Volvulus

Question 1

What is volvulus?

Answer 1

An obstruction caused by a loop of the intestine twisting around itself and its mesentery. 

Question 2

What are the different types of volvulus?

Answer 2

Most common types: 
1.Sigmoid colon - 65%
2. Caecum - 30%
3. Volvulus Neonatorum - occurs in neonates and typically affects the midgut

Question 3

What are the risk factors for sigmoid volvulus?

Answer 3

older patients, chronic constipation, chagas disease, neurological conditions (eg. parkinsons), psychiatric conditions (eg. schizophrenia)

Question 4

What causes caecal volvulus?

Answer 4

all ages, adhesions, pregnancy

Question 5

What causes Midgut volvulus?

Answer 5

Volvulus in a neonate or infant presents as midgut volvulus secondary to intestinal malrotation

Question 6

What are the risk factors for volvulus?

Answer 6

Adults:
- Long sigmoid colon
- Long mesentery
- Mobile caecum
- Chronic constipation e.g., Hirschsprung disease
- Adhesions
- Chagas disease
- Parasitic infections
Neonatal:
- Malnutrition

Question 7

What are the presenting symptoms of volvulus?

Answer 7

• Severe colicky abdominal pain and swelling
• Absolute constipation
• Vomiting
• There may be a history of transient attacks in which spontaneous reduction of the volvulus has occurred
• Neonatal volvulus presents around 3 months
• History of abdominal pain → decreases after explosive passage of stool/gas
• Slowly progressive symptoms of bowel obstruction → abdominal pain, distension, bilious vomiting

Question 8

What signs of volvulus can be found on physical examination?

Answer 8

• Signs of bowel obstruction with abdominal distension and tenderness
• Absent or tinkling bowel sounds (intestinal obstruction)
• Fever
• Tachycardia
• Signs of dehydration
• Bowel Ischaemia → tachycardia, hypotension, peritonitis (rebound tenderness)
• Caecal Volvulus → features of Small bowel obstruction & recurrent episodes of RLQ abdominal pain
• Gastric Volvulus → failure to pass NG tube (along with epigastric pain and vomiting)
• Midgut Volvulus in Infants → bilious vomiting, haematochezia, haematemesis, hypotension, tachycardia

Question 9

What investigations are used to diagnose/ monitor volvulus?

Answer 9

1. AXR:
   - Large bowel obstruction + Coffee bean sign. Two dilated loops with no haustration. LLQ → RUQ.
   - Caecal Volvulus ⇒ Small bowel obstruction may be seen. Kidney bean/embryo sign. Marked dilation of one loop with haustration. RLQ → LUQ.
2. Erect CXR - if perforation is suspected
3. Water-soluble contrast Barium enema - bird’s beak shape 
   - Shows site of obstruction
4. CT Scan- whirl sign
5. FBC
6. US
7. ABG

Question 10

How is volvulus managed?

Answer 10

1. Initial Resus (Mx of Bowel Obstruction) → IV fluids, NBM, placement of NGT
2. Sigmoid Volvulus → rigid sigmoidoscopy with rectal tube insertion (detorsion)
   - Surgery for Sigmoid Volvulus (if signs of peritonitis or decompression not working) → sigmoid colectomy (haemodynamically stable patient with viable bowel) or hartmann procedure (haemodynamically unstable patients or those with ischaemic bowel)
3. Caecal Volvulus → management is usually operative. Right hemicolectomy is often needed.
4. Intestinal Malrotation → Ladd Procedure (emergency surgery)

Question 11

What complications may arise from volvulus?

Answer 11

• Volvulus causes bowel obstruction, infarction, death intestinal wall 
• Risk of sepsis if intestinal wall breaks 
• Cardiovascular collapse 

Question 12

Describe the prognosis of volvulus?

Answer 12

Mortality with midgut volvulus ~ 10% and depends on degree of intestinal necrosis. Survivors 10% risk recurrence.