Volvulus (GI) Flashcards
Define volvulus.
Twisting of a loop of bowel on its mesentery –> compromised blood flow and closed loop obstruction
What is volvulus one of the most common causes of?
Intestinal obstruction
What are the two most common sites of volvulus in adults?
- sigmoid volvulus (65-80%) - LBO by sigmoid colon twisting around sigmoid mesocolon
- caecal volvulus (20-30%) - developmental failure of peritoneal fixation of proximal bowel (in majority, caecum is retroperitoneal so not at risk of twisting)
What are the risk factors for sigmoid volvulus? (5)
- older patients
- chronic constipation
- Chagas disease
- neurological conditions e.g. Parkinson’s
- psychiatric conditions e.g. schizophrenia
What are the risk factors for caecal volvulus? (3)
- all ages (vs older patients in sigmoid volvulus)
- adhesions
- pregnancy
How does volvulus present in neonates or infants?
Midgut volvulus secondary to intestinal malrotation
What are some general clinical features of volvulus? (3)
- abdominal pain - steady, may have colicky characteristics, varies from vague discomfort –> excruciating
- severe unremitting pain = gangrenous bowel
- pain decreases after explosive passage of stool/gas
- periumbilical/hypogastric pain
- slowly progressive symptoms of bowel obstruction - abdominal pain, distension, N&V (bilious), constipation/diarrhoea
- constipation
What might you see on examination of volvulus? (8)
- diffuse abdominal distension and tenderness
- faint/no bowel sounds
- rigid abdomen
- guarding
- rebound tenderness (peritonitis)
- fever
- haematochezia (passing fresh blood through anus)
- tachycardia/hypotension in bowel ischaemia
What are the signs of bowel ischaemia? (3)
- tachycardia
- hypotension
- rebound tenderness (peritonitis)
What are signs of caecal volvulus?
Features of SBO and recurrent episodes of RLQ abdominal pain
What are the features of gastric volvulus? (3)
- failure to pass NG tube
- epigastric pain
- vomiting
What are the signs of midgut volvulus (secondary to intestinal malrotation) in infants? (5)
- bilious vomiting
- haematemesis
- haematochezia (fresh blood through anus)
- hypotension
- tachycardia
What is the first-line investigation for volvulus?
Abdominal x-ray
What scans can we do in volvulus? (3)
- abdominal XR - dilated bowel loops, abdominal free air with perforation
- CT scan - whirl sign
- barium enema - bird’s beak sign
What do we see on abdominal XR in sigmoid volvulus? (3)
- large bowel obstruction (large, dilated loop of colon often with air-fluid levels)
- coffee-bean sign (two dilated loops with no haustration)
- LUQ–>RLQ
What do we see on abdominal XR in caecal volvulus? (3)
- may see small bowel obstruction
- kidney bean/embryo sign (marked dilation of 1 loop with haustration)
- RLQ–>LUQ
What sign might you see in CT in volvulus?
Whirl sign
What sign might you see in barium enema in volvulus?
Bird’s beak sign
What might ABG show in volvulus?
May be normal or metabolic acidosis, elevated lactate
What are some differential diagnoses for volvulus? (4)
- other forms of LBO (especially carcinoma of sigmoid colon)
- pseudo-obstruction (reduced colonic motility and dilatation)
- giant sigmoid diverticulum
- severe constipation
What initial management is needed for bowel obstruction (volvulus)? (3)
Initial resuscitation:
- IV fluids
- NBM
- placement of NGT
How do we manage sigmoid volvulus?
- rigid sigmoidoscopy with rectal tube insertion (detorsion)
- surgery - if signs of peritonism or decompression not working:
- sigmoid colectomy (haemodynamically stable patient with viable bowel)
- Hartmann procedure (haemodynamically unstable patient/ischaemic bowel)
How do we manage caecal volvulus?
Operative management - right hemicolectomy often needed
How do we manage midgut volvulus secondary to intestinal malrotation (neonates/infants)?
Ladd procedure (emergency surgery)
