Volvulus Thamer A Bin Traiki Definition Volvulus refers to a torsion or twist of an organ on a pedicle In colonic volvulus The bowel becomes twisted on its mesenteric axis with partial or complete obstruction amp a variable degree of impairment of its blood supply ID: 242468
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Slide1
Colonic Volvulus
Thamer
A. Bin
TraikiSlide2
Definition
Volvulus
refers to a torsion or twist of an organ on a pedicle
.
In colonic
volvulus
:
The bowel becomes twisted on its mesenteric axis with partial or complete obstruction & a variable degree of impairment of its blood supply .Slide3
Cont…
Could happen in any portion of large bowel
if that segment is attached to a long & floppy mesentery that fixed to the
retroperitonium
by narrow base .
The sigmoid colon is involved in up to 90% of cases,
T
he
cecum
<
20
%(
this involving
Rt
colon & TI
Cecal
volvulus
or
cecum
alone in highly mobile
cecum
called
cecal
bascule
)
Transverse
colon.Slide4
Incidence
Geographical variation .
In an unusual
report from the high-altitude area of the
Bolivian and
Peruvian Andes at 13,000 feet above sea level,
sigmoid
volvulus
accounted for 79% of all intestinal obstruction.
The reason is not clear but may be related to the
increased gas
volume in the bowel because of high
altitude .Slide5
Sigmoid VolvulusSlide6
Risk Factors
Chronic constipation
may produce a large, redundant colon (
chronic
megacolon
)
Aging
average age at presentation being in 7
th
to 8
th
decade
Neuropsychiatric
condition treated with psychotropic drugs
High fiber & vegetableSlide7
Clinically
A
volvulus
may reduce spontaneously, but more commonly produces bowel
obstruction (
Acute
or
subacut
)
,
which can progress to strangulation, gangrene, and perforation
.
The abdomen is markedly distended & tympanic which often more dramatic than in other causes of intestinal obstruction .
In case of previous attack resolved spontaneously there will be marked distention with minimal tenderness .Slide8
Clinical presentation
2 presentations :
‘‘
Acute Fulminating
type
’’
Patient
is
generally younger , onset is
sudden
, course
is rapid
.
Generally
, there is little history of
previous episodes
,
Symptoms
include early vomiting,
diffuse abdominal
pain and tenderness, marked prostration,
and the
early appearance of gangrene
.
Distention
may be
minimal,
In
its
classic form
the acute fulminating variety of sigmoid
volvulus
produces
no distinctive diagnostic signs except for
the clinical
picture of an acute abdominal catastrophe
;
The actual diagnosis
is made at
celiotomy
.
Ann
Surg
1957;
146:52–60Slide9
Subacute
Progressive Type
,
The
more common presentation.
The
patient is
generally older
,
onset
more gradual, and the early course
more benign
.
There
is often a history of previous attacks
and chronic
constipation.
Vomiting
occurs late, pain is minimal,
Signs
of peritonitis are usually not present
.
Abdominal distention
is generally extreme in this form
,
Radiographic findings
are usually diagnostic
.
Ann
Surg
1957; 146:52–60Slide10Slide11
Radiographic Finding
characteristic
bent inner tube
or
coffee bean
appearance, with the convexity of the loop lying in the right upper quadrant (opposite the site of obstruction).
CT scan reveals characteristic mesenteric whirl sign .
Gastrografin
enema shows a narrowing at the site of the
volvulus
and a
pathognomonic
bird's beak
.Slide12Slide13Slide14Slide15
Treatment
Resuscitation
Nonoperative
Treatment
Operative TreatmentSlide16
Nonoperative Treatment
Depends
on whether the surgeon believes that the bowel is viable or
nonviable .
Attempt
at reduction should be made by means of
proctosigmoidoscopy
and insertion of a rectal tube
.
If
the
volvulus
can be reduced, an explosive discharge of gas and feces will occur.
The
rectal tube should be left in place, either taped or, ideally, sutured to the buttock for about 48 hours to avoid the possibility of immediate recurrence.Slide17
Proctosigmoidoscopic
examination should be
undertaken even if the patient has signs and symptoms of nonviable bowel
to
confirm the extent of involvement and
to
establish the diagnosis with certainty.
???!!!
The
procedure should be
performed with
great care to avoid perforating the bowel. Slide18
Flexible sigmoidoscopy
and colonoscopy
It has
the advantage of
evaluating the
viability of a greater area of colonic
mucosa.
B
ut
the procedure must be performed with limited manipulation and limited air to minimize the risk of perforation of the distended and edematous
bowel.
Intraluminal
stenting
to prevent early recurrence can be accomplished through the use of flexible plastic tubing or a blunt-ended guide
wire .
An attempt at
colonoscopic
reduction may be considered if
proctosigmoidoscopic
manipulation has been unsuccessful.Slide19
Cont…
Outcomes :
More recent studies generally indicate that if the bowel is viable, one may anticipate successful reduction of the
volvulus
at least 90% of the time
.
The
risk of recurrence is high (40
%).
For
this reason, an elective sigmoid
colectomy
should be performed after the patient has been stabilized and undergone an adequate bowel preparation.Slide20
Operative treatment
The
presence of necrotic mucosa, ulceration, or dark blood noted on endoscopy examination suggests strangulation and is an indication for operation
.
If
dead bowel is present at
laparotomy
, a sigmoid
colectomy
with end colostomy (Hartmann procedure) may be the safest operation to perform.Slide21
Cecal volvulusSlide22
Cecal
volvulus
results from
nonfixation
of the right colon.
Rotation
occurs around the
ileocolic
blood vessels and vascular impairment occurs early
.
Plain
x-rays of the abdomen show a characteristic kidney-shaped, air-filled structure in the left upper quadrant (opposite the site of obstruction), and a
Gastrografin
enema confirms obstruction at the level of the
volvulusSlide23Slide24Slide25
Treatment
Unlike sigmoid
volvulus
,
cecal
volvulus
can almost never be
detorsed
endoscopically
.
Moreover
, because vascular compromise occurs early in the course of
cecal
volvulus
, surgical exploration is necessary when the diagnosis is made.
Right
hemicolectomy
with a primary
ileocolic
anastomosis
can usually be performed safely and prevents recurrence.
Simple
detorsion
or
detorsion
and
cecopexy
are associated with a high rate of recurrence.Slide26
Transverse colon volvulus Slide27
Extremely
rare
.
Nonfixation
of the colon and chronic constipation with
megacolon
may predispose to transverse colon
volvulus
.
The
radiographic appearance of transverse colon
volvulus
resembles sigmoid
volvulus
, but
Gastrografin
enema will reveal a more proximal obstruction.
Although
colonoscopic
detorsion
is occasionally successful in this setting, most patients require emergent exploration and resection.Slide28
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