Sigmoid Volvulus

INTRODUCTION:
  • 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 - 
  1. Sigmoid volvulus(- 75%)
  2. Cecal volvulus (< 25%)
  3. Transverse colon
  4. Splenic flexure
SIGMOID VOLVULUS:
  • Most common site of volvulus
  • Rotation in sigmoid volvulus nearly always occur in anticlockwise direction
  • 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.
PREDISPOSING FACTOR:
  • 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)
  • Band of adhesion Long pelvic meso colon with Narrow attachment 
SIGNS & SYMPTOMS: 
  •  Sigmoid Volvulus more often than not presents with sudden-onset lower abdominal pain along with abdominal distension with inability to pass gas or have a bowel movement.
  • There may also be insidious onset of chronic abdominal distension, constipation, and colicky pain in stomach along with severe vomiting episodes.
  • The affected individual may have periods where he may experience recurrent attacks of constipation followed by passing of large amounts of stool or gas.
  • If the distension becomes quite severe then the individual may experience vomiting episodes
  • If an abdominal examination is conducted then it will reveal a distended abdomen. There may also be a palpable mass observed.
  • In cases of colonic perforation due to Sigmoid Volvulus then high fever may also be observed.
  • Any delay in treatment for Sigmoid Volvulus may lead to development of colonic ischemia or peritonitis.
DIAGNOSIS: 
  •  Plain Xray abdomen finding in Sigmoid Volvulus :
  • Characteristic bent inner tube or coffee bean appearance with convexity of distended bowel loop lying in the right upper quadrant (opposite to the site of obstruction) with it's apex in rt. Hypochondrium 
  • Contrast study (gastrografin enema) - bird beak appearance i.e. narrowing at the site of volvulus. 
TREATMENT:
  •  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.
  • Endoscopic decompression is contraindicated if there is evidence of strangulation or perforation.
  • Emergency Laparotomy is performed if strangulation or perforation is suspected or if attempts of endoscopic decompression fail.

Exam Question
  •  Coffee bean sign is seen in Sigmoid volvulus
  • A plain abdominal X-ray in a patient with a sigmoid volvulus will show a distended bowel loop with its apex in Rt. Hypochondrium 
  • Bird of Prey sign is seen in the radiographic barium examination of Sigmoid volvulus
  • Sigmoid volvulus is more common than caecal volvulus
  • Sigmoid volvulus is More common in psychiatric patients
  • Definitive treatment of sigmoid volvulus is sigmoid colectomy
  • Rotation in sigmoid volvulus nearly always occur in anticlockwise direction
  • Age of 60-70, neurological impairment, psychiatric condition ,Band of adhesion & Long pelvic meso colon with Narrow attachment are some Predisposing factors for sigmoid volvulus

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