Makindo Medical Notes

Related Subjects: Small Bowel Obstruction | Colonic (Large Bowel) Obstruction | Small Bowel Ischemia | Hartmann's Procedure | Sigmoid and Caecal Volvulus | Acute Colonic Pseudo-obstruction

🔄 Volvulus is a leading cause of acute colonic obstruction in adults. 🚑 Emergency endoscopic decompression, detorsion, and reduction (EDDR) aim to decompress the dilated colon and untwist it. ✅ EDDR is the treatment of choice in uncomplicated patients.

📖 About

• ⚠️ A common cause of large bowel obstruction, particularly in older adults.
• Accounts for up to 5–10% of intestinal obstructions in Western countries, but much higher in endemic regions (e.g., South America, Africa).

🧬 Aetiology & Pathophysiology

• 🔁 Redundant sigmoid colon with a narrow mesenteric base predisposes to twisting.
• 🌀 "Volvulus" (Latin volvere) = to roll or twist around its axis.
• Leads to luminal obstruction ± vascular compromise → risk of ischaemia, gangrene, and perforation.
• Sigmoid colon most common; caecal volvulus less frequent but often more severe.

🤝 Associations

• 👴 Age 60–70 years, more common in men (M:F ≈ 2:1).
• 🧠 Neurological conditions: Parkinson’s disease, Multiple Sclerosis (MS).
• 💩 Chronic constipation, laxative abuse, psychiatric illness.
• 🌽 High-fibre diet, Chagas disease (in endemic regions).

🩺 Clinical Presentation

• 🚫 Constipation (intermittent or absolute).
• 😖 Colicky abdominal pain + progressive distension.
• 🤢 Nausea, vomiting, ± faeculent discharge.
• 🛑 Can progress to obstruction → peritonitis if perforated.
• 📜 40–60% report recurrent prior episodes ("chronic volvulus").

🔍 Investigations

• 📸 Abdominal X-ray (AXR): "Coffee-bean sign" = massively dilated sigmoid loop pointing to the right upper quadrant.
• 🖥️ CT Scan: Highly sensitive — shows "whirl sign" of twisted mesenteric vessels.
• 🦆 Barium enema: "Bird’s beak" appearance at the point of torsion. Contraindicated if ischaemia/strangulation suspected.

⚕️ Management

• 🔧 Initial: ABC resuscitation, IV fluids, NBM, correct electrolytes, analgesia, NG tube if vomiting.
• Sigmoid Volvulus: 🌬️ Flexible sigmoidoscopy with rectal tube decompression (successful in ~70–90%). ⏱️ Leave flatus tube for 24–48h to prevent immediate recurrence. 🔁 High recurrence rate (40–50%) → elective sigmoid colectomy often advised after stabilisation. 🚨 If peritonitis, ischaemia, or failed endoscopy → emergency laparotomy ± resection (mortality up to 25%).
• Caecal Volvulus: ❌ Endoscopic decompression rarely effective. 🔪 Surgical approach: caecostomy or right hemicolectomy if gangrenous. ⚡ Mortality higher due to delayed diagnosis.

📚 References

• Sigmoid Volvulus Case Presentation (VideoGIE)
• RCP Emergency Surgery guidance (UK context).