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Volvulus

A twisting of the intestine at least 180 degrees on its mesentery, volvulus results in blood vessel compression and ischemia.

Causes

In volvulus, twisting may result from an anomaly of rotation, an ingested foreign body, or an adhesion; in some cases, however, the cause is unknown. Adhesions are common causes of volvulus in pregnant women. Chronic constipation is thought to be a cause in elderly people.

Volvulus usually occurs in a bowel segment with a mesentery long enough to twist. The most common area, particularly in adults, is the sigmoid; the small bowel is a common site in children. Other common sites include the stomach and cecum. Volvulus secondary to meconium ileus may occur in patients with cystic fibrosis.

Signs and symptoms

Signs and symptoms of colonic obstruction include nausea, vomiting, cramps, abdominal pain, absence of bowel movements, and failure to pass flatus. Without the appropriate intervention, volvulus can lead to strangulation, ischemia, perforation and, finally, peritonitis.

Diagnosis

• A stool guaiac is positive for blood in the stool.
• An upper GI x-ray with small bowel follow-through shows a malrotated bowel or midgut volvulus.
• A CT scan may show evidence of intestinal obstruction.
• A barium enema often shows an abnormal position of the bowel, suggesting malrotation.
• Blood tests to check the electrolytes may show abnormalities.

Treatment

Therapy varies according to the severity and location of the volvulus. For children with midgut volvulus, treatment is surgical. For adults with sigmoid volvulus, a flexible sigmoidoscopy examination is performed to check for infarction, and nonsurgical treatment includes reduction by careful insertion of a sigmoidoscope or a long rectal tube to deflate the bowel.

Success of nonsurgical reduction results in expulsion of flatus and immediate relief of abdominal pain. If the bowel is distended but viable, surgery consists of detorsion (untwisting); a necrotic bowel warrants exploratory laparostomy and resection.