Volvulus - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

It is a phenomenon when a loop of the intestine twists around itself and the mesentery (a fold of membrane that attaches the abdominal wall and intestine to hold it in place). This twisting of the intestine causes bowel obstruction. In addition, the mesentery is so tightly twisted that the blood supply is cut off, leading to bowel ischemia. Other symptoms include abdominal pain, distension, constipation, vomiting, or bloody stools.

The appearance of symptoms can be either slow and gradual or very sudden. A higher chance of volvulus is noticed in neuropsychiatric disorders such as Parkinson's disease or multiple sclerosis. In adults, the cecum and sigmoid colon are commonly affected, whereas, in children, the stomach and intestine are most affected. Initial treatment options are barium enema or sigmoidoscopy for sigmoid volvulus. However, the recurrence rate is very high, so bowel resection with anastomosis within two days of diagnosis is recommended. In severe twisting or blood supply cuts, emergency surgery is required.

What Are the Causes of Volvulus?

• In the case of adults, sigmoid volvulus is most common, followed by cecal volvulus. Whereas in children, the small intestine is most affected.

• In most cases, sigmoid volvulus is an acquired disorder, whereas cecal volvulus is due to incomplete dorsal mesenteric fixation of the cecum or right colon or long mesentery.

• Some of the conditions associated with volvulus are intestinal malrotation, Hirschsprung disease (disease of the intestine characterized by absence of nerves from the parts of the intestine), abdominal adhesion (sticking of the walls of organs or intestine), pregnancy, and chronic constipation.

• Sigmoid volvulus is more commonly seen in neuropsychiatric disorders, Parkinson's disease, and multiple sclerosis.

Parkinson’s Disease: Is a brain disorder characterized by shaking, difficulty in walking, stiffness, and compromised balance and coordination.

Multiple Sclerosis: A disease of the brain and spinal cord in which the immune system consumes the protective covering of the nerves.

• High fiber intake in the diet can cause excessive load on the sigmoid colon, causing it to twist around the mesentery.

• Some neuroleptic drugs can interfere with colonic motility and trigger volvulus.

• Bed-ridden nursing home patients with chronic constipation have a high risk of developing volvulus.

• Chagas disease, caused by the parasite Trypanosoma cruzi, can also act as a predisposing factor for volvulus.

What Is the Pathophysiology of Volvulus?

• Cecal volvulus can be mesenteroaxial (cecal bascule) or organoaxial (cecocolic or true cecal volvulus). In the organoaxial type, the distal ileum and ascending colon twist around each other in a clockwise direction. Whereas, in the mesenteroaxial sub-type, the cecum is not fixed completely and is located in front of the ascending colon at 90 degrees to the mesentery.

• Sigmoid volvulus predisposes by two mechanisms, chronic constipation or a high-fiber diet. In both cases, the sigmoid is dilated and loaded with stools, making it prone to torsion. With repeated attacks of torsion, there is a shortening of the mesentery due to inflammation. The development of adhesion traps the sigmoid colon into a fixed twisted position. The direction of volvulus in these cases is counterclockwise.

• The midgut volvulus in children is due to rotation defects of the intestine.

What Are the Symptoms of the Volvulus?

In most cases, the onset of symptoms is acute; however, in almost one-third of cases, the symptoms can be insidious.

The general symptoms of volvulus in adults are:

1. Abdominal pain.

2. Abdominal Distension- Abnormal outward swelling of the abdomen.

3. Vomiting- A forceful outward throw of the food consumed is referred to as vomiting.

4. Obstipation- Severe or complete constipation of the bowel.

5. Constipation- Difficulty passing out stool every day, with less than three bowel movements in a week.

6. Hematochezia- The passing of fresh blood from the anus, usually with the stool.

7. Fever- Rise in body temperature.

Symptoms in children are:

1. Bilious Emesis- It is also known as bilious vomiting.

2. Hematochezia- The passing of fresh blood from the anus, usually with the stool.

3. Upper abdominal swelling (distension).

4. Diarrhea in older children.

5. Compromised growth of the body.

How to Diagnose the Volvulus?

• The diagnosis of colonic volvulus is often made clinically; however, radiographic imaging is necessary for confirmation.

• The first step of the investigation is a plain X-ray of the abdomen, looking for signs like 'coffee bean' or 'bent inner tube' appearance. These are characteristic signs for sigmoid volvulus. Demonstrate a "bird's beak" at the point of the colon where it twists to form the volvulus.

• The plain radiograph for the cecal volvulus reveals swelling of the small and large intestine.

• Radiographic images in children suffering from volvulus show paucity of gas throughout the intestine, few scattered air-fluid levels, and an abnormally placed duodenojejunal on the right side of the abdomen.

• Lab tests that can be advised are complete blood count and serum levels, which can help to evaluate electrolyte abnormalities and leukocytosis.

What Is the Treatment for Volvulus?

• Medications such as broad-spectrum antibiotics should be administered preoperatively. The vitals should be monitored along with urine output measurement periodically.

• The initial treatment for sigmoid volvulus is sigmoidoscopy. It helps to diagnose sigmoid volvulus. The process includes gentle insertion of the endoscopic tube just below the site of torsion, and air insufflation is attempted. If the tip of the endoscope fails to reach the site, it can be used to follow the twisted mucosa and reach the apex. Alternatively, a soft flatus tube or red rubber tube can be inserted, which leads to detorsion and decompression. The flatus tube is kept in-situ after the endoscopic reduction to prevent an early recurrence.

• The contraindications to endoscopic reduction are bowel gangrene with fever, sepsis, persistent hematochezia, and perforation peritonitis. Immediate resuscitation and surgery are recommended in such cases.

• Surgical options for sigmoid volvulus include bowel resection and conservative bowel surgery. Resection is recommended over conservative surgery.

• If there is bowel perforation, the Hartmann procedure is performed in which the part of the colon is removed, and sometimes the rectum is also removed.

• In cases of cecal volvulus, rectopexy can be performed. The ideal procedure for cecal volvulus is right hemicolectomy. If the bowel is necrotic, resection with colostomy and an ileostomy is suggested.

• If the patient is critically ill and not suitable for general anesthesia, a percutaneous tube cecostomy can be performed.

Conclusion:

As stated in the article, the phenomenon of twisting of the intestinal loop within themselves and the mesentery is called volvulus. It can cause bowel obstruction and, in some cases, ischemia (shortage of blood supply). The major symptoms include abdominal pain, vomiting, abdominal distension, and constipation. The treatment depends on the type of volvulus, whether sigmoid volvulus or cecal volvulus.