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Volvulus, Emergency Medicine

Basics

Description

- Sigmoid (43%): - More common in: - Elderly - Institutionalized - Chronic bowel motility disorders (Parkinson) - Psychiatric diseases (schizophrenia)

- 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

- Presence of gangrenous bowel: - Increased pain - Peritoneal signs: Guarding, rebound, and rigidity - Fever - Blood on digital rectal exam - Tachycardia and hypovolemia

- 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

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

  • 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 oldDue to improper congenital fusion of the mesentery with the posterior parietal peritoneum, causing the cecum to be freely mobile in varying degreesAssociated with increased gas production (malabsorption and pseudo-obstruction)Can be seen in pregnancy and after colonoscopy
  • Sigmoid (43%):More common in:ElderlyInstitutionalizedChronic bowel motility disorders (Parkinson)Psychiatric diseases (schizophrenia)Due to redundant sigmoid colon with narrow mesenteric attachmentAssociated 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 abdomenEntire midgut from the descending duodenum to the transverse colon rotates around its mesenteric stalk, including the superior mesenteric arteryCommon in neonates (80% <1 mo old, often in 1st week; 6 " 20% >1 yr old)Males > females, 2:1Sudden onset of bilious emesis (97%) with abdominal painMay have previous episodes of feeding problems/bilious emesisIn children >1 yr old, associated with failure to thrive, alleged intolerance to feedings, chronic intermittent vomiting, bloody diarrheaConstipationMild distention, since obstruction higher in GI tractMay not appear toxic based on degree of ischemia

Diagnosis

Signs and Symptoms

History

  • Infants: Vomiting in 90%:
  • 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 uncommonMore insidious onsetAbdominal 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 painPeritoneal signs: Guarding, rebound, and rigidityFeverBlood on digital rectal examTachycardia and hypovolemia
  • Cecal volvulus:Distended abdomenOften 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 acidosisPrerenal azotemia due to dehydration
  • Urinalysis:Elevated specific gravity and ketones

Imaging

  • Plain abdominal radiograph:Suggestive but often inconclusiveDiagnostic finding present in <70% of casesSigmoid volvulus: Inverted U-shaped loop of dilated colon arising from the pelvisCecal volvulus " dilated and displaced:Cecum in the left abdomen (kidney shaped), often with dilated loops of small bowel
  • CT scan: "Whirl " sign in cecal volvulusMay 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 torsionPerform cautiously because of perforation riskBeware 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 mesentery3rd 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 loopEstablished by upper GI swallow: Coiled spring/corkscrew appearance of jejunum in the right upper quadrantPlain 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 equivocalCan 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:ColicHenoch " Sch Άnlein purpuraInborn errors of metabolismTraumaGastroesophageal refluxPyelonephritisMeningitis

Treatment

Pre-Hospital

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% successful60% 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 volvulusRecurrence is commonElective 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 studyDefer 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 symptomsIf 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.

See Also (Topic, Algorithm, Electronic Media Element)

Bowel Obstruction

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)