VOLVULUS

Question 1

Definition

Answer 1

It is the twist (rotation) in the axis of the loop of the bowel either clockwise or anticlockwise.

15% of large bowel obstruction is due to volvulus.

Sigmoid colon is the commonest site (anticlockwise)-65%.

Question 2

Caecal volvu/us incidence

Answer 2

, Caecum is the second common site (clockwise) (C for C)-30%.

, It is common in females, present as intestinal obstruction.

Question 3

Caecal volvulas presentation

Answer 3

,, Caecal bascule → cecum fold on its self

,, Caecum will be markedly distended and found in the centre of the abdomen.

,, It is due to lack of fixation of the caecum-mobile caecum.

,, Occasionally, it is associated with malrotation.

,, Caecal volvulus is the commonest cause of large bowel obstruction in pregnancy.

Question 4

caecal volvulous tx + dx

Answer 4

,, X-ray shows round gas shadow in right iliac region. CT scan is very useful. Barium enema is also helpful.

, Resection and anastomosis (surgery) is the only treatment.

Question 5

SIGMOID VOLVULUS (Volvulus of Pelvic Colon)risk factors

Answer 5

Ogilvie’s syndrome Mentally-retarded individuals Chaga’s disease Hypothyroidism

Anticholinergic drugs Multiple sclerosis Scleroderma Parkinson’s disease
🧿high fiber diet
🥶patients with chronic constipation with laxative abuse.
🤔sigmoid colon, band, narrow root of the mesmesentery, long mesentery

Question 6

Features ofsigmoid

Answer 6

Pain in the abdomen- initially left sided, eventually all over. 
Absolute constipation (obstipation-no faeces, no flatus).

Enormous distension of abdomen, starting from left iliac fossa extending to the whole of the abdomen ( Tympanic abdomen).
Late vomiting and eventually dehydration.

Features of peritonitis.

Hiccough and retching can occur.

Tyre like feel of the abdomen is diagnostic.

Question 7

Investigations

Answer 7

1. Plain X-ray (diagnostic in 70-80%) ,
   😨 (omega sign)-single, grossly distended loop of colon arising out of the pelvis and extending towards the diaphragm.
   🥶Coffee-bean sign or Bent-inner tube sign.
   2-Contrast enema (dilute barium/water soluble contrast media is used):

Birds beak sign (ace of spades appearance)-Upper end of barium column tapers into the spirally twisted distal sigmoid colon.

3. CT scan (for difficult cases):Shows characteristic whirl pattern.
4. Blood-Haematocrit, renal function tests, serum electrolytes.

Question 8

Treatment of sigmoid

Answer 8

RT aspiration; IV fluids; Catheterisation; Antibiotics.

A flatus tube or Sigmoidoscope is passed in operation theatre (proper care is taken otherwise it leads to perforation). If it derotates, patient will pass flatus and faeces; and distension reduces.

If derotation does not occur, laparotomy through midline incision should be done. Dilated sigmoid colon is derotated manually and checked for viability. If viable, it can be fixed to the lateral wall of abdomen or pelvis- sigmoidopexy.

If sigmoid colon is gangrenous, it is resected and proximal cut end is brought out as colostomy and distal end is brought out as mucous fistula