Makindo Medical Notes.com

Related Subjects: Small Bowel Obstruction | Colonic (Large bowel) Obstruction | Caecal Volvulus | Small Bowel Ischaemia | Hartmann's procedure | Sigmoid Volvulus | Acute Colonic Pseudo-obstruction | |

Leading cause of acute colonic obstruction. Emergency endoscopic decompression, detorsion and reduction (EDDR) aims to decompress the dilated colon and untwist the volvulus. EDDR is the treatment of choice in uncomplicated patients.

About

• A cause of large bowel obstruction in older patients
• "volvere" to twist or turn

Aetiology

• Redundant loop of sigmoid colon with narrow base of attachment of the mesosigmoid
• Twisting of the sigmoid colon on its mesentery the sigmoid mesocolon.

Associations

• Age of onset: 60-70 years; M>F
• Parkinson's disease, MS
• Chronic constipation and laxative abuse
• Chagas disease, High fibre diet

Clinical

• Intermittent Constipation
• Absolute Constipation and obstruction
• Colicky abdominal pain and distension
• Develops intestinal obstruction +/- Peritonitis
• Abdomen distended, fever, shock if peritonism
• 40-60% have history of previous attacks

Investigations

• AXR: large, dilated loop of the colon, often with a few gas-fluid levels.
• CT: large gas filled loop with evidence of crossing loops of bowel
• Barium enema: :bird's beak Contraindicated if strangulation is suspected

Management

• Detorsion and decompressed initially with flatus tube and if that fails by rigid/flexible sigmoidoscopy, colonoscopy and rectal tube placement can be attempted. There may be a great deal of faeculent material under pressure released. Ensure that you are prepared and well covered and stand out of the line of fire or else you may need a change of clothes and shoes.
• Laparotomy and resection if signs of peritonism, raised WCC, lactate, temp. May need Sigmoidopexy suturing the sigmoid colon to the anterior abdominal wall. Mortality rate is 25% related to bowel ischaemia.
• 40-50% recurrence rate so must be followed by a second operative procedure
• If there is Bowel ischaemia and gangrene: Sigmoid colectomy + end colostomy + mucus fistula or Hartmann's procedure

References

• Sigmoid Volvulus Cases Presentation