Colonic - PowerPoint Presentation

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; 146:52–60Slide10
Slide11

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

.Slide12
Slide13
Slide14
Slide15

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

volvulusSlide23
Slide24
Slide25

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

Thank you