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A - MSRA Gastrointestinal [7] > [19] Volvulus > Flashcards

[19] Volvulus Flashcards

1
Q

What is a volvulus?

A

The twisting of a loop of intestine around its mesenteric attachment, resulting in a closed loop obstruction

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2
Q

What happens to the affected bowel in a volvulus?

A

It can often become ischaemic due to a compromised blood supply, rapidly leading to bowel necrosis and perforation

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3
Q

Where do most volvuli occur?

A

At the sigmoid colon

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4
Q

What is the importance of volvuli?

A

It is the leading cause of bowel obstruction in many developing countries, and is tUKhe third most common cause in the UK and USA

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5
Q

What are the most common causes of bowel obstruction in the UK?

A

Maligancy and diverticular disease

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6
Q

Where else can volvuli occur?

A

Stomach
Small intestine
Caecum
Transverse colon

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7
Q

Why is the sigmoid colon most likely to get a volvulus?

A

Because the long mesentery of the sigmoid colon means that this segment of bowel is prone to twisting on its mesenteric base to form a volvulus

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8
Q

What are the risk factors for developing a volvulus?

A 
Neuropsychiatric conditions
Resident in nursing home
Advanced age
Chronic constipation or laxative
Male gender
Previous abdominal surgeries
Diabetes mellitus
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9
Q

How will patients with a volvulus present?

A

With the clinical features of a bowel obstruction

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10
Q

How can the recurring nature of volvuli be relevant?

A

Means that the patient may have had a previous history of volvulus formation

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11
Q

What is the result of the distal location of the sigmoid colon on the presentation of a volvulus?

A

Vomiting is usually a late sign

Colicky pain, abdominal distention, and absolute constipation occur earlier

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12
Q

What will be found on examination in a volvulus?

A

The abdomen will be markedly distended, with increased bowel sounds and tympanic percussion

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13
Q

What should you be sure to examine for with a suspected volvulus?

A

Signs of perforation or generalised peritonism

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14
Q

Why is it important to examine for signs of perforation or generalised peritonism in a suspected volvulus?

A

As this is a surgical emergency

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15
Q

What are the main differential diagnoses to consider in a suspected volvulus?

A

Other causes of bowel obstruction, as well as severe constipation, pseudo-obstruction, and severe sigmoid diverticular disease

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16
Q

What investigations should be done in suspected volvulus?

A

Routine bloods

Imaging

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17
Q

What bloods should be checked in suspected volvulus?

A

Electrolytes
Calcium
TFTs

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18
Q

What is the purpose of checking TFTs in a suspected volvulus?

A

To exclude any pseudo-obstruction

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19
Q

What is the most decisive initial investigation for a suspected sigmoid volvulus?

A

An abdominal x-ray

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20
Q

What will be shown on abdominal x-ray in volvulus?

A

Will classically show a ‘coffee-bean sign’, arising from the left iliac fossa

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21
Q

What % of cases of volvulus have the coffee bean sign?

A

60-75% cases

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22
Q

What will be seen on a AXR in volvulus if the ileocaecal valve is incompetent?

A

There will be signs of small bowel dilation

23
Q

When might a CT scan be warranted in suspected volvulus?

A

If the diagnosis remains unclear, or clinical features suggest a potential bowel ischaemia developing

24
Q

What will CT imaging classically show with a volvulus?

A

A ‘whirl sign’ from the twisting mesentery around it’s base

25
Q

What can aid in any unclear diagnosis in suspected volvulus?

A

Barium enema

26
Q

How should all patients with suspected sigmoid volvulus be managed initially?

A

As per any bowel obstruction

27
Q

What is involved in the conservative management of a sigmoid volvulus?

A

Decompression with a sigmoidoscope, and insertion of a flatus tube

28
Q

How is a sigmoidoscope decompression performed?

A

The patient is placed in the left lateral position, and a lubricated sigmoidoscope is gently guided into the rectum. It is maneuvered to locate the twisted bowel, and once the sigmoidoscope is in the correct position, there will be a rush of air and liquid faeces as the obstruction is relieved

29
Q

How long is a flatus tube left in situ after initial decompression of a sigmoid volvulus?

A

Up to 24 hours

30
Q

What is the purpose of a flatus tube after a sigmoid volvulus>

A

It allows continued passage of contents, and aids in recovery of the affected area

31
Q

What % of sigmoidoscopic approaches may not be able to adequately locate the lead point for twisting?

A

24%

32
Q

What may result from a sigmoidoscopic approach not being able to locate the lead point for twisting?

A

Colonoscopic approach may be required

33
Q

What are the surgical options in the management of a sigmoid volvulus?

A

Either primary anastomosis or Hartmann’s procedure

34
Q

What are the indications for surgical management of a sigmoid volvulus?

A

Repeated failed attempts at decompression
Necrotic bowel noted at endoscopy
Suspected or proven perforation or peritonitis

35
Q

What will the decision of which operation to perform depend on?

A

The patients nutritional status
Adequacy of blood supply
Haemodynamic stability
Presence of any perforation or peritonitis

36
Q

What may patients with recurrent volvulus, but who are otherwise healthy choose to do?

A

May choose to have an elective procedure to prevent further recurrence

37
Q

What elective procedure may be used to prevent recurrence of a volvulus?

A

Most commonly a sigmoidectomy with primary anastomosis

38
Q

What is the main immediate complication of a sigmoid volvulus?

A

Bowel ischaemia and perforation

39
Q

What are the longer term complications of a sigmoid volvulus?

A

Risk of recurrence

Complications arising from any stoma placed

40
Q

What is the risk of recurrence of a sigmoid volvulus?

A

Up to 90%

41
Q

What is the second most common site for a volvulus?

A

Caecum

42
Q

What % of colonic volvuli are caecal?

A

25-40%

43
Q

At what age are caecal volvuli most common?

A

The age of those affected occurs in two peaks, 10-29 years, and 60-79 years

44
Q

What causes caecal volvuli in younger patients?

A

Intestinal malformation

Excessive exercise

45
Q

What causes caecal volvuli in older patients?

A

Chronic constipation
Distal obstruction
Dementia

46
Q

How is a diagnosis of caecal volvulus made?

A

Initially via abdominal x-ray

47
Q

What will be shown on abdominal x-ray with caecal volvulus?

A

Coffee bean sign, with lead point from right lower quadrant

48
Q

What can aid in an unclear diagnosis of caecal volvulus?

A

Barium enema

49
Q

What is involved in the conservative management of a caecal volvulus?

A

Endoscopic decompression

50
Q

What is the success rate of endoscopic decompression of a caecal volvulus?

A

30%

51
Q

What is involved in the surgical intervention for a caecal volvulus?

A

Detorsion and caecostomy

52
Q

What is normally the primary treatment for a caecal volvulus?

A

Surgical management

53
Q

Why is surgical management usually the primary treatment for a caecal volvulus?

A

Because of the higher chance of ischaemia in caecal volvulus

54
Q

Is recurrence following surgery common in caecal volvulus?

A

No, it is rare

A - MSRA Gastrointestinal [7] (44 decks)

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