Colonic Volvulus Flashcards
Most Common form
Sigmoid volvulus
50% to 90% of all cases.
RF
2: 1 male predominance
increasing age
> seventh decade of life or beyond
diet
race
diabetes
pregnancy
constipation/ dysmotility
Institutionalized patients
psychiatric and neurologic disorders
Diagnosis relies upon radiographic findings
“bent inner tube” or “omega loop,”
If plain films are nondiagnostic
> Do (CT) > mesenteric whirl and paucity of rectal gas
Initial Management in Stable PT
If no evidence of colonic ischemia > fever or peritonitis
- endoscopic detorsion By rigid proctoscope or a flexible endoscope.
Rigid proctoscopy > only in the setting of a lack of access to standard flexible endoscopy
higher risk of perforation and does not visually inspect colonic mucosa.
Classic appearance in Scope and What to do
- classic “pinwheel” appearance at the point of torsion
- scope should be passed through the torsed segment.
- Rates of successful endoscopic detorsion 55% to 94%.
- After detorsion, Leave a soft red-rubber catheter in the colon to allow for continued decompression and prevention of a short-term recurrence
Recurrence after Endoscopic detorsion sigmoid
85-90%
Operations Options
- Current gold standard approach for the prevention of recurrent sigmoid volvulus is sigmoid colon resection with primary anastomosis.
Other Options if severe colonic edema is encountered:
- Resection with end colostomy and Hartmann’s pouch
- primary anastomosis with diverting loop ileostomy
When Should the procedure take place ?
Within the index admission
specific setting in which recurrence rates remain high after sigmoidectomy
- Megacolon
- Recurrence > greater than 80%
- Consideration may be given to subtotal colectomy.
When to Consider Emergency Operation
- Signs of ischemia, perforation, sepsis, or evidence of shock
- Fail attempted endoscopic detorsion.
IV Fluids , Cross Match, Abx , OT
Intraop Considerations
- Compromised bowel should not undergo detorsion before resection
- In the setting of perforation, copious irrigation of the abdomen
Things to put in Mind intraop that affect your decision
- Proximal bowel dilatation
- fecal contamination
- presence of ongoing hemodynamic abnormalities
- nutritional
- functional
- frailty status
Why they do detorsion then Prevention surgery ?
Surgical resection in the emergent setting is associated with higher rates of mortality.
Cecal Volvulus
The second most frequent type
10% to 40% of colonic volvulus
Types
two types of volvuli that can occur in the cecum.
- The most common > axial twisting of the cecum and accounts for up to 90% of cases.
cecum rotates around its long axis forming a clockwise twist, leaving the cecum in the right lower quadrant. - The less common type is not a true volvulus
folding of the cecum upon itself directed toward the hepatic flexure, known as a bascule.
Overall this accounts for only 10% of reported cases.
RF
mobile cecum
chronic constipation
psychiatric illness
high fiber diet
chronic laxative use
pregnancy
prior abdominal surgeries
female predominance of 1.4: 1.
Diagnosis
Plain films > classic “coffee bean” sign pointing to the left upper quadrant
paucity of rectal gas.
CT scan > assessing bowel for ischemia or signs of impending ischemia.
Intestinal thickening
hypoenhancement of the bowel wall
pneumatosis
abdominal free fluid
When To go for Emergency Sx
- signs of cecal ischemia, perforation, or shock
- aggressive fluid resuscitation
- administration of broad-spectrum antibiotics
- proceed to the operating room for emergent intervention.
What Sx to Do
- ileocolic resection or right hemicolectomy
- Primary anastomosis Depending on :
hemodynamics
comorbidities
fecal contamination
local inflammatory changes.
If patient is Stabe, no Shock, Abdomen Good
- surgical intervention remains urgent in nature.
- endoscopic reduction is not recommend
- 30% success rate and may lead to perforation.
Intraop You should do what ?
- assessment of bowel viability
- necrosis of the cecum is a common finding
> resection with consideration of primary anastomosis. - If no necrosis > right hemicolectomy or ileocolic resection with a side-to-side stapled anastomosis is typically performed.
What about nonresection techniques
- Detorsion with or without cecostomy and cecopexy
- not recommended
- high recurrence rates
- high morbidity and mortality.
Both cecostomy and cecopexy are reserved for patients who are poor resection candidates due to comorbid conditions or physiologic status.
- It is important to assess the quality of the bowel wall
- The fragile or edematous tissue > poor candidate for holding suture > lead to complications > leak and failure of apposition to the abdominal wall or retroperitoneum.
Other Types of Volvulus
Transverse colon and splenic flexure volvuli
2% to 5% of all colonic volvulus cases.
occur in a younger patient population
increased incidence in women.
Signs on imaging
- Diagnosis is rarely made by using plain films alone.
- Splenic flexure volvulus i> “coffee bean” sign in the left upper quadrant on abdominal x-ray.
- volvulus of the transverse colon can be characterized by an “inverted coffee bean” sign.
Treatment of these rare types
No Endoscopy
asses Bowel Viability
Noncompromised bowel may be detorsed before resection.
Options:
extended right hemicolectomy
segmental resection
primary anastomosis Vs End Colostomy
Very Rare volvulus
- ileosigmoid knotting
Type 1 MC
portion of ileum encircles the sigmoid colon.
Type 2
wrapping of the sigmoid colon around a loop of ileum.
Type 3
ileocecal segment wrapping around the sigmoid colon.
Diagnosis
- Diagnosis can be challenging
- Dilated loops of small bowel
distended sigmoid loop.
CT > whirling of the ileal and sigmoid mesentery with associated medial deviation of the cecum and left colon.
Can be confused with Sigmoid volvulus
- Ileosigmoid knotting may be confused for sigmoid volvulus on imaging prompting attempted endoscopic decompression
- In these cases, endoscopic decompression will fail due to the wrapping of the mesentery, further raising the suspicion for ileosigmoid knotting.
