Volvulus

Volvulus is a twisting of the intestine at least 180 degrees on itself. It's marked by sudden onset of severe abdominal pain. Volvulus results in blood vessel compression and causes obstruction both proximal and distal to the twisted loop.

Volvulus occurs in a bowel segment long enough to twist. The most common area, particularly in adults, is the sigmoid colon; the small bowel is a common site in children. Other common sites include the stomach and cecum.

Causes

A volvulus is a condition in which the bowel becomes twisted. This twisting causes obstruction of the intestine, and also often cuts off the blood supply to the intestine. The resulting death of some or all of the intestine may in turn cause the person to die.

Signs and Symptoms

The patient with volvulus complains of severe abdominal pain and may report bilious vomiting. If the patient is an infant, the parents may report increased vomiting of feedings. The history may also reveal the passage of bloody stools.

On inspection, the patient appears to be in pain. Abdominal inspection and palpation may reveal distention and a palpable mass.

Diagnostic tests

Abdominal X-rays may show multiple distended bowel loops and a large bowel without gas. In midgut volvulus, abdominal X-rays may be normal.

In cecal volvulus, barium from a barium enema fills the colon distal to the section of cecum; in sigmoid volvulus, barium may twist to a point and, in adults, take on an "ace of spades" configuration.

White blood cell count, in strangulation, is greater than 15,000/µl. In bowel infarction, it's greater than 20,000/µl.

Treatment

The severity and location of the volvulus are considered when determining therapy. For children with midgut volvulus, surgery is required. For adults with sigmoid volvulus, nonsurgical treatment includes proctoscopy to check for infarction and reduction by careful insertion of a flexible sigmoidoscope to deflate the bowel. Expulsion of flatus and immediate relief of abdominal pain indicate success of nonsurgical reduction.

If the bowel is distended but viable, surgery consists of detorsion (untwisting); if the bowel is necrotic, surgery includes resection and anastomosis. Prolonged total parenteral nutrition and l.V. administration of antibiotics are usually necessary. Sedatives may be needed.