CASE

PRESENTATION

PRECEPTOR: DR. JOHN DOMINIC LOCSIN

IDENTIFYING DATA

Name: MJ
Age: 40
Sex: Male
Occupation:security guard
Reliability:90%
CHIEF COMPLAINT

Recurrent abdominal pain

HISTORY OF PRESENT ILLNESS

One month PTA, the patient noted sudden onset of colicky

abdominal pain associated with absence of flatus and bowel movements for 2
days with distention of his abdomen, which suddenly resolved after the 2nd
day. He did not seek any medical consultation at that time because the pain was
relieved on its own.
2 days PTA, the patient had the same abdominal pain, it was
colicky, and he also noted distention of his abdomen and he was not able to
pass out flatus or BM for 2 days. Worried about his condition, the patient went
to the ED.
PAST MEDICAL HISTORY

Patient is a non diabetic

Non hypertensive
Non asthmatic
No history of previous hospitalization
No history surgeries , injuries.
FAMILY HISTORY

No history of diabetes mellitus, hypertension and bronchial asthma in the family.

PERSONAL AND SOCIAL HISTORY

Works as security guard in local mall.

REVIEW OF SYSTEM
General : (-) weight loss ,(-) fever.
Skin : (-) blisters, (-) discoloration.
Head : (-) headache , (-)deformity.
Eyes : (-) redness , (-) dryness.
Ear : (-) hearing difficulty, (-) tinnitus.
Nose : (-) congestion, (-) nose bleeding.
Mouth and Throat:(-) excess salivation, (-) sore throat.
Neck: (-) lumps, (-) stiffness.
 REVIEW OF SYSTEM

Respiratory : (-)shortness of breath, (-) wheezing

Cardiovascular : (-) palpitations, (-)cyanosis, (-) dyspnea,(-)orthopnea
Gastrointestinal : (-)vomiting, (-)diarrhea .
Genitourinary: (-) Difficulty in urination,(-) Blood in urine.
Musculoskeletal : (-) myalgia , (-) arthralgia.
Psychiatric : (-) suicidal ideation, (-)depression, (-)anxiety.
Endocrine : (-) excessive thirst, (-) heat or cold intolerance.
Hematologic: (-) pallor, (-) easy bruising.
 PHYSICAL EXAMINATION
VITAL SIGNS:
HR- 90bpm(normal).
RR- 23(Tachypnea).
BP- 130/70 mmHg( hypertensive).
Temp - 38C(febrile).
ANTHROPOMETRICS:
Ht-5’7
Wt -70 kg
BMI – 24.1
General :Awake, NIRD, Cooperative
Skin : warm, no diaphoresis, rashes, no jaundice

HEENT: Symmetric, no sunken eye balls, no nasal discharge, no hearing loss, pink
palpebral conjunctiva.
Throat and mouth: Pinkish mucosa, no ulceration, no tonsillitis.
Neck : Trachea in midline, no cervical lymphadenopathy.
Chest and lungs:
Inspection: symmetric, no retractions, no chest wall deformities.
Palpation: equal chest expansion,normal tactile fremitus.
Percussion: resonant on percussion.
Auscultation: clear breath sounds, no wheezes, crackles noted.
Cardiovascular:
Inspection: adynamic preordium
Palpation: no heaves and thrills.
Auscultation: distinct S1 and S2 noted.
no murmurs heard.
Abdomen:
Inspection: abdomen distended, no lesions, no scars, no visible veins.
Auscultation: loud metallic sounds.
Percussion: tympanic on all quadrants.
Palpation: no palpable mass, no tenderness. no organomegaly noted.
Extremities: strong pulses, CRT <2 secs,
no edema
 SALIENT FEATURES

PERTINENT POSITIVE IN HISTORY PERTINENT NEGATIVE IN HISTORY

40yrs /M No jaundice
CC- recurrent abdominal pain No vomiting
No bloody stool
HPI – No bilious vomiting
• Sudden onset off colicky abdomen pain 1 month PTA.
• 2 days history of absence of flatus and bowel movements.
• Distention of his abdomen resolved after 2 days.
• 2 days PTA, recurrence of colicky abdominal pain.
 SALIENT FEATURES

PERTINENT POSITIVE IN P.E PERTINENT NEGATIVE IN P.E

PE - Awake, Conscious, NIRD. No abdominal tenderness

No Murphy’s sign
vitals -HR- 90 bpm(normal) No palpable masses
RR- 23(Tachypnea)
BP- 130/70 mmHg
Temp - 38C(febrile)
Ht-5’7 Wt -70kgs BMI – 24.1
Abdomen examination:
Inspection -The abdomen was distended,
Auscultation- loud metallic sounds
Percussion - it was tympanic
 INITIAL IMPRESSION

COMPLETE INTESTINAL OBSTRUCTION PROBABLY

SECONDARY TO SIGMOID VOLVULUS
DIFFERENTIAL DIAGNOSIS
[Link] Abdominal wall hernia

RULE IN RULE OUT

(+) Abdominal distention (-) Nausea

(+) Abdominal pain (-)Bulge in abdomen

(+) No bowel movement for 2 days (-) Vomiting

(+) fever (-) hx of surgery
 [Link] Megacolon

RULE IN RULE OUT

(+) abdominal pain (-) nausea

(+) abdominal distension (-)vomiting

(+)inability to have bowel (-)history of infection

movement s (-) History of chronic
constipation
3. Paralytic Ileus

RULE IN RULE OUT

(-) nausea
(+) abdominal distension (-)vomiting
(-)history of abdominal/pelvic surgery
(+)inability to pass gas or have a bowel (-) opioid use
movement (-)no signs of intra abdominal inflammation
 ADMITTING ORDER
 Admit the patient under service of [Link] under general surgery.
 Secure consent
 Diet NPO
 Monitor vital signs every 4 hrs
 NGT tube insertion for decompression
 Foley Catheter insertion
 Start IVF PLR 104cc/hr.
MEDICATION
- Ceftriaxone 1g IVTT q12hr.
- Omeprazole 40 mg IVTT OD
- Parecoxib 200 mg IVTT BID
- Paracetamol 500 mg IVTT q4h prn fever
ADMITTING ORDER
Order labs:
- Abdominal x ray (erect and supine)
- Chest x ray
- ECG
- CBC with differentials
- Serum creatinine
- Serum electrolytes
- FBS
- Lipid profile
- Urinalysis
- Liver function test
 DOCTORS ORDER

The patient remained stable during the work up period.

Vital signs all remained normal HR 89 (normal) , RR 18 (normal) , BP 130/70(normal), Temp 37
(normal)
CBC WBC 6 normal , Neutrophils 60, HCT 39, Plt 400
Crea 89 normal
Na 140, K 3.7 normal
FBS 5.1, Lipid profile were all normal
SGPT 40 normal
CXR Normal
Urinalysis normal
ECG Normal
Abdominal X Ray
revealed a dilated segment of the large bowel that has occupied the right upper quadrant. A
coffee bean shaped colon was noted. The walls are non thickened and the diameter of the colon
was 8 cms.
- Monitor intake and output q shift
- Refer accordingly, prepare OR for colonoscopic detorsion.
- Refer IM for CP clearance
- Refer anesthesia for preoperative clearance
 DOCTORS ORDER

The patient underwent Colonoscopic detorsion. The procedure was a success and
the patient was discharged 2 days after the procedure.
 FINAL DIAGNOSIS

SIGMOID VOLVULUS
CASE DISCUSSION
 Volvulus

1)Volvulus occurs when an air-filled segment of the colon twists about its mesentery.

2) It can occur at any site in the gastrointestinal tract that is both mobile and long enough to rotate on a
narrow, fixed base.

3)The sigmoid colon is involved in up to 90% of cases, but volvulus can involve the cecum (<20%) or
transverse colon.( these are the most mobile parts)

4) A volvulus may reduce spontaneously, but more commonly produces bowel obstruction, which
progress to strangulation, gangrene, and perforation.
Types of volvulus
The different types can be distinguished with the help of radiological images
All of them present with the symptoms of intestinal obstruction
ANTICLOCKWISE TWIST IN SIGMOID VOLVULUS

 Rotation nearly always occur in anticlockwise direction

 >180 degree rotation-obstruction

 >360 degree rotation-strangulation (Due occlusion of mesenteric vessels)

 As the twist is in anticlockwise direction, for detorsion the bowel is rotated in

clockwise direction.
 E tio lo g y

 Elderly patient with chronic constipation Consumption of high fibre diet

 Increased incidence in institutionalized patients having neuropsychiatric

disorders receiving psychotropic drugs Genetic predisposition identified within
certain families and tribes.

 Average age of patients-40-60 years in developing countries.

 Incidence in higher in males as compared to females due

 to dolichomesocolic anatomy (sigmoid mesocolon is longer than wide) in

males.

 Sigmoid volvulus is rare in children

Sigmoid volvulus is more common in patients with conditions associated with a redundant
sigmoid colon such as

 Chaga's disease, (Trypanosoma cruzi)

 Parkinson disease,

 Chronic neurologic disorders, Diabetes,

 Laxative abuse,

 High-altitude

 Previous surgery involving mobilization of the sigmoid

 colon.
 Epidemiology
Sigmoid volvulus is a condition characterized by the twisting or rotation of the sigmoid colon,
resulting in a bowel obstruction. It is more commonly observed in certain regions of the world
and has specific epidemiological patterns.

1. Geographical Distribution: Sigmoid volvulus is more prevalent in certain geographic

regions, including parts of Africa, Asia, and South America.

2. Age and Gender: Sigmoid volvulus can occur at any age, but it is more commonly seen in
older adults.
CLINICAL FEATURES
SYMPTOMS
Abdominal pain Sudden onset colicky pain in lower abdomen

Abdominal distension (Asymmetric)

Vomiting
Constipation or Obstipation Obstipation-patient cannot pass stool or gas
Hiccough and retching
SIGNS
Percussion of abdomen Tympanic note all over abdomen

Palpation a) No tenderness or rebound tenderness-

Viablebowel
b)Tenderness or rebound tenderness-Non viable
bowel
c) Guarding and guarding all over abdomen-
possibility of perforation
DIAGNOSTIC TESTS
LABORATORY TESTS:
● complete blood count (CBC) with differential : An elevated white blood cell (WBC) count and
left shift indicate bowel ischemia, peritoneal infection, or systemic sepsis. Bowel obstruction may
cause significant changes in electrolyte levels.
● SERUM ELECTROLYTES
● SERUM CREATININE
● SGPT
● CXR
● U/A
● ECG

● Other diagnostic studies include PLAIN ABDOMINAL RADIOGRAPHY, computed

tomography (CT), GASTROGRAFIN ENEMA
 Investigations - Radiological
[Link] abdominal radiograph

a)Coffee Bean sign or bent inner tube

sign(PATHOGNOMOMIC SIGN OF SIGMOID VOLVULUS)

b)Omega loop sign

[Link] enema

a) Birds beak sign

[Link] scan abdomen

a) Whirl sign
PLAIN ABDOMINAL RADIOGRAPH

Plain abdominal radiograph-in sigmoid volvulus

coffee bean bent inner tube

 GASTROGRAFIN ENEMA
A contrast enema should be performed
in patients who show no evidence of
peritonitis and in whom plain
abdominal radiographs are not
diagnostic.
Gastrografin enema shows a
narrowing at the site of the volvulus
and a pathognomonic bird’s beak
appearance.
CT SCAN
The whirl sign is due to the twisting of Mesentery

Axial CT scan abdomen

whirl sign
OTHER FINDINGS SEEN ON PLAIN ABDOMINAL RADIOGRAPHY

Plain abdominal radiograph - in sigmoid volvulus

Northern star sign

Dilated sigmoid colon extending above (Cranial) the transverse colon

OTHER FINDINGS SEEN ON PLAIN ABDOMINAL RADIOGRAPHY

Plain abdominal radiograph-in sigmoid volvulus

Frimann-Dahl sign

Three dense lines, representing the sigmoid walls, are seen

converging towards the site of obstruction in sigmoid volvulus and
associated with empty rectal gas
ENDOSCOPIC DETORSION

● Unless there are obvious signs of peritonitis or gangrene, the initial management of sigmoid
volvulus is resuscitation followed by endoscopic detorsion.
● Detorsion is usually most easily accomplished by using a rigid proctoscope, but a flexible
sigmoidoscopy or colonoscopy may also be effective.
● A rectal tube may be inserted to maintain decompression.
● The bowel is then prepared, and surgery is undertaken electively during the same
hospitalization.
● After adequate decompression, the endoscope is used for untwisting of the bowel loop
● Inability to detorse the sigmoid volvulus endoscopically is an indication for immediate
surgical intervention.

.
 PARAMETERS FOR ENDOSCOPIC DETORSION
● No signs of peritoneal irritation on physical examination at the time of application.

● Findings compatible with sigmoid volvulus in radiological examinations performed at the time of application
(conventional abdominal X-ray and abdominal computed tomography examination).

● No findings of complications (such as intra-abdominal free air, signs of ischemia in the colon wall, and intra-
abdominal stool contamination) in the same radiological examinations.

● Neither shock and/nor sepsis findings (such as hypotension, tachycardia, and fever).

Sigmoidoscopic detorsion is successful in more than 90% of patients with sigmoid volvulus but colonoscopic detorsion is
successful in only 10-15% of patients with cecal volvulus,
 COMPLICATIONS

 Gangrene of bowel

 Perforation and faecal peritonitis Secondary renal failure

 Multiorgan failure

 Abdominal compartment syndrome-rare

 Reperfusion syndrome
It occurs following de-torsion of an ischemic or gangrenous sigmoid colon.
Bacterial toxins may enter into the veins and systemic circulation which may lead to multi-
organ failure in these patients. Control of the vascular pedicle, before untwisting of sigmoid
colon, will reduce the venous drainage of toxins into the circulation but may not be
technically possible
PROGNOSIS

● Any delay in the diagnosis of cecal or sigmoid volvulus can be associated with high
morbidity and mortality.
● Mortality rates appear to be much higher for cecal volvulus compared to sigmoid
volvulus.
● When the volvulus is treated non surgically, rates of recurrence are very high
approaching 40-60%. When surgery is done in unstable patients, mortality rates of 12-
15% have been reported.
A month after, the patient again had an episode of the same signs and symptoms, before
the patient was able to reach the ED, the patient experiences sudden onset of severe
abdominal pain and abdominal distention.
At the ED, the patient was tachycardic, dyspnea and tachypnea. On PE there was
peritonitis on all quadrants.
 IMPRESSION

Acute Abdomen S/P colonoscopic detorsion

of sigmoid volvulus
ADMITTING ORDER
● Admit the patient under service of [Link] under room of choice
● Secure consent
● Diet NPO
● Monitor vital signs every 4 hrs
● Monitor urinary output every 8 hrs
● NGT tube insertion for decompression
● Foley Catheter insertion

MEDICATION

● PARECOXIB IVTT 200 MG,BID

ADMITTING ORDER
LAB ORDERS

● ABDOMINAL X RAY
● CBC
● FBS

PLAN

● HARTMANN'S PROCEDURE
 HARTMANN PROCEDURE ( TWO STAGE
PROCEDURE)

Hartmann's operation includes

[Link] of sigmoid colon
[Link] of the rectal stump
[Link] colostomy done

The timing of the second operation to reverse the colostomy after

the Hartmann procedure is variable and may be done after 4 to 6
weeks,
 FINAL DIAGNOSIS

Generalised Peritonitis secondary to perforated

sigmoid volvulus S/P colonoscopic detorsion ,
Hartmann's procedure.
REFERENCES

● Schwartz’s Principles of Surgery (11th Edition)

● Sabiston Textbook of Surgery (21st Edition)
● Bailey and Love’s Short Practice of Surgery (28th Edition)
THANK YOU DOCTORS