Colonic volvulus

Definition

Colonic volvulus is a twisting of the intestinal loop around the axis of the mesentery with impaired nutrition and blood supply to the intestinal wall, forming an obstruction of the digestive tube. The first clinical sign is a sharp contraction-like pain in the abdomen, a few hours later replaced by constant pain, a feeling of bloating, vomiting of intestinal contents, lack of stool, or diarrhea. The most informative method of diagnosis is radiologic examination; control of the biochemical and acid-base state of blood is mandatory. Treatment of some forms of intestinal ingestion is recommended to start with conservative measures, but in most cases, surgery is required.

General information

Colonic volvulus is a mechanical intestinal obstruction that develops due to a loop of intestine rotating around the mesenteric axis. It is most common in elderly patients (the predominant age of patients is 60 years and older). In most cases, twisting is localized in the large intestine: 80% of cases involve the sigmoid colon, 15% involve the cecum, and less than 5% involve the transverse colon. Colonic volvulus accounts for about 5% of all cases of intestinal obstruction and 10-15% of all episodes of colonic obstruction.

For children, a twist in the small intestine is more characteristic, in one way or another, associated with congenital pathology. In pregnant women, this form of intestinal obstruction usually occurs in the third trimester, when the enlarged uterus displaces the sigmoid colon, provoking its torsion. 

Causes

Most often, the sigmoid and small intestine are twisted. According to the degree of torsion, the twist is divided into partial (up to 270°), complete (270-360°), and repeated. The occurrence of pathology is usually associated with congenital features of the intestinal mesentery and anomalies of its attachment; adhesions, in which adhesions bring individual loops of the intestine closer together, provoking stagnation of contents and stretching of the intestine, fixation of loops and mesentery.

In most cases, the cause of small bowel ingestion is an abnormal development of the mesentery and, less commonly, abdominal adhesions. Usually, the intestinal loops turn clockwise, and the entire small intestine may be involved. Causes of twisting of the large intestine are adhesions, large tumors, cysts of the abdominal cavity, pregnancy, postoperative period during interventions on the abdominal cavity, and prescription of drugs that increase intestinal peristalsis. Most often, the twist occurs in the area of the sigmoid since it has the longest mesentery. Less often, pathology occurs in the right half of the colon, in the area of the splenic angle.

Bowel obstruction can complicate the course of such diseases as acute appendicitis, Hirschsprung’s disease, cystic fibrosis of the intestine, megacolon, GI carcinomas, enteroptosis, senile dementia, various psychiatric disorders, and multiple sclerosis. Often, this pathology develops against the background of taking psychotropic drugs, salt, and osmotic laxatives after a colonoscopy.

Symptoms of intestinal twisting

The clinical presentation depends on which part of the intestine is torsioned. Common criteria for clinical diagnosis are abdominal pain, significant bloating, and abdominal asymmetry, accompanied by delayed gas and stool discharge, fecal vomiting, and absence of symptoms of peritoneal irritation. Through the anterior abdominal wall an overinflated driving loop of the intestine can be palpated. Due to pronounced losses of fluid and electrolytes, dehydration develops, accompanied by tachycardia. With torsion of any intestinal compartments, the clinic will depend on the degree and speed of intestinal twisting.

Small bowel obstruction is manifested by the onset of acute intense pain in the epigastrium or umbilical region, less often in the lower abdomen. The onset of pain is accompanied by vomiting of food eaten, which gradually becomes more frequent and intensifies. In the initial stages, feces may be excreted; later, feces and gases are not excreted.

At the beginning of the disease, intestinal peristalsis is significantly increased, but in the following hours, it gradually fades and is replaced by intestinal paresis. 

Torsion of the sigmoid colon may be acute or subacute. Acute twisting of the sigmoid colon is manifested by contraction-like pain in the left side of the abdomen, fecal vomiting, and a sharp drop in blood pressure. With this form of pathology, necrotization occurs very quickly; peritonitis develops in the first hours of the disease. The subacute form of sigmoid colon torsion unfolds stealthily and flows more easily. Most often, patients seek medical help a few days after the onset of the disease, complaining of recurrent pain, abdominal bloating, and only at later stages – vomiting. Rectal examination identifies a dilated and empty ampulla of the rectum. 

There is an attack-like, very intense pain around the navel and frequent exhaustive vomiting. At the beginning of the disease, a scanty amount of feces may be excreted, and then stool and gases cease to be excreted. On the left side of the abdomen is a determined overblown loop of the intestine; above it is heard a tympanic sound. Palpation of the abdomen in the right flank reveals emptiness, as the twisted cecum is displaced to the center or upward.

Complications

Intestinal perforation, peritonitis, the development of generalized infection, critical dehydration, and hypovolemic shockmay complicate the course of pathology. With a prolonged course of subacute intestinal perforation, the formation of mesenteric cysts, stenosis of the intestinal loop, and chylous ascites is possible.

Diagnosis

Initial complaints often lead the patient to consult a gastroenterologist. After clinical examination and diagnosis of intestinal ingestion, the patient is referred to a surgical hospital. Diagnosis is carried out by an abdominal surgeon. When the sigmoid colon is bewitched, review radiography reveals an enlarged intestine, the upper border of which can reach the diaphragm. Two fluid levels are visible – in the proximal and distal intestine.

If the cecum is twisted, a rounded, overinflated loop is identified in the right half of the abdominal region, and the width of the horizontal level of fluid may reach 20 cm. In the case of twisted loops of the small intestine, multiple fluid levels are also detected in it; the distal intestine is narrow and spasmodic. In radiography of barium passage through the small intestine, there is a delay of contrast at the level of the twist and an absence of contrast in the colon in 6-12 hours from the beginning of the study.

Diagnosis of pathology in pregnancy is difficult, as the use of radiologic techniques is limited. Examination of the pregnant woman begins with an ultrasound of the abdominal cavity; in case of suspected ingestion, it is not recommended to perform a colonoscopy; the most informative method will be diagnostic laparoscopy. Differential diagnosis involves diverticulosis, tumors and nodules, and intestinal adhesions. Sigmoid intussusception is clinically similar to colon cancerand mesenteric ischemia. 

Treatment for colonic volvulus

At the beginning of the diagnostic search, the patient may be in the department of gastroenterology, but after the diagnosis is made, he should be transferred to the department of abdominal surgery. Conservative therapy and preparation for surgery begin with the introduction of a nasogastric tube to unload the intestine and the removal of stagnant contents and gases. Infusion therapy aims to restore fluid balance, water-electrolyte balance of blood, and protein levels. Antibacterial therapy is mandatory if peritonitis or sepsis is suspected – it is started immediately after hospitalization if these complications are excluded – two hours before surgery.

Torsion of the small intestine is treated exclusively by surgery. During surgery, the surgeon must try to straighten the twisted loops; in the presence of necrosis of the intestines is segmental resection of the small intestine and anastomosis of the small intestine to the small or large intestine. If peritonitis is detected during surgery, an ileostomy is applied, and three months later, reconstructive surgery is performed. Surgery for colonic volvulus includes performing hemicolectomy with inter-intestinal anastomosis or ileostomy (in the presence of inflammatory exudate in the abdominal cavity). 

Therapy of sigmoid colon occlusion should preferably begin with sigmoidoscopy or colonoscopy, during which a flexible tube is inserted into the sigmoid colon to relieve the bowel. If necessary, after decompression, radical surgery is performed, the indications for which are acute sigmoid intestinal protrusion and lack of effect from conservative therapy. After surgery, it is necessary to continue massive antibacterial and infusion therapy and monitor the patient for early detection of complications: infection, failure of intestinal sutures, formation of inter-intestinal abscesses and fistulas, and development of generalized infection.

All these treatment options are available in more than 690 hospitals worldwide (https://doctor.global/results/diseases/colonic-volvulus). For example, Sigmoidectomy can be performed in 25 clinics across Turkey for an approximate price of $7.4 K (https://doctor.global/results/asia/turkey/all-cities/all-specializations/procedures/sigmoidectomy). 

Prognosis and prevention

Since colonic volvulus develops in the vast majority of cases in elderly patients, the prognosis of this disease is quite serious due to the poor initial state of health and the presence of severe concomitant pathology. Mortality in case of late detection of pathology (more than three days from the onset of the disease) reaches 40%, and postoperative lethality—30%. After endoscopic treatment, recurrences of the disease occur in half of patients.

Prevention requires controlling the prescription and intake of psychotropic and laxative drugs, which increase or slow intestinal peristalsis. The amount of coarse dietary fiber in the diet should be sufficient but not excessive. Preventing the formation of adhesions after surgical interventions is mandatory.