Volvulus Flashcards
What is a volvulus?
- Twisting of a loop of bowel
- Around its mesenteric attachment
Why is a volvulus bad?
- Surgical emergency
- Closed loop bowel obstruction forms within affected segment
- Compromise of blood supply due to twisting
- Rapidly leads to bowel necrosis and perforation
Where do most volvulus occur and why?
- Sigmoid colon due to its long mesentery
- = prone to twist
- Other sites inc stomach, caecum, small intestine and transverse colon
RF for volvulus
- Advanced age
- Neurological disorders eg Parkinsons or vascular dementia
- Psychiatric disease - on antipsychotics esp
- Reduced mobility
- Male
Why are all these risk factors increasing the risk?
- Increase chance of chronic constipation and slow transit time
- = redundant sigmoid colon (longer than space to fit)
- = prone to twist
Symptoms of sigmoid volvulus
- Abdominal distension
- Absolute constipation
- Varying degrees of abdominal pain
- Then vomitting secondary to obstruction later
Compared to other causes of bowel obstruction, how do symptoms differ?
- Rapid onset - over a few hours
- Degree of abdominal distension - very
Examination of volvulus
- Distended abdomen
- Tympanic to percussion
- Localised tenderness
- Peritonism = ?bowel ischaemia developing
Sigmoid volvulus x-ray
Often done first line even though less sensitive than CT
Management of all patients with volvulus
- IV fluids - resuscitation
- NG tibe esp if vomitting
- Urinary cathter for fluid balance
- Analgesia
- Correct electrolytes
Bedside and bloods for ?volvulus
- FBC
- U&E
- CRP
- Clotting screen
- VBG - pH and lactate - bowel ischaemia?
Imaging for volvulus sigmoid
- CT abdomen pelvis + IV contrast
- = very dilated sigmoid colon with whirl sign
- Also allows to check for bowel ischaemia, if ileocaecal valve is incompetent = signs of SBO
Conservative management sigmoid volvulus
- Decompression via sigmoidoscope and insertion of flatus tube
How is sigmoidoscope decompression done?
- Patient placed in left lateral position
- Lubricated sigmoidoscope into rectum - often need to use flexible one instead of rigid as difficult
- Manoeuvered to locate the twisted bowel
- Gentle pressure to untwist the volvulus
- When in correct position - rush of air and liquid faeces as obstruction is relieved
What is the flatus tube for?
- Left in situ for up to 24hrs after initial decompression
- Allows for continued passage of contents and aid recovery of affected area
When is surgery for volvulus needed?
- Evidence of bowel ischaemia
- Perforation
- Repeated failed endoscopic decompression
Surgery for sigmoid volvulus
- Sigmoid colectomy - often as Hartmanns procedure via laparotomy
- Primary anastomosis not advised as co-morbid and frail
What happens if patients get recurrent volvulus?
- May choose to have elective surgery
- Sigmoid colectomy with primary anastomosis or end colostomy
- Balance risk of recurrence with risk of surgery
Complications of volvulus
- Bowel ischaemia
- Bowel perforation
Ages that caecal volvulus affects
- Bimodal
- 10-29 - may have intestinal malformation or sometimes excessive exercise
- 60-79
Managament caecal volvulus
- Right hemicolectomy
Imaging for caecal volvulus
- CT abdomen pelvis
- Distended caecum, mesenteric whirl and SBO
