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Sigmoid and caecal volvulus

  • Volvulus = rotation of the gut on its own mesenteric axis
  • Produces partial or complete intestinal obstruction
  • Blood supply compromised resulting in intestinal ischaemia
  • Venous congestion leading to infarction can occur
  • Arterial supply rarely compromised
  • Long narrow based mesentery predisposes to volvulus

Sigmoid volvulus

  • Sigmoid is commonest site of colonic volvulus
  • Accounts for 5% of large bowel obstruction in UK
  • Usually seen in elderly or those with psychiatric disorders
  • Commonest cause of obstruction in Africa / Asia
  • >Incidence is 10 times higher than in Europe or USA

Clinical features

  • Large bowel obstruction – pain, constipation and vomiting
  • Disproportionate abdominal distension
  • 50% patients have had a previous episode
  • Severe pain and tenderness suggests ischaemia
  • Plain abdominal x-ray may show a large ‘bean’ shaped loop of large bowel arising from pelvis

Sigmoid volvulus

  • If diagnostic doubt consider a water soluble contrast enema
  • Will demonstrate site of obstruction

Management

  • Resuscitation with intravenous fluids is essential
  • Conservative management can be attempted if so clinical features of ischaemia
  • Sigmoidoscopy can be both diagnostic and therapeutic
  • Obstruction usually at 15 cm which when advanced passed produces release of flatus
  • Flatus tube can be inserted and left for 2-3 days
  • 80% of patients will settle with conservative management
  • If decompression occurs no emergency treatment required
  • 50% further episode of volvulus within 2 years
  • If decompression fails or features of peritonitis
  • Options are:
    • Sigmoid colectomy and primary anastomosis
    • Hartmann’s procedure
    • Paul Mickulicz Colostomy
  • Sigmoidopexy best avoided

Sigmoid volvulus

Picture provided by Shanker Sathappan, Hospital Alor Setar, Kedah State, Malaysia

Caecal volvulus

  • Incidence is less than that of sigmoid volvulus
  • Accounts for about 25% cases of colonic volvulus
  • Incomplete midgut rotation is a predisposing factor
  • Results in inadequate fixation of caecum to posterior abdominal wall
  • Volvulus usually occurs clockwise around ileocolic vessels
  • Usually also involves terminal ileum and ascending colon

Clinical features

  • Presents with clinical features of proximal large bowel obstruction
  • Colicky abdominal pain and vomiting are common
  • Abdominal distension may occur
  • Plain abdominal x-ray shows a comma shaped caecal shadow in mid abdomen
  • Small bowel loops may lie to the right of the caecum

Radiological appearance of a caecal volvulus

  • If diagnostic doubt consider a water soluble contrast enema
  • Will show beaked appearance in ascending colon

Management

  • Colonoscopic decompression may be appropriate if patient unfit for surgery
  • Laparotomy is normally required
  • If colon is ischaemic then right hemicolectomy should be performed
  • Primary anastomosis may be inappropriate
  • Exteriorisation of both ends of the bowel might be the safest option
  • If the caecum is viable and the volvulus reduced the following can be considered
    • Reduction alone is associated with high recurrence rate
    • Right hemicolectomy
    • Caecostomy
    • Caecopexy

Caecal volvulus

Bibliography

Madiba T E,  Thompson S R.  The management of sigmoid volvulus.  J R Coll Surg Ed 2000;  45:  74-80.

Rabanovici R,  Simansky D A,  Kaplan O,  Mavor E,  Manny J.  Cecal volvulus.  Dis Colon Rectum 1990;  33:  765-769.

 

 
 

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