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volvulus_sigmoid

sigmoid volvulus

introduction

  • volvulus occurs when colon twists on its mesenteric axis with a greater than 180-degree rotation, producing obstruction of intestinal lumen and mesenteric vessels
  • the most common location is at the sigmoid (see also caecal volvulus, and also may less commonly occur at splenic flexure or transverse colon))
  • in Western countries, the far majority occur in elderly mainly bed bound patients

aetiology

  • in Western countries, the far majority occur in bed bound elderly patients with chronic constipation
  • rarely, may occur in young adults with:
    • adult Hirschsprung's disease
    • those from developing countries with high fibre diets being thought to be a major cause

clinical features

acute fulminating volvulus

  • total bowel obstruction
  • sudden onset periumbilical pain with vomiting and constipation
  • upper abdominal distention with tympany
  • empty rectum
  • visible peristalsis may be seen
  • may have peritoneal signs
  • gangrene and perforation occur early

subacute progressive volvulus

  • partial bowel obstruction
  • especially elderly
  • more subtle clinical picture often leading to delayed diagnosis
  • poorly characterised abdominal cramping esp. on left side
  • upper abdominal distention with tympany
  • empty rectum
  • visible peristalsis may be seen

radiologic signs

  • omega or horseshoe sign
  • bird's beak sign
  • Y sign
  • northern exposure sign
  • coffee bean sign
  • bent inner tube or ace of spades sign
  • left pelvic overlap or left flank overlap sign
  • liver overlap sign
  • the whirl sign
  • empty left iliac fossa sign

www.ncbi.nlm.nih.gov_pmc_articles_pmc3298211_bin_wjem-13-01-19w-f01.jpg

Coffee bean sign courtesy of ncbi

ED Management

  • discuss with surg. registrar ASAP
  • if evidence of bowel ischaemia (eg. fever, tachycardia, peritonism, or air in bowel wall on plain CT abdo), then needs iv antibiotics and urgent surgery
  • if no evidence bowel ischaemia, usually needs urgent rectal tube to decompress and this will usually resolve the volvulus
volvulus_sigmoid.txt · Last modified: 2016/07/24 09:01 (external edit)