SIGMOID VOLVULUS
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Introduction
• Volvulus refers to torsion of a segment of the alimentary tract,
which often leads to bowel obstruction
• The most common sites of volvulus are the sigmoid colon and
cecum
• Volvulus of other portions of the alimentary tract, such as the
stomach, gallbladder, small bowel, splenic flexure, and
transverse colon, are rare
– Sigmoid colon ~ 80%
– Cecum ~ 15%
– Transverse colon ~ 3%
– Splenic flexure ~ 2%
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Sigmoid volvulus
• It accounts for 80% of all LBO in developing countries
these are young male pts with a staple high fiber
diet
anatomical redundant sigmoid colon is commonly
present
• It accounts for 1-5% of all LBO in Developed world
these are old frail female pts with long Hx. of
constipation
it occurs as a result of secondary sigmoid
elongation
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• Classically, it occurs in anti-clock wise direction
• The site of torsion is approximately 15 cm above the
anal verge .
• The twist results in a closed loop obstruction +
gangrene.
• The degree of torsion is
1800 in 35%
5400 in 10%
360o in 50%
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Pathogenesis
• Occurs when an air-filled loop of the sigmoid colon
twists about its mesentery
• Obstruction of the intestinal lumen and
impairment of vascular perfusion occur when the
degree of torsion exceeds 180 and 360 degrees,
respectively
• A variant of sigmoid volvulus (ileosigmoid knotting)
occurs when the ileum wraps itself around the
sigmoid, usually in a clockwise manner
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Risk factors
• Anatomic factors
a long redundant sigmoid colon with a narrow
mesenteric attachment
it is hypothesized that chronic fecal overloading from
constipation may cause elongation and dilatation of
the sigmoid colon, predisposing pts to sigmoid
volvulus, thereby explaining its higher incidence in
older institutionalized adults with constipation
• Colonic dysmotility: may predispose to torsion
of the sigmoid colon
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Clinical features
• The majority of pts present with the insidious
onset of slowly progressive abdominal pain,
nausea, abdominal distension, and constipation
• Vomiting usually occurs several days after the
onset of pain
• The pain is usually continuous and severe, with a
superimposed colicky component during peristalsis
• Due to the insidious presentation, the majority of
pts usually present 3-4 days after the onset of
symptoms
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• Younger pts may have an atypical presentation
with recurrent attacks of abdominal pain with
resolution due to spontaneous detorsion
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• Lab evaluation including a CBC and electrolytes are
usually normal in pts with sigmoid volvulus in the
absence of gangrene, peritonitis, or sepsis
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Dx
• Hx
• P/E
• Lab
• Imaging----the diagnosis of a sigmoid volvulus
is established by imaging
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P/E
• Distended and tympanitic with tenderness to
palpation
• Fever, tachycardia, hypotension, abdominal guarding,
rigidity, and rebound tenderness are absent in the
early stages of the disease, but if present are
indicative of perforation and/or peritonitis
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Imaging
• Abdominal CT scan
• Abdominal X-ray
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Abdominal CT scan
• Diagnostic findings of sigmoid volvulus include a
whirl pattern, caused by the dilated sigmoid colon
around its mesocolon and vessels, and a bird-beak
appearance of the afferent and efferent colonic
segments
• Typical imaging features may be absent in one-fourth
of CT scans
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Abdominal radiographs
• Typical features-----presence of a U-shaped, distended
sigmoid colon seen as an ahaustral collection of gas
(sometimes referred to as a "bent inner tube") extending
from the pelvis to the right upper quadrant as high as the
diaphragm
• Plain abdominal radiographs can establish the dx of
sigmoid volvulus in only 60% of pts
• Contrast enema(contraindicated if perforation)---the
characteristic appearance of a sigmoid volvulus on contrast
enema is a twisted taper or a bird's beak configuration
where contrast tapers to the point of obstruction
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Mgt
• Goal of Rx:
to reduce the sigmoid volvulus
to prevent recurrent episodes
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Management algorithm
Sigmoid volvulus
Non compelling signs Compelling signs
Deflated Not deflated
Elective surgery laparotomy
Resection Non resectional
Viable Gangrene
Derotation Primary resection Colostomy
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• Sigmoidoscopic guided deflation + Elective
resection and anastomosis
Success: 70-90% of cases, 91% from Gondar
rectal tube should be placed in situ longer
recurrence: 18-90%, Mortality: 5-14
risks: Perforation, reduction of a gangrenous
bowel
followed by elective resection after 2 wks during
the same admission
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Emergency surgery
• Indications
failed rectal tube decompression
Signs of bowel gangrene
• Surgery for a Viable sigmoid
derotation and rectal tube deflation ---recurrence
rate of 14-38%
primary resection and anastomosis
Hartman's procedure
non-resectional treatment
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When to resect ?
• Resection after the first episode ~ 15% mortality.
• Resection after repeated attacks ~ 9%, especially if > 70 years
• Recurrent attacks are protective against gangrenous
transformation
Reason: Increased blood supply as a result of recurrent
episodes
Reason: Fibrotic meso-sigmoid is protective against
vascular compromise
• Conclusion:
resect after the first attack for those younger than 70
years ; second attack for those older than 70 years
• Resection of just the omega loop is enough!
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Gangrenous sigmoid volvulus
• Do not untwist the loop and resection is the rule.
• Resection can be followed by either primary
anastomosis or a Hartman’s procedure.
• Following primary anastomosis, there is a uniform
higher mortality rate!!
• The colostomy should be reversed after 3 months.
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