Volvulus, Emergency Medicine

Basics

Description

Axial twist of a portion of the GI tract around its mesentery causing partial or complete obstruction of the bowel
Often associated with other GI abnormalities
In pediatric setting, infants typically involved:
- Abnormal embryonic development
Can be precipitated by pathologic distention of the colon
Blood supply may be compromised by venous congestion and eventual arterial inflow obstruction, leading to gangrene of the bowel and potential infarction

Etiology

3rd most common cause of colonic obstruction (10 " 15%) following tumor and diverticular disease
Epidemiology:
- 0 " 1 yo: 30%
- 1 " 18 yo: 20%
- Over 18 yo: 50%
Often associated with other GI abnormalities
Cecum (52%):
- More common in young adults, < 50 yr old
- Due to improper congenital fusion of the mesentery with the posterior parietal peritoneum, causing the cecum to be freely mobile in varying degrees
- Associated with increased gas production (malabsorption and pseudo-obstruction)
- Can be seen in pregnancy and after colonoscopy
Sigmoid (43%):
- More common in:
  - Elderly
  - Institutionalized
  - Chronic bowel motility disorders (Parkinson)
  - Psychiatric diseases (schizophrenia)
- Due to redundant sigmoid colon with narrow mesenteric attachment
- Associated with chronic constipation and concomitant laxative use
Transverse colon and splenic flexure (5%)
Gastric volvulus (rare) associated with diaphragmatic defects

Midgut volvulus:
- Due to congenital malrotation in which the midgut fails to rotate properly in utero as it enters the abdomen
- Entire midgut from the descending duodenum to the transverse colon rotates around its mesenteric stalk, including the superior mesenteric artery
- Common in neonates (80% <1 mo old, often in 1st week; 6 " 20% >1 yr old)
- Males > females, 2:1
- Sudden onset of bilious emesis (97%) with abdominal pain
- May have previous episodes of feeding problems/bilious emesis
- In children >1 yr old, associated with failure to thrive, alleged intolerance to feedings, chronic intermittent vomiting, bloody diarrhea
- Constipation
- Mild distention, since obstruction higher in GI tract
- May not appear toxic based on degree of ischemia

Diagnosis

Signs and Symptoms

History

Infants: Vomiting in 90%:
- May be bilious
Older children and adults: Variable and often insidious:
- 80% with chronic symptoms; weeks to months to years
Bowel obstruction secondary to volvulus:
- Colicky, cramping abdominal pain (90%)
- Abdominal distention (80%)
- Obstipation (60%)
- Nausea and vomiting (28%)
Cecal volvulus:
- Highly variable; intermittent episodes to sudden onset of pain and distention
Sigmoid volvulus:
- Vomiting uncommon
- More insidious onset
- Abdominal pain/distention, nausea, and constipation
Gastric volvulus:
- Triad of Borchardt: Severe epigastric distension, intractable retching, inability to pass nasogastric tube (30% of patients)

Physical Exam

Presence of gangrenous bowel:
- Increased pain
- Peritoneal signs: Guarding, rebound, and rigidity
- Fever
- Blood on digital rectal exam
- Tachycardia and hypovolemia
Cecal volvulus:
- Distended abdomen
- Often a palpable mass in the left upper quadrant/midabdomen

Child will appear well with normal exam early in clinical course
70% present with chronic symptoms
40% of neonates with bilious vomiting will require a surgical intervention
Hematochezia, abdominal distention or pain, and shock indicate ischemia/necrosis

Essential Workup

CBC, BMP, UA
Plain abdominal radiograph
Upper GI series (best initial exam for children)
CT abdomen/pelvis with IV contrast (optimal for adults)
Barium enema
US

Diagnosis Tests & Interpretation

Lab

May give clues as to the presence of gangrenous bowel, but normal lab values do not exclude the diagnosis
CBC:
- Leukocytosis (WBC >20,000) suggests strangulation with infection/peritonitis.
Electrolytes, BUN, creatinine, glucose:
- Anion gap acidosis due to lactic acidosis
- Prerenal azotemia due to dehydration
Urinalysis:
- Elevated specific gravity and ketones

Imaging

Plain abdominal radiograph:
- Suggestive but often inconclusive
- Diagnostic finding present in <70% of cases
- Sigmoid volvulus: Inverted U-shaped loop of dilated colon arising from the pelvis
- Cecal volvulus " dilated and displaced:
  - Cecum in the left abdomen (kidney shaped), often with dilated loops of small bowel
CT scan:
- "Whirl " sign in cecal volvulus
- May be useful in sigmoid volvulus to determine extent of obstruction
Upper GI series (best for duodenum, but operator dependent):
- Abrupt ending or corkscrew tapering of contrast seen (75%)
- Subtle findings (25%)
Barium enema:
- "Birds beak " deformity at the site of torsion
- Perform cautiously because of perforation risk
- Beware of false positives with infants who normally have inadequately fixed cecums
US (specific but not sensitive):
- Abnormal position of the superior mesenteric vein (anterior or left of SMA)
- "Whirlpool " sign of volvulus: Vessels twirled around the base of the mesentery
- 3rd part of duodenum not in normal retromesenteric position (between mesenteric artery and aorta)

Diagnosis of midgut volvulus:
- Duodenum lies entirely to the right of the spine on plain films
- "Double-bubble " sign on an upright film due to distended stomach and proximal duodenal loop
- Established by upper GI swallow: Coiled spring/corkscrew appearance of jejunum in the right upper quadrant
- Plain x-ray normal or equivocal in 20% of cases

Evaluate any child with signs/symptoms of obstruction (including bilious vomiting and abdominal pain) for malrotation, even if he or she appears nontoxic
Delay in diagnosis >1 " 2 hr results in gangrenous bowel, necessitating large resection and leading to permanent parenteral nutrition with its associated complications

Diagnostic Procedures/Surgery

Laparoscopy:
- Useful when diagnostic imagining equivocal
- Can differentiate congenital malrotation from volvulus

Differential Diagnosis

Obstruction due to colonic tumor or diverticulitis
Small bowel obstruction
Ileus
Intussusception
Appendicitis
Pelvic inflammatory disease and salpingitis, especially for cecal volvuli
Ovarian torsion
Perforated viscus
Cyclic vomiting syndrome

Meconium ileus
Hirschsprung disease
Duodenal atresia
Meckel diverticulum
Necrotizing enterocolitis (especially premature infants)
Intussusception
Appendicitis
Medical conditions:
- Colic
- Henoch " Sch Άnlein purpura
- Inborn errors of metabolism
- Trauma
- Gastroesophageal reflux
- Pyelonephritis
- Meningitis

Treatment

Pre-Hospital

Establish IV assess
NPO

Initial Stabilization/Therapy

ABCs
Aggressive fluid resuscitation with 0.9% NS bolus of 20 mL/kg (peds) or 2 L bolus (adult)
NGT

Ed Treatment/Procedures

Obtain surgical and/or GI consultation
NPO
Correct hypovolemia and electrolyte abnormalities
Preoperative broad-spectrum antibiotics if suspected sepsis or perforation

Definitive Therapy
Sigmoid Volvulus

Nontoxic patient:
- Reduce volvulus nonoperatively with sigmoidoscopy:
  - 80 " 95% successful
  - 60% recurrence (within hours to weeks)
- Follow with elective sigmoid resection and primary anastomosis (<3% recurrence)
Toxic patient:
- Emergent resection of sigmoid and any gangrenous bowel, with placement of end colostomy
Endoscopic decompression with rectal tube placement:
- Successful in 78% of patients with sigmoid volvulus; less effective for cecal volvulus
- Recurrence is common
- Elective surgical treatment after endoscopic detorsion

Cecal Volvulus

Emergent operative reduction followed by colectomy and primary anastomosis (preferred), or cecopexy if the cecum is still viable (higher recurrence)

Laparotomy within 1 " 2 hr to reduce risk for ischemia
Surgical detorsion of bowel with resection of gangrenous bowel and a Ladd procedure is performed to prevent recurrent volvulus

Medication

Ampicillin sulbactam (Unasyn): 3 g (peds: 100 " 200 mg/kg/24 h) IV q6h
Cefoxitin (Mefoxin): 2 g (peds: 80 " 160 mg/kg/24 h) IV q6h
Ceftriaxone 1 " 2 g IV q12 " 24h (peds: 50 " 75 mg/kg/d q12 " 24h) AND metronidazole 500 mg IV q8h (peds: 30 mg/kg/24 h q6h)
Piperacillin " tazobactam 3.375 " 4 g IV q4 " 6h (peds: 200 " 300 mg/kg/d of piperacillin component q6 " 8h)

Follow-Up

Disposition

Admission Criteria
Admit with a surgical consult all suspected of having a volvulus.
Discharge Criteria
None
Issues for Referral

Surgical consultation necessary
Atypical malrotation: Asymptomatic or symptoms of gastroesophageal reflux:
- Close observation with repeat contrast study
- Defer surgery

Followup Recommendations

Surgical follow-up postoperatively

Pearls and Pitfalls

Consider volvulus in any child <1 mo old presenting with vomiting:
- Bilious vomiting is due to mechanical intestinal obstruction until proven otherwise
Delayed diagnosis leads to increased morbidity, more often with adults than children:
- 70% adults not diagnosed until >6 mo from initial presentation; most present with chronic abdominal symptoms
- If gangrene present, mortality = 25 " 80%
Operative repair for all adult patients
Upper GI contrast series is the best initial test for children
CT abdomen/pelvis is preferable for adults

Additional Reading

ASGE Standards of Practice Committee, Harrison ME, Anderson MA. The role of endoscopy in the management of patients with known and suspected colonic obstruction and pseudo-obstruction. Gastrointest Endosc. 2010;71(4):669 " 679.
Cappell MS, Batke M. Mechanical obstruction of the small bowel and colon. Med Clin North Am. 2008;92:575 " 597.
Durkin ET, Lund DP, Shaaban AF, et al. Age-related differences in diagnosis and morbidity of intestinal malrotation. J Am Coll Surg. 2008;206(4):658 " 663.
Louie JP. Essential diagnosis of abdominal emergencies in the first year of life. Emerg Med Clin North Am. 2007;25:1009 " 1040.
Madiba TE, Thomson SR. The management of cecal volvulus. Dis Colon Rectum. 2002;45(2):264 " 267.
Nehra D, Goldstein AM. Intestinal malrotation: Varied clinical presentation from infancy through adulthood. Surgery. 2011;149:386 " 393.

Codes

ICD9

537.89 Other specified disorders of stomach and duodenum
560.2 Volvulus
751.5 Other anomalies of intestine

ICD10

K31.89 Other diseases of stomach and duodenum
K56.2 Volvulus
Q43.8 Other specified congenital malformations of intestine

SNOMED

9707006 intestinal volvulus (disorder)
235811005 Cecal volvulus (disorder)
253786009 Congenital volvulus (disorder)
197060001 sigmoid volvulus (disorder)
71851009 Gastric volvulus (disorder)
79812002 Volvulus of duodenum (disorder)

Home

Erectile Dysfunction

Doctor123.org