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VolvulusEdit

Volvulus refers to a twisting of a loop of intestine around its mesentery, which can obstruct the bowel and compromise blood flow. The condition is most commonly seen in the sigmoid colon of adults and in the midgut of infants, but it can involve other segments such as the cecum or transverse colon. When the twist damages circulation, it can lead to ischemia and necrosis if not relieved promptly. Because volvulus is a surgical disease, timely recognition and appropriate intervention are vital to preventing severe complications and death.

In overview, volvulus arises from an anatomic configuration that permits abnormal mobility of a bowel segment. Predisposing factors include a longer-than-normal mesentery (a dolichosigmoid in the case of sigmoid volvulus), congenital malrotation, prior abdominal surgery, or chronic constipation that contributes to redundancy and twisting. Geographic and demographic patterns vary, with sigmoid volvulus accounting for a notable share of large-bowel obstruction in some regions, whereas midgut volvulus predominates in neonates and young children. The condition is a prime example of how congenital or acquired pelvic- and abdominal-space factors interact with physiological motility to produce acute surgical illness.

Pathophysiology and Types

Sigmoid volvulus

The sigmoid colon may be excessively long and redundant, allowing it to twist around its mesenteric axis. This twist can obstruct both the lumen and the blood vessels supplying the bowel, producing a cascade from colonic obstruction to bowel ischemia if not promptly treated. Patients are often older adults or individuals with chronic constipation or neuropsychiatric or immobilization-related factors. In some regions, a high-fiber diet and prolonged stool burden have been linked to the condition, though the exact contributions of diet versus anatomy can be debated. sigmoid colon is the principal site in adults.

Cecal volvulus

Cecal volvulus involves twisting of the cecum around its mesentery and is less common than sigmoid volvulus but carries a similarly urgent need for intervention. The path to obstruction and ischemia can be rapid because the cecum has a relatively mobile configuration in certain anatomical variants. cecum volvulus is diagnosed and managed differently from sigmoid volvulus in many cases.

Midgut volvulus

In neonates and infants, midgut volvulus typically results from congenital malrotation, where the intestines fail to assume their normal position during development. This form demands urgent attention because it may rapidly progress to extensive bowel ischemia. The standard corrective operation in the context of malrotation is the Ladd procedure.

Other and less common variants

Twisting can occur at other sites, such as the transverse colon, but these forms are rarer and often require individualized surgical planning. In all forms, the common danger is the potential progression from obstruction to vascular compromise.

Clinical Presentation

  • Sudden onset of abdominal pain that can be cramping or constant, often accompanied by abdominal distention.
  • Nausea and vomiting, with decreasing passage of stool and gas (obstipation) as obstruction worsens.
  • Abdominal examination may reveal tympany with distension, tenderness, and, in advanced cases, peritoneal signs if ischemia or perforation has occurred.
  • Vital signs may show tachycardia and signs of systemic inflammation when ischemia develops.

In older patients with sigmoid volvulus, the history can be dominated by chronic constipation and episodes of intermittent obstruction. In infants with midgut volvulus, irritability, poor feeding, bilious vomiting, and abdominal tenderness are typical, and the condition is a surgical emergency.

Diagnosis

  • Imaging is central to diagnosis and often guides urgent management. Plain abdominal radiographs may show a markedly dilated, bent loop of bowel forming a characteristic pattern sometimes described as a “coffee-bean” sign in sigmoid volvulus. X-ray findings can prompt further evaluation.
  • Computed tomography (computed tomography) often demonstrates a twisting pattern known as the whirl sign, as well as signs of bowel wall thickening or edema if ischemia is present.
  • Contrast studies, such as a water-soluble contrast enema, can be diagnostic for sigmoid volvulus and may also provide a therapeutic detorsion in stable patients. However, enema reduction is not appropriate in the presence of peritonitis or suspected bowel perforation.
  • Endoscopic evaluation with detorsion via flexible sigmoidoscopy is commonly used in stable patients with sigmoid volvulus, serving both diagnostic confirmation and immediate nonoperative treatment. If detorsion is successful, a plan for elective resection may be made to prevent recurrence.
  • In suspected midgut volvulus, particularly in neonates and infants, prompt surgical exploration is often required (with interpretation of findings guiding the procedure).

Management

The management of volvulus is dictated by site, degree of ischemia, patient stability, and risk of recurrence.

  • Nonoperative management (detorsion) is appropriate for selected cases of sigmoid volvulus in stable patients without signs of peritoneal irritation or ischemia. Endoscopic detorsion can relieve the obstruction and stabilize the patient, but recurrence is common if the underlying redundancy is not addressed. This approach is often used as a temporary bridge to elective resection. detorsion is the key term here.
  • Elective surgical resection after detorsion is widely advocated to prevent recurrence in sigmoid volvulus. Resection of the redundant sigmoid with primary anastomosis is preferred in suitable patients; in higher-risk situations or after complicated detorsion, a Hartmann procedure may be performed.
  • In cecal volvulus, nonoperative detorsion via endoscopic or radiologic means is less reliably durable, and operative management with resection or detorsion followed by fixation is frequently indicated.
  • For midgut volvulus in infants, urgent surgical exploration is usually required. Corrective procedures such as the Ladd procedure aim to ensure proper bowel positioning and reduce future volvulus risk.
  • In all forms, timely intervention is essential to minimize the risk of bowel necrosis and sepsis. Postoperative care focuses on bowel function restoration, infection prevention, and monitoring for anastomotic integrity.

Special situations - Pregnancy can complicate the presentation and management of volvulus due to anatomic and physiologic changes; multidisciplinary care is often necessary. - In resource-limited settings, nonoperative approaches may be employed to stabilize patients before definitive surgery, but the higher risk of recurrence and complications is a key consideration.

Controversies and Debates

  • Nonoperative detorsion versus immediate resection for sigmoid volvulus: A central debate centers on whether to attempt detorsion first to avoid immediate surgery or to proceed directly to resection to prevent recurrence. Proponents of detorsion argue it reduces operative risk in unstable patients and preserves bowel in the short term, especially when surgical resources are constrained. Critics counter that recurrence after detorsion can lead to repeated hospitalizations and cumulative risk, making elective resection a more economical and definitive solution in many cases. The balance between short-term safety and long-term outcomes is a frequent topic of discussion in surgical practice.
  • Recurrence risk after nonoperative management: Recurrence after endoscopic detorsion varies across studies, but it is generally recognized as substantial. This has led to guidelines that often favor planning elective resection when feasible in patients who tolerate it, to reduce future emergencies and associated costs.
  • Regional variations in practice and access: In some regions, sigmoid volvulus is more common and resources for rapid imaging and surgical intervention may be limited, leading to greater reliance on nonoperative maneuvers. Critics of such approaches contend that broader access to definitive surgical care improves outcomes and reduces the burden on emergency services over time.
  • Pediatric volvulus management: In infants with midgut volvulus due to malrotation, the urgency of intervention is undisputed, but the specifics of timing, perioperative management, and future developmental considerations remain topics of ongoing discussion among pediatric surgeons and neonatologists.
  • Interpreting diagnostic signs: While signs like the whirl pattern on CT or the coffee-bean appearance on X-ray can strongly suggest volvulus, clinicians still weigh the risks of delaying surgery against the desire to confirm diagnosis noninvasively, especially in unstable patients.

Prognosis

  • With prompt recognition and appropriate intervention, many patients recover without lasting consequences. Outcomes worsen with delayed treatment, advanced ischemia, or perforation, and mortality rises accordingly.
  • Recurrence after nonoperative detorsion is a known risk in sigmoid volvulus, which is why a definitive resection is commonly pursued when the patient’s condition allows.
  • In neonates with midgut volvulus due to malrotation, timely surgical correction is critical; delays can lead to extensive bowel loss and significant morbidity.

See also