Volvulus

Regardless of cause, volvulus causes symptoms by two mechanisms: • Bowel obstruction manifested as abdominal distension and bilious vomiting. • Ischemia (loss of blood flow) to the affected portion of the intestine. Depending on the location of the volvulus, symptoms may vary. For example, in patients with cecal volvulus, the predominant symptoms may be those of small bowel obstruction (nausea, vomiting, and lack of stool or flatus), because the obstructing point is close to the ileocecal valve and small intestine. In patients with sigmoid volvulus, although abdominal pain may be present, symptoms of constipation may be more prominent. Volvulus causes severe pain and progressive injury to the intestinal wall, with accumulation of gas and fluid in the portion of the bowel obstructed. Ultimately, this can result in necrosis of the affected intestinal wall, acidosis, and death. This is known as a closed-loop obstruction because there exists an isolated ("closed") loop of bowel. Acute volvulus often requires immediate surgical intervention to untwist the affected segment of bowel and possibly resect any unsalvageable portion. Sigmoid volvulus is the most common form of volvulus of the gastrointestinal tract. and is responsible for 8% of all intestinal obstructions. Sigmoid volvulus is particularly common in elderly persons and constipated patients. Patients experience abdominal pain, distension, and absolute constipation. Cecal volvulus is slightly less common than sigmoid volvulus and is associated with symptoms of abdominal pain and small bowel obstruction. Volvulus can also occur in patients with Duchenne muscular dystrophy due to smooth muscle dysfunction. Gastric volvulus causes nausea, vomiting, and pain in the upper abdomen. The Borchardt triad is a group of symptoms that help doctors identify gastric volvulus. The symptoms are intractable retching, pain in the upper abdomen, and inability to pass a nasogastric tube into the stomach. Complications • Strangulation • Gangrene • Perforation • Faecal peritonitis • Recurrent volvulus ==Causes==

Midgut volvulus occurs in people (usually babies) who are predisposed because of congenital intestinal malrotation. Segmental volvulus occurs in people of any age, usually with a predisposition because of abnormal intestinal contents (e.g., meconium ileus) or adhesions. Volvulus of the cecum, transverse colon, or sigmoid colon occurs, usually in adults, with only minor predisposing factors such as redundant (excess, inadequately supported) intestinal tissue and constipation. Types • volvulus neonatorum • Volvulus of the small intestine • midgut volvulus (due to intestinal malrotation) • volvulus of the caecum (cecum), also cecal volvulus • sigmoid colon volvulus (sigmoid volvulus) • Volvulus of the transverse colon • volvulus of the splenic flexure, the rarest • gastric volvulus • ileosigmoid knot ==Diagnosis==

After taking a thorough history, the diagnosis of colonic volvulus is usually easily included in the differential diagnosis. Abdominal plain x-rays are commonly confirmatory for a volvulus, especially if a coffee bean sign is seen. These refer to the shape of the air-filled closed loop of the colon, which forms the volvulus. Should the diagnosis be in doubt, a barium enema may demonstrate a "bird's beak" at the point where the segment of proximal bowel and distal bowel rotate to form the volvulus. This area shows an acute and sharp tapering and looks like a bird's beak. If a perforation is suspected, barium should not be used due to its potentially lethal effects when distributed throughout the free intraperitoneal cavity. Gastrografin, which is safer, can be substituted for barium. The differential diagnosis includes the much more common constricting or obstructing carcinoma. In approximately 80 percent of colonic obstructions, invasive carcinoma is found to be the cause. This is usually easily diagnosed with endoscopic biopsies. Diverticulitis is a common condition with different presentations. Although diverticulitis may be the source of a colonic obstruction, it more commonly causes an ileus, which appears to be a colonic obstruction. Endoscopic means can be used to secure a diagnosis, although this may cause a perforation of the inflamed diverticular area. CT scanning is the more common method to diagnose diverticulitis. The scan will show mesenteric stranding in the involved segment of edematous colon, which is usually in the sigmoid region. Microperforations with free air may be seen. Ulcerative colitis or Crohn's disease may cause colonic obstruction. The obstruction may be acute or chronic, and after years of uncontrolled disease, it leads to the formation of strictures and fistulas. The medical history is helpful in that most cases of inflammatory bowel disease are well known to both the patient and doctor. Other rare syndromes, including Ogilvie's syndrome, chronic constipation, and impaction, may cause a pseudo-obstruction. • Abdominal x-ray – tire-like shadow arising from the right iliac fossa and passing to the left • Upper GI series File:Sigmavolvulus - Coffee-bean-sign - LSL.jpg|Coffee bean sign in a person with sigmoid volvulus File:Sigmavolvulus - 91w - CT cor - 001 - Annotation.gif|Coronal view of sigmoid volvulus with "whirlpool sign" File:CT of small bowel volvulus (annotated).jpg|CT scan of a small bowel volvulus. It shows two juxtaposed segments of narrowing, which is the spot of mesentery rotation. The other signs indicate strangulation. File:Voluculus.PNG|An x-ray of a person with a small bowel volvulus. File:CecalVolvulusXray.png|Plain X ray of a cecal volvulus File:CecalVolvulus.png|CT scan of a cecal volvulus ==Treatment==

Sigmoid Treatment for sigmoid volvulus may include sigmoidoscopy. If the mucosa of the sigmoid looks normal and pink, a rectal tube for decompression may be placed, and any fluid, electrolyte, cardiac, kidney, or pulmonary abnormalities should be corrected. The affected person should then be taken to the operating room for surgical repair. If surgery is not performed, there is a high rate of recurrence. It has been associated to several diseases, including Huntington's disease. Other Laparotomy for other forms of volvulus, especially anal volvulus. ==References==