Volvulus: Difference between revisions
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== Backgound | ==Backgound== | ||
*Twisting of loop of bowel causing bowel obstruction and if severe, ischemia, gangrene, perforation | *Twisting of loop of bowel causing bowel obstruction and if severe, ischemia, gangrene, perforation | ||
*Affects adults aged 60-70 | *Affects adults aged 60-70 | ||
*Severe thirdspacing, electrolyte abnormality, and abdominal distention | *Severe thirdspacing, electrolyte abnormality, and abdominal distention | ||
*Common sites include sigmoid and cecum | *Common sites include sigmoid and cecum | ||
** | **Cecal Volvulus - mobile segment of cecum causing volvulus and cecal folding | ||
** | **Sigmoid volvulus - redundant sigmoid attached to narrow mesentery twists on itself causing obstruction and further diation | ||
===Risk Factors<ref>Weerakkody Y et al. Caecal volvulus. http://radiopaedia.org/articles/caecal-volvulus.</ref><ref>Morgan MA et al. Sigmoid volvulus. http://radiopaedia.org/articles/sigmoid-volvulus</ref>=== | ===Risk Factors<ref>Weerakkody Y et al. Caecal volvulus. http://radiopaedia.org/articles/caecal-volvulus.</ref><ref>Morgan MA et al. Sigmoid volvulus. http://radiopaedia.org/articles/sigmoid-volvulus</ref>=== | ||
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**Cecal mobility cause by congenital abnormality with cecal mesentery failing to fuse with posterior abdominal wall | **Cecal mobility cause by congenital abnormality with cecal mesentery failing to fuse with posterior abdominal wall | ||
== Clinical Features | ==Clinical Features== | ||
*Sigmoid/Cecal volvulus | *Sigmoid/Cecal volvulus | ||
**Triad: Abdominal pain, distention, constipation | **Triad: Abdominal pain, distention, constipation | ||
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**Many only definitively diagnosed at surgery | **Many only definitively diagnosed at surgery | ||
== | ==Management== | ||
* | *Emergent surgery consult | ||
*Sigmoid volvulus | *Fluid resuscitation | ||
*Analgesia | |||
*Antibiotics if perforation or gangrene suspected | |||
** | *Sigmoid volvulus may be managed with endoscopic decompression/detorsion (if no signs of gangrenous bowel/perforation) | ||
**Recurrence possible, which would mandate surgical repair | |||
*Cecal volvulus always requires surgical repair with resection (preferred) or cecopexy | |||
*Cecal volvulus | |||
== Disposition | ==Disposition== | ||
*Admit | *Admit | ||
== See Also | ==See Also== | ||
*[[Volvulus (Peds)]] | *[[Volvulus (Peds)]] | ||
== References == | ==References== | ||
<references/> | <references/> | ||
[[Category:GI]] | [[Category:GI]] | ||
Revision as of 04:28, 12 March 2016
Backgound
- Twisting of loop of bowel causing bowel obstruction and if severe, ischemia, gangrene, perforation
- Affects adults aged 60-70
- Severe thirdspacing, electrolyte abnormality, and abdominal distention
- Common sites include sigmoid and cecum
- Cecal Volvulus - mobile segment of cecum causing volvulus and cecal folding
- Sigmoid volvulus - redundant sigmoid attached to narrow mesentery twists on itself causing obstruction and further diation
Risk Factors[1][2]
- Sigmoid Volvulus
- More common in elderly as opposed to cecal volvulus
- High fiber diet
- Chronic constipation
- Chagas disease (S. America)
- Pts of long term care facilities/psychiatric institutions
- Cecal Volvulus
- Most between 30-60 yoa
- Prior abdominal surgery
- Pelvic mass, 3rd trimester pregnancy
- Cecal mobility cause by congenital abnormality with cecal mesentery failing to fuse with posterior abdominal wall
Clinical Features
- Sigmoid/Cecal volvulus
- Triad: Abdominal pain, distention, constipation
- Vomiting only occurs late as obstruction is rather distal. If so, may be faeculant in nature and indicates long-standing obstruction.
- Vary from subtle to dramatic presentations
- Physical Exam:
- Distended, tympanitic abdomen (mostly upper abdomen and unilateral)
- Severe abdominal tenderness, peritonitis, fever, shock highly suggestive for gangrenous bowel
Differential Diagnosis
- Large bowel obstruction
- Colorectal CA
- Diverticulitis
- Strictures
- Fecal impaction
Diffuse Abdominal pain
- Abdominal aortic aneurysm
- Acute gastroenteritis
- Aortoenteric fisulta
- Appendicitis (early)
- Bowel obstruction
- Bowel perforation
- Diabetic ketoacidosis
- Gastroparesis
- Hernia
- Hypercalcemia
- Inflammatory bowel disease
- Mesenteric ischemia
- Pancreatitis
- Peritonitis
- Sickle cell crisis
- Spontaneous bacterial peritonitis
- Volvulus
Diagnosis
- Sigmoid Volvulus
- Abdominal Series X-rays
- May not be diagnostic
- Grossly distended loop of colon (no haustral markings) either on R/L side.
- Coffee-bean sign
- "Bent inner tube" sign
- Free air on upright chest/lateral decubitus if perforation
- Contrast enema
- Bird's beak sign-contrast fills colon up to point of torsion
- Sigmoidoscopy (both diagnostic and therapeutic)
- CT
- Abdominal Series X-rays
- Cecal Volvulus
- Abdominal Series X-rays
- Not definitive in many cases
- Dilated cecum with air fluid level
- Distended small bowel
- Distal colon with paucity of gas
- "Coffee bean sign"-Large oval gas shadow with line down middle in middle of abdomen
- Free air on upright chest/lateral decubitus if perforation
- Contrast enema
- Helpful to differentiate between sigmoid/cecal volvulus
- Ultrasound
- Not particularly helpful
- CT
- Mesocolon "whirl sign"- twisted mesentery
- Many only definitively diagnosed at surgery
- Abdominal Series X-rays
Management
- Emergent surgery consult
- Fluid resuscitation
- Analgesia
- Antibiotics if perforation or gangrene suspected
- Sigmoid volvulus may be managed with endoscopic decompression/detorsion (if no signs of gangrenous bowel/perforation)
- Recurrence possible, which would mandate surgical repair
- Cecal volvulus always requires surgical repair with resection (preferred) or cecopexy
Disposition
- Admit
See Also
References
- ↑ Weerakkody Y et al. Caecal volvulus. http://radiopaedia.org/articles/caecal-volvulus.
- ↑ Morgan MA et al. Sigmoid volvulus. http://radiopaedia.org/articles/sigmoid-volvulus