Volvulus.pptVIP

Volvulus Colorectal Conference 12/1/05 Nicole Lee, MD Volvulus Obstruction caused by twisting of the intestines more than 180 degrees about the axis of the mesentery 1-5% of large bowel obstructions Sigmoid ~ 65% Cecum ~25% Transverse colon ~4% Splenic Flexure Sigmoid Volvulus Worldwide - up to 50% of obstruction India, Africa, E. Europe More commonly seen in elderly patients in western societies Redundant colon, mesocolon narrowed, twisting at mesentery Risk factors Chronic constipation Psychiatric problems Non-western societies high residue diet Presentation Hx: Abdominal pain, distension, no flatus or bowel movements Exam: tympanitic abdomen, distension, mild tenderness, palpable mass Sigmoid volvulus “bent inner tube” appearance Dilated sigmoid loop with limbs pointing towards the RLQ Sigmoid volvulus “Coffee bean” appearance with the two twisted loops with a central doubled wall component Barium Enema Contraindicated in patients with free air on AXR, clinical signs of peritonitis, or suspicion for necrosed bowel Bird’s beak Can decompress Management of choice Endoscopic decompression Rigid or flexible proctosigmoidoscope inserted into rectum Gush of air/feces -- successful decompression Rectal tube Successful in 85-90% of cases Recurrence rate 60% Decreased risk for bowel necrosis if treated early Colon ischemia, perforation Elective resection Operative management for sigmoid volvulus Elective resection Same admission Emergent laparotomy Operation depends on viability of the bowel Resection and anastomosis Hartmann resection Exteriorization resection Detorsion Detorsion with colopexy Percutaneous colostomy Percutaneous sigmoidpexy Delayed resection with primary anastomosis Mortality rate 8% Operative mortality related to viability of bowel Viable 12% vs nonviable 53% mortality Cecal Volvulus Less common than sigmoid volvulus Parietal peritoneum fails to connect with the cecum and right colon Present in about 10% of population Increased mobility of bo