Synchronous sigmoid-cecal volvulus: a rare case of large-bowel obstruction-a case report.

INTRODUCTION AND IMPORTANCE: Large bowel obstruction caused by volvulus poses a life-threatening risk without immediate intervention. Sigmoid colon volvulus is predominant (43-75%), followed by cecal volvulus 10-52%). Synchronous double colonic volvulus is extremely rare, with limited documented cases in academic literature. CASE PRESENTATION: We report a case of synchronous volvulus involving the sigmoid colon and cecum in a 45-year-old male of the Toro tribe from Fort Portal city in western Uganda who presented with acute abdominal pain, distension, and complete constipation for 2 days, accompanied by five episodes of non-bloody feculent vomiting and anorexia. CLINICAL DISCUSSION: Upon admission, the patient presented with stable vital signs and a mildly tender, tympanic, distended abdomen with absent bowel sounds. Plain radiographs revealed the characteristic "coffee bean" sign, indicative of sigmoid volvulus. Following optimization, laparotomy confirmed synchronous volvulus involving both the sigmoid and cecum. Subsequently, a total colectomy with end ileostomy was performed, after which the patient experienced an uneventful recovery. CONCLUSION: Synchronous double colonic volvulus, a rare condition, is frequently overlooked clinically. Timely recognition and intervention are crucial to address diagnostic challenges and prevent potentially fatal outcomes.

Intestinal Malrotation in a Patient with Gastric Cancer during Laparoscopic Total Gastrectomy: A Case Report.

AIM: Intestinal malrotation (IM) represents a rare congenital anomaly in adults, although it is more common during infancy. This condition originates during embryonic development due to incomplete rotation of the midgut around the superior mesenteric vessels. The primary aim of this case study is to emphasize the importance of surgeon awareness and recognition of this congenital anomaly during laparoscopic gastric surgery to avoid serious complications. CASE PRESENTATION: A 45-year-old male presented to the clinic with a complaint of vague epigastric pain for two months. The patient underwent a comprehensive clinical evaluation, including laboratory tests, endoscopic examination, and radiological imaging. The diagnostic workup revealed early-stage gastric cancer. Incidentally, radiological studies also demonstrated a congenital non-rotation of the small bowel. Given the patient's congenital anatomical anomaly, a laparoscopic total gastrectomy was performed employing a reversed C-shaped Roux-En-Y limb reconstruction. Postoperative recovery was uneventful, and the patient was discharged in stable condition. RESULTS: The patient was doing well at the 2-year follow-up, there were no complications related to the form of anastomosis, and the pathological result was comparable to that of patients with non-rotating small bowls. CONCLUSIONS: Intestinal malrotation is an uncommon asymptomatic congenital abnormality in adults. During laparoscopic gastric surgery, the surgeon should identify this anomaly to optimize surgical approaches, particularly during anastomosis formation. Accurate identification and appropriate management of intestinal malrotation are crucial to mitigate potential postoperative complications, including twisting, obstruction, tension, and anastomosis leak.

Endoscopic detorsion of sigmoid volvulus in a young female: a case report.

BACKGROUND: A volvulus refers to the torsion or rotational twisting of a portion of the gastrointestinal tract, with a predilection for impacting the caecum and sigmoid colon, often resulting in the development of bowel obstruction. The risk factors associated are old age, chronic fecal impaction, psychiatric disorders, colonic dysmotility, prior abdominal surgical procedures, diabetes, and Hirschsprung's disease. Elderly are most commonly affected with sigmoid volvulus but there are few cases among young adults that culminate in grave complications. Although it is rare, but young individuals presenting with acute abdomen secondary to sigmoid volvulus need urgent attention. To prevent more invasive surgical procedures, endoscopic detorsion is preferred nowadays with complete recovery of patients. We present a case of young female who was successfully managed with endoscopic detorsion. CASE PRESENTATION: 27 years old Asian Pakistani female presented with worsening abdominal distention, constipation and vomiting since 2 days. On examination she was afebrile, vitally stable. Abdomen was distended, tympanic percussion with generalized tenderness. Abdominal radiograph was obtained which showed dilated bowel loops followed by Computed tomography of abdomen which was suggestive of Sigmoid volvulus causing intestinal obstruction. Patient was immediately moved to endoscopy unit and endoscopic detorsion of volvulus was done. For individuals who present with sigmoid volvulus and do not exhibit signs of peritonitis or colonic gangrene, the recommended course of action involves acute endoscopic detorsion, followed by scheduled surgical intervention. CONCLUSION: This case report emphasizes the significance of clinicians considering sigmoid volvulus as a rare but important cause when evaluating abdominal pain in young and otherwise healthy patients. A delay in diagnosis and treatment extending beyond 48 hours leads to colonic necrosis, amplifying the associated morbidity and mortality. Swift intervention is imperative to mitigate these complications and attain a conclusive remedy.

Presentations of Waugh's syndrome:intra-luminal cecal cyst and trans-anal prolapsing intussusception: a case report.

BACKGROUND: Intussusception with intestinal malrotation is termed as Waugh's syndrome. The incidence of Waugh's syndrome is less than 1%. There are very few reported cases. Once presented, it is a pediatric surgical emergency. CASE PRESENTATION: We present here two cases of Waugh's syndrome: an 11-month-old male patient of Punjabi descent and a 4-month-old female patient of Afghan descent who presented to us with abdominal pain and bleeding per rectum. Abdominal sonography revealed an intussusception with a target sign. They were explored and perioperatively had intestinal malrotation alongside intussusception, thus a diagnosis of Waugh's syndrome was made. A right hemicolectomy and Ladd's procedure was performed. CONCLUSION: Waugh syndrome is a rare congenital anomaly but can present with vague abdominal symptoms. Once presented, it is a pediatric surgical emergency. The patient should be optimized followed by surgical exploration.

Cecal volvulus - a rare cause of acute abdomen with ileus.

In this article, we present case reports of two patients admitted to the University Hospital in Pilsen for acute abdomen due to a disorder of the passage through the gastrointestinal tract (GIT). Both were indicated for surgery. The patients were diagnosed intraoperatively with rarely occurring cecal volvulus (CV). The findings required an ileocecal resection; nevertheless, both patients fully recovered despite the need the resection.

Modified cranial approach to right-sided colon cancer in a patient with intestinal nonrotation: A case report.

Managing colon cancer with intestinal nonrotation, a type of congenital intestinal malrotation, is challenging due to the presence of anatomical abnormalities and severe adhesions. When patients have nonrotation, it is markedly more difficult to determine which vessels correspond to the colic vessels and ileal vessels until all vascular branching patterns become evident. The optimal approach for right-sided colon cancer with intestinal nonrotation has yet to be established. In the present case of ascending colon cancer with intestinal nonrotation, we performed laparoscopic right hemicolectomy with D3 dissection using a modified cranial approach. This approach involves tracing, without resecting, branches from the superior mesenteric vein and superior mesenteric artery in a cranial-to-caudal manner until the ileocolic artery and ileocolic vein, which course toward the cecum, are identified, followed by the dissection of the colic vessels and lymph nodes in a caudal-to-cranial fashion.

Sigmoid and cecum colon volvulus: a case report.

INTRODUCTION: Colon volvulus is the twisting of a segment of colon on its mesenteric axis, which can lead to the obstruction of the lumen and the blood supply. Colon volvulus is common in "volvulus belt" countries and can involve the sigmoid (60-70%) and cecum (25-40%). CASE PRESENTATION: We report a case of a 47-year-old male, Alawites, who presented with bowel obstruction and dilated abdomen without any specific abdominal pain. Abdominal laparotomy showed both sigmoid and cecum volvulus with no signs of perforation or ischemia. DISCUSSION AND CONCLUSION: One of the possible risk factors of sigmoid colon volvulus is the length of the rectum and sigmoid, while mobile cecum is considered as a possible reason for cecum volvulus. The management remains controversial and is specific for every case, depending mainly on the vitality of the colonic walls and the general condition of the patient.

Dependent functional status is an independent risk factor for 30-day mortality and morbidities following colectomy for volvulus: An ACS-NSQIP study from the United States.

OBJECTIVES: Colonic volvulus is a common cause of bowel obstructions and surgery is the definitive treatment. Functional status is often associated with adverse postoperative outcomes but its effect on colectomy for volvulus remained under-explored. This study sought to analyze the effect of functional status on the 30-day outcomes of colectomy for volvulus. MATERIALS AND METHOD: National Surgical Quality Improvement Program (NSQIP) targeted colectomy database from 2012 to 2022 was utilized. Only patients with volvulus as the primary indication for colectomy were included. Thirty-day postoperative outcomes were compared between patients with dependent functional status (DFS) and independent functional status (IFS), adjusted for demographics, baseline characteristics, preoperative preparation, indication for surgery, and operative approaches by multivariable logistic regression. RESULTS: There were 1,476 patients with DFS (945 partially DFS and 531 fully DFS) and 8,824 (85.67 %) IFS patients who underwent colectomy for volvulus. After multivariable analysis, DFS patients had higher risks of mortality (aOR=1.671, 95 CI=1.37-2.038, p < 0.01), pulmonary complications (aOR=2.166, 95 CI=1.85-2.536, p < 0.01), sepsis (aOR=1.31, 95 CI=1.107-1.551, p < 0.01), prolonged postoperative nothing by mouth (NPO) or nasogastric tube (NGT) use (aOR=1.436, 95 CI=1.269-1.626, p < 0.01), discharge not to home (aOR=3.774, 95 CI=3.23-4.411, p < 0.01), and 30-day readmission (aOR=1.196, 95 CI=1.007-1.42, p = 0.04). Moreover, DFS patients had a longer length of stay (p = 0.01). CONCLUSION: DFS was identified as an independent risk factor for increased mortality and complications after colectomy for volvulus. Given the substantial overlap between DFS patients and those who have colonic volvulus, these insights can contribute to preoperative risk assessments and postoperative care in these patients.

High risk and low incidence diseases: Pediatric digestive volvulus.

INTRODUCTION: Pediatric digestive volvulus is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of pediatric digestive volvulus, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: Pediatric digestive volvulus is a deadly condition most commonly associated with malrotation. It occurs when the stomach or small intestine twists on itself, resulting in ischemia and potentially strangulation with necrosis and perforation. Presentation differs based on the gastrointestinal (GI) segment affected, degree of twisting, and acuity of the volvulus. Gastric volvulus most commonly presents with retching with or without nonbilious emesis and epigastric distension with pain, while midgut volvulus typically presents with bilious emesis in infants. Patients with GI necrosis and perforation may present with hemodynamic compromise and peritonitis. If suspected, emergent consultation with the pediatric surgery specialist is necessary, and if this is not available, transfer to a center with a pediatric surgeon is recommended. Imaging includes plain radiography, ultrasound, or upper GI series, while treatment includes resuscitation, administration of antibiotics, and emergent surgical decompression and detorsion of the involved segments. CONCLUSION: An understanding of pediatric digestive volvulus and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease.

Multiple endocrine neoplasia type 2B diagnosed after small intestinal volvulus with progressive megacolon in an adolescent.

Multiple endocrine neoplasia type 2B is a rare autosomal dominant disease characterized by the presence of medullary thyroid carcinoma, pheochromocytoma, Marfan-like fatigue, a peculiar face with thickening of the lips, mucosal neuromas on the lips and tongue, and gastrointestinal phenomena. Most patients harbor pathological variants of the RET gene. Herein, we present the first case of a 14 year-old boy who experienced small intestinal volvulus along with a megacolon, and he was diagnosed with multiple endocrine neoplasia type 2B. The patient complained of constipation since he was 2 years old and slowly progressive abdominal distension at school age. At 14 years of age, he presented with remarkable megacolon mimicking Hirschsprung's disease and complicated with small intestinal volvulus. The volvulus was successfully repaired, and the particularly dilated transverse colon was resected following a rectal biopsy. Histopathological evaluation of the resected transverse colon revealed to be compatible with ganglioneuromatosis. After emergency surgery, the patient was diagnosed with multiple endocrine neoplasia type 2B with medullary thyroid carcinoma, and a de novo variant of RET was confirmed. Gastroenterologists should consider it when treating patients with constipation, especially those with megacolon. Therefore, timely diagnosis may lead to appropriate treatment of medullary thyroid carcinoma and improve mortality.

Small bowel obstruction in adults, Ladd's band is an exceptional cause: a case report.

Malrotation of the gut is a congenital anomaly of foetal intestinal rotation and it's principally discovered in early childhood as acute intestinal obstruction. This condition is veritably rare and constantly silent in adults. Intestinal malrotation in adults is frequently asymptomatic and is diagnosed as a casual finding during a radiological examination performed for other reasons. Infrequently, it can be diagnosed in adults, associated with an acute abdomen. Adult patients rarely present with acute midgut volvulus or internal hernias caused by Ladd's bands. We present a case of an admitted 18-year-old female with a small bowel obstruction due to an intestinal volvulus complicating intestinal malrotation in the presence of Ladd's band. Laparotomic Ladd's procedure was performed successfully with division of Ladd's band, adhesiolysis, appendicectomy, and reorientation of the small bowel on the right and the cecum and colon on the left of the abdominal cavity; the postoperative evolution was favorable. Although it is a rare pathology, it should be kept in mind in cases of patients presenting small bowel obstruction.

Navigating Inconclusive Upper-Gastrointestinal Series in Infantile Bilious Vomiting: A Case Series on Intestinal Malrotation.

BACKGROUND Bilious vomiting in a child potentially portends the dire emergency of intestinal malrotation with volvulus, necessitating prompt surgical management, with differentials including small-bowel atresia, duodenal stenosis, annular pancreas, and intussusception. Although the upper-gastrointestinal series (UGI) is the diagnostic investigation of choice, up to 15% of the studies are inconclusive, thereby posing a diagnostic challenge. CASE REPORT We report a case series of 3 children referred for bilious vomiting, whose initial UGI was inconclusive and who were eventually confirmed to have intestinal malrotation at surgery. The first child was a female born at 37 weeks with antenatally diagnosed situs inversus and levocardia, who developed bilious vomiting on day 1 of life. The duodenojejunal flexure (DJ) could not be visualized on the UGI because of faint opacification on first pass of the contrast and subsequent overlap with the proximal jejunal loops. The second child was a male born at 36 weeks, presenting at age 4 months with bilious vomiting of 2 days duration. The third child was a female born at 29 weeks, presenting with bilious aspirates on day 3 of life. UGI for all 3 showed persistent hold-up of contrast at the proximal duodenum with no opacification of the distal duodenum or small bowel.Adjunctive techniques during the UGI and ultrasound examination helped achieve a preoperative diagnosis of malrotation in these children. CONCLUSIONS Application of diagnostic adjuncts to an inconclusive initial UGI may help elucidate a preoperative diagnosis of intestinal malrotation in infantile bilious vomiting.

Cecal volvulus in complete common mesentery.

Common mesentery is an abnormal rotation of the primary umbilical loop characterized by inverted positioning of the mesenteric vessels; the mesenteric vein is displaced to the left of the artery. The inversion can be complete or incomplete. If it is incomplete, the mesenteric root is very short, with an empty right iliac fossa and the caecum in high median or subhepatic position. If it is complete, the entire small intestine is on the right, the entire large intestine is on the left; there is no third duodenum, and the second duodenum is anastomosed in the jejunum to the right of the superior mesenteric vessels. Cecal volvulus is a rarely encountered cause of acute intestinal occlusion and should be considered as a surgical emergency. There exist two main types of volvulus: by twisting of the large intestine around its axis, which remains in place; or by tilt and to rotation of the colon, which changes position.

Factors associated with D-lactic acidosis in pediatric intestinal failure: A case-control study.

BACKGROUND: D-lactic acidosis (DLA) is a serious complication of short bowel syndrome (SBS) in children with intestinal failure (IF). Malabsorbed carbohydrates are metabolized by bacteria in the intestine to D-lactate which can lead to metabolic acidosis and neurologic symptoms. METHODS: A retrospective chart review was performed in children ≤18 years old with SBS who had one of the following criteria: unexplained metabolic acidosis, neurologic signs or symptoms, history of antibiotic therapy for small bowel bacterial overgrowth, or high clinical suspicion of DLA. Cases had serum D-lactate concentration >0.25 mmol/L; controls with concentrations ≤0.25 mmol/L. RESULTS: Of forty-six children, median age was 3.16 (interquartile range (IQR): 1.98, 5.82) years, and median residual bowel length was 40 (IQR: 25, 59) cm. There were 23 cases and 23 controls. Univariate analysis showed that cases had significantly lower median bicarbonate (19 vs. 24 mEq/L, p = 0.001), higher anion gap (17 vs. 14 mEq/L, p < 0.001) and were less likely to be receiving parenteral nutrition, compared with children without DLA. Multivariable analysis identified midgut volvulus, history of intestinal lengthening procedure, and anion gap as significant independent risk factors. Midgut volvulus was the strongest independent factor associated with DLA (adjusted odds ratio = 17.1, 95% CI: 2.21, 133, p = 0.007). CONCLUSION: DLA is an important complication of pediatric IF due to SBS. Patients with IF, particularly those with history of midgut volvulus, having undergone intestinal lengthening, or with anion gap acidosis, should be closely monitored for DLA.