Volvulus

Question 1

Describe sigmoid volvulus

Answer 1

80% of volvulus
→ LBO
Not associated with malignancy

Question 2

Describe caecal volvulus

Answer 2

→ SBO
Not at risk of twisting in 80% as it is a retroperitoneal structure
20% = developmental failure of peritoneal fixation of the proximal bowel
Bimodal age of onset
Associated with malignancy

Question 3

Risk factors for volvulus

Answer 3

Age (older for sigmoid, younger for caecal)
Co-morbidities e.g. Parkinson’s, vascular dementia
Previous abdominal surgery
Abdominal or inguinal hernia
Male
Reduced mobility (chronic constipation)
Chronic constipation

Question 4

Symptoms of volvulus

Answer 4

LLQ pain
- Steady
- Colicky pain
- May be periumbilical or hypogastric
Nausea and vomiting
Haematemesis
Diarrhoea or constipation (depends on degree and location)
Bloating

Question 5

Signs of volvulus

Answer 5

Fever
Rebound tenderness
Diffuse abdominal distension and tenderness
Faint or no bowel sounds
Rigid abdomen with guarding
Haematochezia
Occult or frank blood on DR

Question 6

Investigations for volvulus

Answer 6

FBC
U&Es
CRP
Clotting
VBG

AXR: bowel obstruction, dilated bowel loops, air fluid levels
- sigmoid: coffee bean
- Caecal: embryo sign
CT abdomen (contrast): bowel obstruction, “Whirl sign”, signs of bowel ischaemia
Barium/water soluble contrast enema: bird’s beak sign at stricture of volvulus

Question 7

Management of volvulus

Answer 7

1. A-E
2. IV fluid resuscitation
3. Supportive
   
   1. Vomiting → NG tube
   2. Pain → analgesia
   3. Catheter for fluid balance assessment
   4. Correct electrolyte abnormalities
4. Flatus tube (like catheter) through the rectum to allow the gas to be released
   Often left in for a period of time (up to 24h) to allow for continued passage of contents

Sigmoid volvulus → therapeutic sigmoidoscopy with rectal tube insertion (if peritonism → laparotomy)
- In left lateral position
- Once in the correct position, there is a rush of air and liquid faeces as the obstruction is relieved
Caecal volvulus → laparotomy [right hemicolectomy is often needed

Signs of ischaemia or perforation/failed endoscopic decompression → sigmoid colectomy (lap Hartmann’s)

Question 8

Complications of volvulus

Answer 8

Bowel obstruction → Bowel ischaemia → Perforation
Risk of recurrence (90%)