present with the following signs and symptoms:

  • Nausea accompanied by vomiting
  • Constipation
  • Passing blood or dark colored stools
  • Vomiting up green colored bile like material
  • Tenderness in the abdominal region
  • Abdominal distention
  • Shock 

In addition, affected individuals would also complain of recurrent attacks of abdominal pain accompanied by several vomiting bouts which tend to cease without treatment. Such symptoms are characteristic of condition known as intermittent volvulus; wherein the bowel suddenly twists giving rise to unpleasant symptoms and untwists by itself [7].

Respiratory Insufficiency
  • The patient was admitted to the hospital with enormous abdominal distension and acute respiratory insufficiency. A boy was emergently taken to the operating room for exploratory laparotomy.[ncbi.nlm.nih.gov]
Cerebral Palsy
  • We presented transverse colon volvulus in a 16-year-old boy with cerebral palsy. Chronic constipation in neurologicaly impaired patient was a risk factor predisposing to volvulus.[ncbi.nlm.nih.gov]
  • palsy N/A Resection with primary anastomosis 13 Jornet 2003 12 M distension nil 180 Detorsion 14 Liolios 2003 10 F vomiting constipation distension trisomy 13, mental retardation, chronic constipation 360 clockwise Detorsion.[wjes.biomedcentral.com]
Vomiting
  • These include, nausea accompanied by vomiting, pain in the abdomen, abdominal distention, passing dark colored or blood in stool, constipation and recurrent bouts of vomiting.[symptoma.com]
  • -Bilious vomiting -infant age -dark blood in diaper -abdominal distension - Pre-term Baby - Intramural Air - Distended Abdomne - ( ) Blood in stool -age 6 to 12 months -male gender -abdominal pain -vomiting -lethargy/irritability -blood per rectum/ currant[fprmed.com]
  • Gastrointestinal symptoms described in this syndrome include difficulties in feeding, regurgitation and vomiting which may lead to aspiration pneumonia, abdominal pain, distention, and constipation.[ncbi.nlm.nih.gov]
  • A 55-year female presented in surgical emergency with 3 days history of abdominal pain, distension and absolute constipation; and 2 days history of vomiting. Her past surgical history was significant for hysterectomy 5 years back.[ncbi.nlm.nih.gov]
  • It can transform into acute volvulus with specific symptoms including severe epigastric pain and vomiting.[karger.com]
Abdominal Pain
  • Volvulus caused by mesenteric masses is a rare but potentially life-threatening cause of abdominal pain, which should be considered in the differential diagnosis of paediatric acute abdominal pain.[ncbi.nlm.nih.gov]
  • In the presence of an elongated splenic pedicle, torsion of the spleen or neighboring organs may occur, which results in acute or chronic abdominal pain.[ncbi.nlm.nih.gov]
  • Patients experience abdominal pain, distension, and absolute constipation. Cecal volvulus is slightly less common than sigmoid volvulus and is associated with symptoms of abdominal pain and small bowel obstruction.[en.wikipedia.org]
  • Gastrointestinal symptoms described in this syndrome include difficulties in feeding, regurgitation and vomiting which may lead to aspiration pneumonia, abdominal pain, distention, and constipation.[ncbi.nlm.nih.gov]
  • The abdominal pain persisted and progressed in severity even after the administration of analgesic drugs.[nejm.org]
Abdominal Tenderness
  • Physical examination revealed central abdominal tenderness but no clinical features of peritonism.[ncbi.nlm.nih.gov]
  • The physical examination revealed hypoactive bowel sounds and diffuse abdominal tenderness with rebound; there was no fever, abdominal rigidity, or guarding.[nejm.org]
  • This may be due to a condition known as ‘intermittent volvulus,’ which occurs when the bowel just happens to twist, then untwist on its own. [2] Symptoms which may indicate bowel obstruction due to volvulus include: Abdominal tenderness Nausea or vomiting[iffgd.org]
  • Physical examination may show mild right sided abdominal tenderness or no abnormalities.[pmj.bmj.com]
Abdominal Bloating
  • Volvulus Coronal CT of the abdomen, demonstrating a volvulus as indicated by twisting of the bowel stock Specialty General surgery Symptoms Abdominal pain , abdominal bloating , vomiting, constipation , bloody stool [1] [2] Complications Ischemic bowel[en.wikipedia.org]
  • Symptoms are that of a large bowel obstruction: constipation, abdominal bloating, nausea and/or vomiting. Onset may be acute or chronic.[radiopaedia.org]
  • These patients often have abdominal bloating, constipation, and nausea that may or may not be accompanied by vomiting. SV is thought to be associated with neurological pathologies such as multiple sclerosis and Parkinson’s disease.[news-medical.net]
Pelvic Mass
  • Individuals with a gravid uterus or those with huge pelvic mass are also susceptible to develop volvulus. Repeated attacks of torsion cause the base of sigmoid colon to become shortened. The loop becomes inflamed and forms paddle-like configuration.[symptoma.com]
  • mass, violent coughing, atonia of the colon, extreme exertion, unpressurised air travel, or third-trimester pregnancy.[radiopaedia.org]
  • The presence of a gravid uterus or a large pelvic mass alters the relative positions of the intra-abdominal organs, also predisposing to formation of volvulus.[emedicine.medscape.com]
  • A pelvic mass may displace the sigmoid colon sufficient to cause it to twist. This explains the association of sigmoid volvulus with pregnancy and massive ovarian tumors.[lapsurgery.com]
Thrombosis
  • Manifestations can range from lymphatic and venous congestion with simple edema to full intestinal necrosis secondary to arterial and venous thrombosis.[theexpertinstitute.com]
Oliguria
  • Rapid-onset and bilious vomiting, leading to metabolic acidosis, lactataemia, oliguria, hypotension and shock with advancing ischaemia. [ 8 ] Careful examination may reveal a palpable abdominal mass in some patients.[patient.info]
  • Shock and oliguria are serious signs that indicate either late simple obstruction or strangulation. Obstruction of the large bowel usually causes milder symptoms that develop more gradually than those caused by small-bowel obstruction.[merckmanuals.com]
  • Abnormal hemorrhage, hyperbilirubinemia and oliguria are late findings.[aafp.org]

Workup

Several tests are employed for diagnosing the condition of volvulus. At preliminary level, preliminary physical examination is carried out after obtaining a careful medical profile of the patient. Thereafter, stool tests are done to determine presence of blood in it. Abdominal X-rays help in confirming the condition of volvulus, especially when they show signs of coffee bean shape of the air filled loop of the colon [8]. If this does not help in arriving at appropriate diagnosis, then barium enema tests would be carried out. Following this, imaging studies such as CT scan of the abdomen would be required which would show signs of intestinal volvulus [9].

Suppression
  • Entomological measures of transmission are important metrics specified by the World Health Organization to document the suppression and interruption of transmission of Onchocerca volvulus, the causative agent of onchocerciasis.[ncbi.nlm.nih.gov]

Treatment

Under emergency situation, surgical procedures would be required to correct the twisted volvulus. In such procedures, the bowels are corrected and the blood supply re-established. When there are signs of necrosis, the dead tissue is removed and the ends are joined back. In other cases, colostomy or ilesostomy is done, so that the intestinal contents can be removed through the tube [10].

Prognosis

Outcome of patients with volvulus is good if the condition is diagnosed on time and prompt treatment initiated. In cases, when the bowel undergoes necrosis the outcome is poor. This is a potentially life threatening condition, which can further call for secondary complications to set in.

Etiology

Volvulus that strikes the children or infants usually occurs due to birth defect called congenital intestinal malrotation. In such conditions volvulus occurs during the early years of life. However, there are instances, when the condition can occur even without a malrotation. Other causative factors include adhesions, abnormal intestinal contents can also favor the development of segmental volvulus [2]. Types of volvulus other than segmental volvulus commonly strike the adult population and majorly occur due to constipation and or surplus intestinal tissue [3].

Epidemiology

The incidence of malrotation occurs in about 1 in 200 or 1 in 500 live births. Majority of the cases of malroration seldom produce any symptoms and therefore goes unreported. Based on this, the true incidence of the condition is still not known. Symptomatic malrotation is known to occur in 1 in 6000 live births [4]. Colonic volvulus is one of the major causes of large bowel obstruction after diverticulitis and cancer; this is based on the figures available from the US government. Males and females are affected in equal numbers, and the disease strikes the adult population in the eighth decade [5].

Sex distribution
Age distribution

Pathophysiology

Chronic constipation as well as excessively high fibrous diet can exert undue pressure on the sigmoid colon, making it susceptible to torsion. Individuals with a gravid uterus or those with huge pelvic mass are also susceptible to develop volvulus. Repeated attacks of torsion cause the base of sigmoid colon to become shortened. The loop becomes inflamed and forms paddle-like configuration.

Intestinal malrotation is a birth defect, which occurs during fetal development. Three stages make up for the development of bowel during fetal growth period. Factors that interfere with normal rotation of the gut during embryonic development cause volvulus to set in. This in turn is associated with abnormalities concerning the gastrointestinal system, which paves way for development of defects of abdominal wall or condition of congenital diaphragmatic hernia [6].

Prevention

The onset of volvulus cannot be prevented; more so if it occurs due to congenital defect. The progression of the disease can be prevented by prompt diagnosis and immediate initiation of treatment.

Summary

Volvulus primarily occurs due to birth defect known as congenital intestinal malrotation. Malrotation develops when the bowel does not get aligned properly during fetal growth. In such instances the bowel no longer is attached to the abdominal wall, which further causes it to shift from its original position and twist. Volulus can also occur in absence of underlying birth defect. There are several types of volvulus such as sigmoid volvulus, cecal volvulus, gastric volvulus, volvulus neonatorum and volvulus of the small intestine. One of the rare types of volvulus is the volvulus of splenic flexure [1].

Patient Information

  • Definition: Volvulus is a condition, characterized by development of twist in the intestine which gradually obstructs the blood flow causing necrosis of the affected part. In such a condition there is axial rotation of a part of the bowel. There are several types of volvulus which are categorized based on underlying etiology.
  • Cause: Congenital defect that causes intestinal malrotation is the major cause of volvulus. However, there are other factors that can favor development of volvulus without the presence of malrotation.
  • Symptoms: Infants with volvulus would experience signs and symptoms similar to bowel obstruction. These include, nausea accompanied by vomiting, pain in the abdomen, abdominal distention, passing dark colored or blood in stool, constipation and recurrent bouts of vomiting.
  • Diagnosis: Preliminary physical examination followed by stool test is done to evaluate the presence of blood in stools. Imaging studies such as CT scan of the abdomen would provide more useful insights about the condition. In addition, barium enema test is also indicated. In many instances, X-ray of the abdomen would be enough to arrive at a definite diagnosis. When the findings are inconclusive, then other tests are required.
  • Treatment: Presence of severe signs and symptoms would indicate immediate hospitalization in order to prevent secondary complications to set in. Such a kind of situation would indicate immediate surgical procedures to correct the twisted intestine. The part of the intestine that has undergone necrosis would also be removed and the healthy ends joined back. Procedures such as ileostomy or colostomy may be performed depending on the condition.

References

Article

  1. Dott NM. Anomalies of intestinal rotation: their embryology and surgical aspects: with report of 5 cases. Br J Surg. 1923;24:251-286.
  2. Drapanas T, Stewart JD. Acute sigmoid volvulus. Concepts in surgical treatment. Am J Surg. Jan 1961;101:70-7
  3. Berseth CL. Disorders of the intestines and pancreas. In: Taeusch WH, Ballard RA, eds. Avery's Diseases of the Newborn. 7th ed. Philadelphia: WB Saunders; 1998:918.
  4. Warner B. Malrotation. In: Oldham KT, Colombani PM, Foglia RP, eds. Surgery of Infants and Children: Scientific Principles and Practice. Philadelphia: Lippincott Williams & Wilkins; 1997:1229.
  5. Halabi WJ, Jafari MD, Kang CY, Nguyen VQ, Carmichael JC, Mills S, et al. Colonic volvulus in the United States: trends, outcomes, and predictors of mortality. Ann Surg. Feb 2014;259(2):293-301.
  6. Stewart DR, Colodny AL, Daggett WC. Malrotation of the bowel in infants and children: a 15 year review. Surgery 1976; 79:716.
  7. Kullendorff CM, Mikaelsson C, Ivancev K. Malrotation in children with symptoms of gastrointestinal allergy and psychosomatic abdominal pain. Acta Paediatr Scand 1985; 74:296.
  8. Long FR, Kramer SS, Markowitz RI, Taylor GE. Radiographic patterns of intestinal malrotation in children. Radiographics 1996; 16:547.
  9. Taylor GA. CT appearance of the duodenum and mesenteric vessels in children with normal and abnormal bowel rotation. Pediatr Radiol 2011; 41:1378.
  10. El-Gohary Y, Alagtal M, Gillick J. Long-term complications following operative intervention for intestinal malrotation: a 10-year review. Pediatr Surg Int. Feb 2010;26(2):203-6.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2017-08-09 18:11