Volvulus

Colorectal

Sigmoid volvulus

Aetiology:

• Aetiology unknown but thought to be secondary to constipation and colonic lengthening.

Risk factors:

• Elderly, debilitated, neurological conditions, institutionalised or taking psychiatric medications, laxative abuse, pregnancy, congenital anomalies e.g. Hirschsprung disease and gut malrotation, and parasitic – Chagas disease. M=F.

Presentation

• abdominal pain, distension and constipation.

Investigations:

• X-ray – coffee bean sign, apex pointing to right upper quadrant.
• CT – whirl sign

Management:

• Fluid and electrolyte abnormalities
• Acute
  • Without perforation or peritonitis
    • Rigid or flexible sigmoidoscopy to detort volvulus
  • With perforation, peritonitis, ischaemia or inability to endoscopically reduce volvulus.
    • Emergency resection
      • Segmental resection + primary anastomosis; unless haemodynamically unstable, intraperitoneal contamination.
• Elective
  • Recurrent sigmoid volvulus or volvulus that was endoscopically detorted
  • Fixation procedures should be avoided. High rate of recurrence

Caecal volvulus

Aetiology:

• Commonly occurs in clockwise orientation when there is lack of retroperitoneal fixation.

Risk factors:

• Younger patient, prior abdominal operation, female, pregnancy and constipation.

Presentation:

• Abdominal pain, distension, nausea and vomiting.

Investigations:

• Xray coffee bean extending across to left upper quadrant
• CT – whirl sign

Types:

• Type 1: clockwise axial twisting along long axis
• Type 2: twisting of caecum and terminal ileum with caecum displaced to ectopic location, usually LUQ, and relocated in an inverted orientation. Usually counter-clockwise.
• Type 3: Caecal bascule – type of caecal volvulus from caecum folding anteriorly onto itself without mesenteric twisting.
  • Often present with intermittent and recurrent obstructive symptoms.
  • CT most useful imaging. Management same for caecal volvulus.

Management:

• Endoscopic decompression should not be attempted
• Definitive operative management required.
  • Once resuscitated, segmental resection and primary anastomosis – if stable
  • Resection and ileostomy if unstable and bowel not viable.
  • Caecostomy and caecopexy are not recommended; high recurrence rate.