Volvulus

Question 1

What is the most common type of volvulus?

Answer 1

Sigmoid

Question 2

What is a volvulus?

Answer 2

Twisting of bowel on it mesenteric attachment. Bowel can become ischaemic due to compromised blood supply and rapidly lead to necrosis and perforation.

Question 3

What are rarer places for volvulus?

Answer 3

Stomach
Caecum
Small intestine
Transverse colon

Question 4

What are the risk factors for volvulus?

Answer 4

Increasing age 
Neuropsychiatric disorders 
Resident in a nursing home 
Chronic constipation or laxative use 
Male gender 
Previous abdominal operations

Question 5

What are the clinical features of volvulus?

Answer 5

Symptoms and signs of bowel obstruction. May have quicker onset and increased degree of abdominal distension.

Question 6

What are the differential diagnosis for sigmoid volvulus?

Answer 6

Other forms of bowel obstruction
Severe constipation
Pseudo-obstruction
Severe sigmoid diverticular disease

Question 7

What investigations should be done for a volvulus?

Answer 7

Routine bloods - electrolytes, Ca, TFTS

CT abdo-pelvis with contrast - whirl sign

AXR - coffee-bean sign

Question 8

What is the conservative management of a sigmoid volvulus?

Answer 8

Decompression by sigmoidoscope and insertion of a flatus tube - unsuccessful in 25-50%

This then requires formal decompression with a flexible sigmoidoscope

Question 9

What are the indications for surgery in volvulus?

Answer 9

Colonic ischaemia or perforation
Repeated failed attempts at decompression
Necrotic bowel noted at endoscopy

Type of operation varies form pt to pt but include Hartmanns procedure or sigmoidecomy with primary anastomosis

Question 10

What are the complications of sigmoid volvulus?

Answer 10

Bowel ischaemia
Perforation

Risk of recurrence
Complications from a stoma

High mortality in surgery due to usually being old and frail and multiple co-morbidities.

Question 11

Where is the second most common site of a volvulus?

Answer 11

Caecum

Question 12

Where is the second most common type of volvulus likely to occur?

Answer 12

Caecum

Question 13

What is the distribution of caecal volvulus?

Answer 13

Bimodal - 10-29, 60-79

Question 14

What are the causes of caecal volvulus in younger patients?

Answer 14

Intestinal malformations

Excessive exercise

Question 15

What are the causes of caecal volvulus in older patients?

Answer 15

Chronic constipation
Distal obstruction
Dementia

Question 16

What is the management of caecal volvulus?

Answer 16

Always laparotomy and ileocaecal resection - assuming patient well enough