SIGMOID VOLVULUS

RASHID SWED S. (MD4)

MWANYINGILI JOHN A. (MD3)
PART 1:CASE PRESENTATION
WM 75 years old male ,a peasant from Rungwe
Referal case from Makandana hospital
He came with chief complaign of abdominal
distension for 7 days
….
The patient was apparent well until 7 days ago when
he started experiencing sudden onset of abdominal
distension which was more marked on the right upper
part of the abdomen and right lower part of the
abdomen
The distension was progressive increasing with time
and it was associated with abdominal pain,vomiting
and lack of passing stools
He denied any history of vomiting blood or passing
loose stools.
…
The patient has no history of previous operation on
the abdomen,taking high fiber diet , the excessive use
of laxative drugs or the previous history of difficult in
passing stools.
ROS
CNS
The patient denied history of headache,diziness,loss
of consciousness visual problems or auditory problems
Cardiorespiratory system
He denied history of chest pain,coughing,or difficult
in breathing
He also had no heartbeat awareness,shortness of
breath,or air hunger at night
…
GUT
The patient denied to have blood in urine,painful
urination,or change in frequency of urination
Musculoskeletal system
He had no join pain or genealized body weakness
PMHX
He has never been admitted before,blood
transfusion,drug allergies or any chronic illness
FSHX
He is married and living with his wife with 9 children.
He do not smoke or drink alcohol
SUMMARY 1
A 75 years old male patient,referal from Makandana
hospital.
Was presenting with abdominal distension for 7 days
associated with abdominal pain,vomiting and lack of
passing stools.
GENERAL EXAMINATION
He was allert and oriented to people,place and time
He has normal hair texture,colour and distribution
He has no eye,ear or nose discharge
He was not pale ,cyanotic or jaundiced
Has no finger clubing
He had no any palpable lymph node or lower limb
swelling
VITALS
BP=129/102 mmHg
Temp=36.7C
PR=88BPM regural
RR=25 cycles per min
SYSTEMIC EXAMINATION
ABDOMINAL EXAM
He had an asymmetrical distended abdomen which
moves with respiration and deviated to the right upper
quadrant ,and right iliac region(defining a sausage shaped
abdomen)
He had a flat umbilicus and therapeutic marks
He had a generalized tender abdomen with no any
organomegally or any mass palpated
 He had a hypertympanic pulcasion note and 8 exagerated
bowel sounds per minute were heard on auscultation
On genitalias there was scrotal swelling above reached

On DRE the rectum was empty and gloved finger

stained mucus
CNS
The patient was alert with GCS of 15/15
All Cranial nerves were intact
He had a normal muscle bulkness,power and tone
He had no neck stiffness,negative kernings sign as well
as negative brudzinsk sign
Normal coordination and gait
CVS
He has no neck vein distension,no precordial
hyperactivity
Apex beat was felt at 5th ICS along the MCL
No any palpable murmur(heaves or thrills)
On auscultation normal s1 and s2 were heard with no
any added murmur
RS
The chest was elliptical bilateral symmetric moving
with respiration
He has no any therapeutic marks
The trachea is centrally located
He had normal vocal fremitus
A normal resonant sound were heard on percusion
Normal vesicular sounds were heard on auscultation
SUMMARY2
A 75 years old male patient was presenting with
abdominal distension for 7 days which was associated
with abdominal pain, vomiting and constipation
On examination he had an asymmetrical distended
abdomen with sausage shape which was tender on
palpation and had hyper tympanic note and
exaggerated bowel sounds.
The provisional diagnosis is mechanical intestinal
obstruction 2nd to sigmoid volvulus
Ddx
Distended and downward displaced transverse colon
Sigmoid colon CA
Rectal CA
INVESTIGATIONS
Plain abdominal xray in supine and erect
Supporting investigations
 FBP
 Serum electrolytes
 Blood grouping and xmatching
PLAN
Pre laparatomy
Catheterization
NGT
IV fluid infusion
Metronidazole
In theatre
Aseptic technic
Laparatomy
Extended midline incision
Resection and imediately anastomosis
Blood transfusion
Abdominal lavage with RL
Rubber drainage and abdominal close
POST OPP ORDER
Vitals
Anti pain
Maintanace fluid
PART 2: LITERATURE REVIEW

VOLVULUS
a condition in which bowel become twisted on its mesenteric axis
resulting in complete or partial intestinal obstruction.

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Classifications:
Site: Sigmoid volvulus
Caecal volvulus
Transverse colon volvulus
Small bowel volvulus
stomach volvulus
Type: simple
& compound- ileosigmoidal knoting
Clinical: Acute fulminating volvulus
acute onset of severe abd pain, vomiting & abs constipation, toxic
tachycardia (?? Perforation if increased pulse without pyrexia and
absent bowel sound)
& sub acute volvulus abdominal distenson with minimal
tenderness
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Anatomy
 Sigmoid is the last part of
colon measuring about 38
cm in length.
 It is anchored to the dorsal
abdominal wall by the
mesocolon which is a fan
shaped.
 Its main function is
absorption of fluid and
electrolyte from semi
digested intestinal contents.

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PREDISPOSING FACTORS:
 Age 60+
 Psychotropic drugs
 Bands from previous operation
 Overloaded sigmoid colon?? High fiber vegetable diet & roughage,
bulky food after fasting
 Laxatives, antiparkinsonian, anticholonergic e.g anthraquinone lead to
myeteric plexus injury and result in constipation and megacolon
 Conditions:
Chagas’ disese, 30% develop s.v
Pregnacy, 44% of int obstruction in preg is due to s.v
DM, paralysis, Vit B defficiency
 Chronic constipation
 Round worms infestation

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EPIDEMIOLOGY

 Sigmoid volvulus comprises 60 – 75% of large bowel volvulus

followed by cecal and tranverse colon and causes 8% of the
intestinal obstruction.
3rd cause of I.O

 It is common in males compared to female (83%). Male has longer

sigmoid colon, female has wider pelvis and more space for the colon
to detorse spontaneously
 The commonest age is above 50 yrs
 Epidemiological profile based on geographical regions, It is
common in south America, Africa, and parts of Asia.
 Mortality rate is 20-25%

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PATHOGENESIS
The actual cause why
the intestines start to
twist around its
mesentery is not known
yet.
Partial twisting of the
sigmoid colon occurs
but most of them
resolve spontaneously.

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PATHOGENESIS…..
 Food, fluids, digestive secretions, and gas accumulate in the bowel
if obstruction is complete.
 The proximal bowel distends, and the distal segment collapses.
 The normal functions of the mucosa are depressed, and the bowel
wall becomes oedematous and congested.
 Complete intestinal obstruction is causes progressive, increase in
peristalsis
 Accumulation of secretions, oedema and vomiting increases the
risk of dehydration, gangrene and perforation, peritonitis, and
death.

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PATHOGENESIS…..
 When the twisting continues it
causes ischemia of the bowel
wall hence gangrene
 Strangulation initially begins
with venous obstruction, which
may be followed by arterial
occlusion, resulting in rapid
ischemia of the bowel wall.
 The bowel becomes
oedematous, ,leading to
gangrene and perforation.

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 TWISTING AIR CAN GET
IN BUT NOT OUT

GASEOUS DISTENSION
ISCHEMIA
COMPROMISE
GANGENE
VENOUS RETURN
PERFORATION

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 CLINICAL PRESENTATION

Relative or absolute constipation

Abdominal distension
Abdominal pain
Vomiting is a late feature
?? Perfortion = tachycardia –pyrexia & absent bowel
sound

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 CLINICAL PRESENTATION..

Dehydration, Patient may present with shock

Abdominal distension usually asymmetrical
Tympanic mass either in the RUQ or center of the
abdomen.
Bowel sounds are exaggerated in the beginning but
later became reduced and absent.
Rectal examination reveal empty rectum.

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Investigation
 Plain abdominal X Ray

 Coffee bean sign/ bent inner

tube with convexity in the
RUQ/large horse shoe.
 Distended loop of sigmoid
colon with loss of haustral
markings
 Air flid ratio of greater than 2:1
& double air fluid levels.

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Radilogical findings…
 Omega sign
 A gas filled dilated loop running
diagnonally from right to left
toward the pelvis.
 Frimann Dahl’s sign
Edematous double walls of dilated
bowels and outlines of lines
converging to LIF where
mesocolon is twisted
 Northern exposure sign dilated
sigmoid colon ascending to
transverse colon

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Barium enema studies

 Indication- atypical plain

radiography
 Contraindication-
gangrenous sv

 Birds beak deformity 15 to

25 cm from anal verge
 Narrowing at the site of
obstruction.

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Other investigations
CT scan
MRI
Sigmoidoscopy
Supporting investigations
 FBP
 Serum electrolytes
 Blood grouping and xmatching

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Differential diagnosis

Distended and downward displaced transverse colon

Sigmoid colon CA
Rectal CA

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MANAGEMENT…..
Aims
Relieve obstruction
Prevent recurrence
Lower morbidity and mortality

Plans of management
General resuscitation
 Fluid and electrolyte replacement
 NGT
 Antibiotics
Conservative
 Endoscopic detorsion using rectal tube, sigmoidoscope, colonoscope,
rigid proctoscope.
surgery

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SURGICAL

emergencyLaparotomy
Indications
 decompression by flatus tube or clonoscopy fails
 ishaemia is suspected
 features of peritonitis
 there is doubt about diagnosis

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Common findings
 Distended sigmoid colon
 Bowel may be viable or non viable.

 Twisting at the base of the mesentery usually

counter clockwise.
 1800 (35%)

 3600 (50%)

 5400 (10%)

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Protocol at BMC

Emergency
Untwisting + decompression
Resection of the redundant viable or gangrenous
bowel
Viable- immediate primary anastomosis
Gangrenous- hartman procedure or paul
mickulicz procedure

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Resection & Primary anastomosis
Adv: One stage procedure
DisAdv:anastomotic dehiscence
Contrainication:very elderly patient, shocked
pt,clinically poorly blood supply/ oedematous
proximal & distal stump, inadequate facilities

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Hartmans procedure
Exteriorisation of proximal stump as terminal colostomy
at LIF and distal stump is closed and left in pelvic
cavity with marker.
Bowel continuity is re-established after 3monhs at
relaparotomy.
Adv: relatively short procedure, fit of elderly and high
risk patient patients
DisAdv: two staged procedure

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outcome
Determinant of out come
 bowel viability. MR viable sc <12% gangrenous <53%
Delay of RX MR > 60%
Co- morbidity

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References
Sabiston textbook of Surgery 17th ed; Beuchamp,
Evers& Mattox: Pg1422-24
Surgery of the Anus, Rectum & Colon 1st ed; Keighley&
William: Pg 1849-52
Schwatz’s Principles of Surgery 8th ed;Pg1098-99
Surgery of the Anus, Rectum & Colon
patrick, Mazier, david, Levier: Pg 657-62
Lecture notes

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