VOLVULUS

Ans. is ‘a’ i.e., Plain X-ray

Volvulus neonatorum

o The fetal alimentary canal returns from the extraembryonic coelom into the abdomen at 8-10 weeks, and the bowel undergoes rotation and fixation at certain points by the attachment of its mesentery to the posterior abdominal wall.

o When the process is incomplete or deviates from the normal plan, the result is malfixation or malrotation.

o Commonly, the normal oblique attachment of the mesentery from duodenojejunal flexure of the caecum is absent, and the small bowel is attached to the posterior abdominal wall by a narrow stalk based around superior mesenteric vessels. The caecum is undescended, i.e., situated in the right hypochondrium and abnormally fixed by peritoneal bands running laterally across the second part of duodenum.

o The poorly attached small bowel undergoes volvulus around the axis of the ‘universal mesentery’, which is twisted so that the flow of blood is cut off, producing a strangulating obstruction of the small bowel. This typically occurs in the newborn, hence the term Volvulus neonatorum’. The terminal ileum and caecum are drawn into the volvulus and are wrapped around the stalk of the mesentery in two or three tight coils.

Clinical feature

o A young infant, previously healthy, starts bile-stained vomiting during the first few days of the live. Abdomen is

soft and non-distended; however, abdominal distension may occur which is limited to upper abdomen (epigastrium). o No obstruction may occur in the first day or two after birth and meconium may be passed normally. Then, with

variable suddenness, bowel actions cease with onset of obstruction.

o The signs vary, depending on the degree of intestinal obstruction versus ischemia. When strangulation occurs there are signs of schock, especially pallor and a vague mass of congested bowel may be palpable in the centre of abdomen. Blood or blood-tinged mucus may be passed rectally.

o Ischemia may result in gangrene and perforation.

Investigations

o Barium contrast studies with fluoroscopy (Barium meal follow through) is the investigation of choice as X-ray is not reliable in early stages of volvulus.

o However, if the perforation is suspected, barium contrast should not be used because of risk of perotinitis. Water soluble contrast studies (iodine based) should be used. Plain X-ray of abdomen/chest is the initial investigation to demonstrate free air under the diaphragm in suspected cases of perforation.

Ans is ‘d’ i.e. Sigmoid 

Ans is ‘c” i.e. Lower GI scopy is contraindicated in sigmoid volvulus 

• Volvulus describes a condition in which there is rotation of a segment of the intestine on an axis formed by its mesentery resulting in partial or complete obstruction of the lumen and may be followed by circulatory impairment of the bowel.
• Most common site is colon, among which following are involved in descending order – Sigmoid volvulus                                               (- 75%)

– Cecal volvulus                 (< 25%)

–  Transverse colon

– Splenic flexure

– Sigmoid volvulus

• Most common site of volvulus
• Volvulus can occur in any segment of large bowel that is attached to a long and floppy mesentery that is fixed to the

retroperitoneum by a narrow base of origin. The mesenteric anatomy is such that volvulus is most commonly seen in sigmoid colon.

• Associated predisposing factors are :

–     age : average age of presentation is 60-70 yrs. – chronic constipation

– institutionalized or neurologically impaired or psychiatric patients (their medication may decrease intestinal

motility, or they may fail to pass stool regularly, leading to fecal loaded large bowel predisposing to volvulus) – diet high in fibre and vegetables (as in third world countries)

• Signs and symptoms are those of acute or subacute intestinal obstruction.
• X-ray picture is dramatic

–      there is a markedly dilated sigmoid colon with the appearance of a bent inner tube or coffee bean appearance. Inferior convergence of the dilated loop points towards left side of pelvis.

–      contrast enema demonstrates the point of obstruction with the pathognomic ‘birds beak’ or ‘bird of prey’ or ‘ace of spades’ sign.

• Management of sigmoid volvulus
• Unless there are obvious signs of gangrene or peritonitis, the initial management is resuscitation followed by endoscopic decompression and detorsion.
• Decompression/detorsion can be achieved by placement of rectal tube through a proctoscope or the use of a colonoscope.
• If detorsion / decompression cannot be achieved with either the rectal tube or colonoscope, laprotomy with resections of the sigmoid colon is done.
• Even if detorsion of the sigmoid volvulus is successful, risk of recurrence is high (approx. 50%). Hence an effective sigmoid colectomy is indicated after the pt. has stabilized.
• Any evidence of bowel gangrene or perforation contraindicates non-operative decompression and an immediate surgical exploration is done.

Cecal volvulus

The condition commonly referred to as cecal volvulus is actually a cecocolic volvulus and consists of an axial rotation of the terminal ileum, cecum and ascending colon.

• Cecal bascule – is a condition in which the cecum folds in a cephalad direction anteriorly over a fixed ascending colon. This causes intermittent bouts of abdominal pain because the mobile cecum causes intermittent episodes of Isolated cecal obstruction. It is relieved spontaneously as the cecum falls back into its normal position.
• Cecocolic volvulus is possible because of lack of fixation of the cecum to the retroperitoneum.
• Associate predisposing factors are:

– previous surgery

–  pregnancy

– malrotation

–  obstructing lesion of the left colon

• Cecocolic volvulus affects a younger age group (late 50s) than sigmoid volvulus (60s & 70s).
• X-ray picture

–  dilated cecum usually occupying the left upper quadrant.

–  haustral markings can be seen in the distended cecocolic segment and is a distinguishing feature from sigmoid colon in which generally there are no haustra.

• Management
• According to Schwartz Surgery – Cecal volvulus, unlike sigmoid volvulus can almost never be detorsed / decompressed endoscopically. As vascular compromise occurs early in the course of cecal volvulus, surgical exploration is necessary when the diagnosis is made. Right hemicolectomy is the procedure of choice.
• Sabiston surgery writes that – ‘Although there have been reports of detorsion of cecocolic volvulus with a colonoscope most cases require operation to correct the volvulus and prevent ischemia.”

An article published in the journal ‘Diseases of Colon and Rectum’ – The management of Cecal Volvulus writes­“Non-operative decompression of cecal volvulus is rarely achievable”

Ans ‘b’ Colectomy

• The definitive treatment of sigmoid volvulus is sigmoid colectomy.
• Management of sigmoid volvulus
• Unless there are obvious signs of gangrene or peritonitis, the initial management of sigmoid volvulus is resucitation followed by endoscopic decompression (by using rigid proctosigmoidoscope or flexible sigmoidoscope or colonoscope); a rectal tube is inserted and kept to maintain decompression) Endoscopic decompression is contraindicated if there is evidence of strangulation or perforation.
• Although endoscopic decompression is susccessful in majority of patients, recurrence rate is quite high. Therefore elective sigmoid colectomy is performed as the definitive procedure after the patient is stabilized and adequate bowel preparation done.
• Emergency Laparotomy is performed if strangulation or perforation is suspected or if attempts of endoscopic decompression fail.

Ans. is ‘d’ i.e., All of the above 

Ans is ‘b’ i.e. Anticlockwise 

“Rotation in Sigmoid Volvulus nearly always occur in the anticlockwise direction”- Bailey & Love Remember

Sigmoid Volvulus—Anticlockwise

Cecal Volvulus —— Clockwise

Ans. is ‘b’ i.e., Anticlock wise 

Ans. C: Sigmoid colon

Volvulus refers to torsion of a segment of the alimentary tract, which often leads to bowel obstruction. The most common sites of volvulus am the sigmoid colon and cecum.

In sigmoid volvulus, rotation nearly occurs in the anticlockwise direction.

Volvulus of other portions of the alimentary tract, such as the stomach, gallbladder, small bowel, splenic flexure, and transverse colon, are rare

Predisposing factors includes a high residue diet and constipation.

Plain Xray abdomen finding in Sigmoid Volvulus 
1. Characteristic bent inner tube or coffee bean appearance with convexity of loop lying in the right upper quadrant (opposite to the site of obstruction) 
2. Contrast study (gastrografin enema) – bird beak appearance i.e. narrowing at the site of volvulus.