Volvulus of the gastrointestinal tract.

Volvulus describes the twisting of the intestine or colon around its mesentery. Intestinal obstruction and/or ischaemia are the most common complications of volvulus. Within the gastrointestinal tract, there is a preponderance towards colonic volvulus. The sigmoid is the most commonly affected segment, followed by the caecum, small intestine and stomach. Distinguishing between the differing anatomical locations of gastrointestinal volvulus can be challenging, but is important for the management and prognosis. This article focuses on the main anatomical sites of gastrointestinal volvulus encountered in clinical practice. The aetiology, presentation, radiological features and management options for each are discussed to highlight the key differences.

Volvo do cólon transverso: uma causa rara de abdome agudo cirúrgico / Transverse colon volvulus: a rare cause of surgical acute abdomen

O volvo do cólon é uma condição cirúrgica incomum que ocorre devido a uma torção do eixo mesentérico, situação que resulta em redução parcial ou completa do trânsito intestinal. O cólon sigmóide é o segmento mais envolvido. O presente estudo descreve caso raro de abdome agudo provocado por um volvo do cólon transverso, associado a obstrução intestinal. A tomografia de abdome evidenciou importante distensão e níveis hidroaéreos nos cólons ascendente e transverso, com interposição de alça entre a cúpula diafragmática direita e o dômus hepático (Sinal de Chilaiditi). Foi submetido a laparotomia exploradora com colectomia direita extendida e anastomose íleocólica látero-lateral. O paciente apresentou boa evolução pós operatória. O diagnóstico dessa patologia nem sempre é feito com facilidade, sendo na maior parte dos casos o diagnóstico definitivo realizado no intra-operatória. (AU)

Colonic volvulus is an uncommon surgical condition that occurs due to a twisting around the mesenteric axis, which results in partial or complete reduction in intestinal transit. The sigmoid colon is the most commonly affected segment. We report a rare case of acute abdomen caused by transverse colon volvulus, associated with intestinal obstruction. Abdominal computed tomography showed significant distension and air-fluid levels in the ascending and transverse colons, with loop interposition between the liver and right hemidiaphragm (Chilaiditi's sign). The patient underwent exploratory laparotomy with extended right colectomy and side-to-side ileocolic anastomosis. The postoperative period was uneventful. Diagnosis of this condition is not always easy, and in most cases a definitive diagnosis is made intraoperatively. (AU)

Endoscopic Decompression of Recurrent Sigmoid Volvulus in Pregnancy.

Sigmoid volvulus is a rare condition seen during pregnancy with high maternal and fetal morbidity and mortality. We report a case of a young 26-year-old woman, primipara, in her third trimester who presented with recurrent sigmoid volvulus at both 30 and 32 weeks of gestation. She underwent successful repetitive endoscopic decompression on both admissions with uneventful recovery. Endoscopic evaluation is safe in pregnancy and uncomplicated volvulus. It allows for diagnostic confirmation and assessment of complications; and it has successful outcomes in the presence of a multidisciplinary team.

Cecal bascule after cardiac surgery: A case report.

Cecal bascule is a form of volvulus resulting from upward and anterior cecal folding, and accounts for 0.01% of adult large bowel obstructions. With a competent ileocecal valve, cecal bascule may progress to closed loop obstruction, ischemia, gangrene, or perforation. Failure to treat cecal bascule has a mortality of 50%. Nonoperative management includes nasogastric and colonoscopic decompression, with a 95% failure rate. The gold standard is right hemicolectomy with a near nonexistent recurrence rate. Severe gastrointestinal complications following cardiothoracic surgery may lead to increased morbidity, length of stay, and mortality. Here, we present the first reported case of cecal bascule following cardiac surgery.

Prognostic value of colonic and peripheral venous lactate measurements in horses with large colon volvulus.

OBJECTIVE: To determine the prognostic value of (1) colonic venous lactate or peripheral lactate values obtained before and after manual correction of a large colon volvulus and (2) a combination of variables including pelvic flexure biopsy. STUDY DESIGN: Prospective clinical study. ANIMALS: Forty adult horses in which large colon volvulus was diagnosed intraoperatively. METHODS: Colonic venous, peripheral venous, and arterial blood samples were collected to measure lactate values before and after manual correction. Mucosal biopsy samples were obtained in cases that underwent enterotomy or colonic resection and anastomosis. Interstitium to crypt (I:C) ratio and hemorrhage scores were measured. Optimal cutoff values were determined by receiver operator curve analysis, and associations between variables and short-term outcome were determined by univariable regression. Short-term survival was defined as horses being discharged from the hospital. P ≤ .05 was considered significant. RESULTS: No association was found between colonic venous lactate values before (P = .011) or after (P = .201) manual correction of large colon volvulus and determination of short-term outcome. Peripheral venous lactate at admission ≥3.2 mmol/L and after manual correction ≥5 mmol/L, arterial lactate postmanual correction ≥3.53 mmol/L, and histomorphometric measurements of mucosal hemorrhage ≥3 and I:C ratio > 1 were associated with poor short-term outcome. CONCLUSION: Peripheral lactate values, histomorphometric measures of I:C ratio, and hemorrhage score provided prognostic information that could help guide recommendations made to owners. CLINICAL SIGNIFICANCE: Peripheral lactate values after manual correction provide important intraoperative diagnostic information to assist in predicting case outcome in the operative and immediately postoperative period.

American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of acute colonic pseudo-obstruction and colonic volvulus.

Colonic volvulus and acute colonic pseudo-obstruction (ACPO) are 2 causes of benign large-bowel obstruction. Colonic volvulus occurs most commonly in the sigmoid colon as a result of bowel twisting along its mesenteric axis. In contrast, the exact pathophysiology of ACPO is poorly understood, with the prevailing hypothesis being altered regulation of colonic function by the autonomic nervous system resulting in colonic distention in the absence of mechanical blockage. Prompt diagnosis and intervention leads to improved outcomes for both diagnoses. Endoscopy may play a role in the evaluation and management of both entities. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on the evaluation and endoscopic management of sigmoid volvulus and ACPO.

Comparative study of intestinal malrotation in infant, children, and adult in a tertiary care center in India.

BACKGROUND: Intestinal malrotation (IM) is an uncommon condition and has varied presentation in different age groups. The study was aimed to evaluate differences in the clinical presentation, diagnosis, treatment, and outcome of IM in infants, children, and adults. METHODS: Data were collected from records of 79 patients with IM. Based on the age of presentation, these patients were categorized into three age groups: infants (up to 1 year), children (1-18 years), and adults (> 18 years). Follow up data were analyzed during 8 to 16 year after corrective surgery. RESULTS: The overall age of presentation ranged from 8 days to 60 years. Twenty-eight, 29, and 22 patients belonged to the infant, children, and adult groups, respectively. The classical presentation of IM (bilious vomiting) was significantly higher in the infant compared to the children and adult groups (100% vs. 62% vs. 9.8%; p < 0.001). All infants presented with acute symptoms. However, children and adults had subacute or chronic presentations, respectively. The incidence of volvulus was significantly higher in the infant group than other two groups, (100% vs. 41% vs. 10%; p < 0.001). Doppler ultrasound was highly accurate in infants (100%), whereas contrast-enhanced computed tomography (CECT) abdomen was found to be most useful in adults. Postoperative complications were more common in adults. CONCLUSION: Intestinal malrotation can present in patients of any age group. An increased awareness about the atypical presentations of this condition among adults may reduce the time to accurate diagnosis of this disease.

[Sigmoid volvulus at the University Hospital of Iceland 2000-2013].

Backround Sigmoid volvulus is an uncommon cause of bowel obstruction in most western societies. Treatment options include colonoscopy in uncomplicated disease with elective surgery later on. The aim of this study was to assess what treatment sigmoid volvulus patients receive along with long-term outcomes at Landspitali University Hospital. Methods The study was retrospective. Patients diagnosed with sigmoid volvulus at Landspitali University Hospital from 2000-2013 were included. Information regarding age, sex, and duration of hospital stay, treatment, short and long-term outcomes were gathered. Results Forty-nine patients were included in the study, of which 29 men and 20 women. Mean age was 74 (25-93). One patient underwent acute surgery on first arrival due to signs of peritonitis. Others (n=48) were treated conservatively in the first attempt with colonoscopy (n=45), barium enema (n=2) and rectal tube (n=1). Three other patients underwent acute surgery due to failed colonoscopy, 8 patients had planned surgery during the index admission. Thirty-six patients were discharged after conservative treatment with colonoscopy (n=35), barium enema (n=1) or rectal tube (n=1). Two patients came in for elec-tive surgery later on. Twenty-two patients (61%) had recurrence. Median time to recurrence was 101 days (1-803). Disease-free probability in 3, 6 and 24 months was 66%, 55% and 22% respec-tively. Total disease related mortality was 10.2%. Mortality (30 days) after acute surgery was 25% (1/4) and 16,6% (3/18) after planned surgery. Conclusions Sigmoid volvulus has high recurrence rate if not treated operatively. Total mortality due to sigmoid volvulus at Landspitali is low but surgery related mortality high.

Nonsurgically Treated Sigmoid Volvulus in a Young Patient 3 Days After Renal Transplant.

Sigmoid volvulus is a rare clinical condition in young individuals. It should be accurately diagnosed and treated in a rapid manner. Surgical and nonsurgical conservative methods are used for the treatment of sigmoid volvulus. Patients having no signs of perforation or peritonitis should be primarily treated by colonoscopic detorsion. A delay in the diagnosis and treatment of this condition may cause significant morbidity and mortality in an immunosuppressed patient with newly performed renal transplant and diffuse abdominal pain. This paper reports a young patient who was diagnosed with sigmoid volvulus during admission with sudden-onset abdominal pain and distension after having undergone renal transplant from a living donor 3 days previously. The patient avoided the burden of a second surgical intervention by a bedside endoscopic detorsion procedure.

Risk of recurrence of sigmoid volvulus: a single-centre cohort study.

AIM: Sigmoid volvulus is a condition with a tendency to recur if treated conservatively. Little is known about the best type of treatment or when to perform definitive surgery. The aim of this study was to review treatment, and assess the outcome, of sigmoid volvulus in adult patients treated at a Swedish university hospital. METHOD: The medical records of patients treated for sigmoid volvulus at Sahlgrenska University Hospital, Sweden from January 2000 to September 2016 were reviewed retrospectively. Median follow-up time was 8.3 years. RESULTS: One hundred and sixty-eight patients were included with a total of 453 admissions for sigmoid volvulus. Nonoperative decompression was attempted as the initial treatment in 438/453 (97%), with a success rate of 92% (403/438), which was not influenced by whether it was the first episode or a recurrence. Without planned surgery, recurrence occurred after 84% of successful nonoperative decompressions with a median of two recurrences (1-16). Recurrence was less common after the first episode compared with subsequent episodes. Median time until recurrence was 58 days. Mortality after planned surgery following successful decompression was 3.3% (2/61) compared with 13% (6/46) following emergency surgery. CONCLUSION: In our cohort, the recurrence rate of sigmoid volvulus following successful nonoperative decompression was high. Still, more than 20% of patients did not experience a recurrence after their first episode. Nonoperative decompression could thus be suggested as the sole treatment for the first episode of volvulus. However, after the second episode it is probable that early planned surgery would improve outcome and reduce health-care consumption.

Sigmoid volvulus in children: a case report.

BACKGROUND: Sigmoid volvulus is frequently reported in the "volvulus belt" (Middle East, Africa, the Indian subcontinent, Turkey, and South America) and is the third leading cause of large bowel obstruction in North America. It is an uncommon problem in children and adolescents, and is rarely considered a diagnosis in this group. A high index of suspicion is necessary to diagnose sigmoid volvulus in children. CASE PRESENTATION: We present a 13-year-old Arabian girl who came with features suggestive of intestinal obstruction. Plain abdominal film revealed classic omega (coffee bean) sign of sigmoid volvulus. The volvulus was successfully decompressed by means of a rectal tube in our emergency department. The next day during the same admission the volvulus recurred and was successfully decompressed by endoscopy. She was discharged home on her parents' request; she presented again 1 month later. This time the volvulus could not be decompressed non-operatively, so she underwent sigmoidectomy with primary anastomosis. Postoperatively she developed paralytic ileus that resolved after 10 days. Following that she did well and was discharged home. She is still free of symptoms 1 year after the resection. CONCLUSIONS: Sigmoid volvulus is an uncommon problem in children and adolescents, and is rarely considered a diagnosis in this group as a cause of intestinal obstruction. Pediatric surgeons should maintain a high index of suspicion, in order not to miss this important diagnosis, as any delay in instituting treatment has a devastating effect on morbidity as well as mortality. Early diagnosis and prompt treatment confer an excellent prognosis.

Food engorgement in 35 dogs (2009-2013) compared with 36 dogs with gastric dilation and volvulus.

The clinical features and management of food engorgement (FE) in dogs have not been previously described. This retrospective observational study describes characteristics and outcome of 35 dogs with FE, and compares features on presentation to 36 dogs with gastric dilation and volvulus (GDV). Cases were retrospectively reviewed for history, clinical findings and outcome. Gastric distension was measured by caudal gastric margin (CGM), level with lumbar vertebrae, on a lateral abdominal radiograph. Frequent characteristics of dogs with FE included tachycardia, tachypnoea, hyperproteinaemia, increased base excess (BE), mild hypernatraemia and hyperlactataemia. There was overlap in CGM between dogs with GDV (CGM range L3 to >L6) and dogs with FE (CGM range

Megacolon andino y vólvulo del sigmoides de la altura: Presentación de 418 casos entre 2008 - 2012 en el hospital C. Monge - Puno, Perú / Andean megacolon and sigmoid volvulus in the high altitude: Presentation of 418 cases between 2008 - 2012 at C. Monge Hospital, Puno, Peru

Objetivo: El presente estudio describe el manejo médico y quirúrgico del vólvulo de sigmoides debido a dolicomegacolon andino en un hospital a una altitud mayor a 3000 msnm. Material y métodos: Estudio descriptivo, observacional, transversal de 418 pacientes con diagnóstico de vólvulo de sigmoides; admitidos inicialmente por cuadros de obstrucción intestinal, en el Hospital de Juliaca Carlos Monge - Puno, Perú, durante el periodo 2008-2012. Los datos fueron procesados a través del programa SPSS versión 21. Resultados: Se registraron 418 pacientes, la media de edad fue de 60 años, rango 18-89 años, con una proporción hombre/mujer de 3,5/1. El manejo no quirúrgico se hizo en 64 (15,4%), el tratamiento empleado fue de enema salino 20 casos 31% y sonda rectal 44 (69%), se presentó recurrencia en 27 pacientes (45%), los cuales tuvieron cirugía con resección anastomosis primaria, de estos la mortalidad correspondió a 8 pacientes (30%). De los 354 pacientes sometidos a manejo quirúrgico de emergencia 325 fueron sometidos a sigmoidectomia con anastomosis primaria (92%), mientras 29 tuvieron colostomía a lo Hartmann (8%), la morbilidad para ambos procedimientos fue de 52 casos (14,7%), la mortalidad para ambos procedimientos fue de 45 casos (12,7%). Conclusiones: El vólvulo sigmoides debido a megacolon andino tuvo una edad media de 60 años. El 15,4% tuvo manejo no quirúrgico, la tasa de recurrencia fue de 45%, mortalidad de 30%. El 84,7% tuvo manejo quirúrgico; el 92% tuvo resección anastomosis primaria y 8% colostomía a lo Hartmann, la morbilidad fue de 14,7% y la mortalidad de 12,7%.

Objective: The present study describes the medical and surgical management of sigmoid volvulus due to Andean dolicomegacolon in a hospital at an altitude above 3000 m. Material and methods: A descriptive, observational, crosssectional study of 418 patients diagnosed with sigmoid volvulus; Admitted initially due to intestinal obstruction, in the Hospital of Juliaca Carlos Monge. Puno-Perú, during the period 2008-2012. The data were processed through the SPSS software version 21. Results: A total of 418 patients were enrolled, the mean age was 60 years, range 18-89 years, and the male/female ratio was 3.5/1. Nonsurgical management was done in 64 (15.4%), the treatment used was saline enema 20 cases (31%) and rectal catheter 44 (69%), recurrence was present in 27 patients (45%), who had surgery with primary anastomosis resection, of which the mortality corresponded to 8 patients (30%). Of the 354 patients undergoing emergency surgical management, 325 were submitted to sigmoidectomy with primary anastomosis (92%), while 29 had Hartmann's colostomy (8%), the morbidity for both procedures was 52 cases (14.7%), Mortality for both procedures was 45 cases (12.7%). Conclusions: In patients with sigmoid volvulus due to Andean megacolon the mean age was 60 years. The 15.4% had non-surgical management, the recurrence rate was 45%, and mortality 30%. Patients with surgical management was 84.7%, from this group; 92% had primary anastomosis resection and 8% Hartmann colostomy, morbidity was 14.7% and mortality was 12.7%.