What happens during volvulus
The loop of intestine twists around the axis of the mesentery, a fold in which the feeding vessels pass. The lumen is blocked in two places at once, so the contents and gases accumulate inside the closed area, stretching the wall. At the same time, first the veins are pinched, then the arteries: the intestine swells, turns blue and stops receiving oxygen. After a few hours, necrosis of the wall begins, it becomes permeable to bacteria, and then can rupture with the development of peritonitis. That is why the time before surgery directly determines the outcome.
- Torsion of the loop around the mesentery
- Closing the lumen in two places
- Clamping of veins and arteries
- Swelling and distension of the intestinal wall
- Necrosis, perforation, peritonitis
Who is at risk and why does it occur?
Volvulus of the sigmoid colon is more common in older people with prolonged constipation, a sedentary lifestyle, in bedridden patients and people with neurological diseases: the sigmoid colon stretches, lengthens and becomes mobile. Anatomical features contribute to torsion - a long mesentery with a narrow base, adhesions after operations, tumors and scars. In children in the first months of life, the cause is congenital intestinal malrotation. Sometimes the trigger is a sudden change in diet or a large meal after fasting.
- Chronic constipation and elongated sigmoid colon
- Old age, immobility, bed rest
- Adhesions after abdominal surgery
- Long mesentery with a narrow base
- Congenital malrotation in infants
- Tumors and scar narrowing of the intestine
Symptoms
The onset is usually sudden. Severe cramping pain appears, which then becomes constant, the abdomen quickly swells, and often asymmetrically. Gases and stools stop passing. Vomiting with small intestinal volvulus occurs early and is profuse, with sigmoid volvulus - later. The condition worsens: weakness increases, the pulse quickens, dry mouth and thirst appear due to loss of fluid. A terrible sign is a decrease in pain while a simultaneous deterioration in the general condition: this may mean necrosis of the intestinal wall.
- Sudden cramping pain in the abdomen
- Rapidly growing, often asymmetrical swelling
- Stopping the passage of gas and stool
- Vomiting, sometimes with intestinal contents
- Weakness, thirst, rapid pulse
- Tension of the abdominal muscles during the development of peritonitis
Diagnostics
The examination is carried out urgently and in parallel with preparation for a possible operation. The surgeon examines the abdomen, assesses muscle tension and peristalsis. Plain x-ray of the abdomen shows characteristic distended loops with fluid levels. Computed tomography with contrast is the most informative: it clarifies the level and cause of obstruction, and also allows you to assess the blood supply to the intestinal wall. Blood tests look for signs of inflammation, dehydration, and acid-base imbalance. In children and pregnant women, preference is given to ultrasound examination.
- Examination by a surgeon and digital examination of the rectum
- Plain radiography of the abdominal cavity
- Computed tomography with contrast
- Abdominal ultrasound
- General and biochemical blood test
- Assessment of electrolytes and inflammation indicators
Treatment
Treatment is always inpatient. They begin with inserting a tube into the stomach and intravenous fluid and electrolyte replacement. If there is volvulus of the sigmoid colon without signs of necrosis, an attempt at endoscopic straightening through a colonoscope is possible; after this, removal of the excess loop is routinely discussed because the risk of recurrence is high. In all other cases and if necrosis is suspected, an emergency operation is performed: the loop is untwisted, the viability of the intestine is assessed, and in case of necrosis, the affected area is removed, sometimes with temporary removal of the stoma.
- Hospitalization and intravenous solutions
- Gastric tube for unloading
- Endoscopic straightening for sigmoid volvulus
- Emergency surgery for necrosis and peritonitis
- Resection of the affected area of the intestine
- Temporary stoma according to indications
- Planned removal of excess loop to prevent recurrence
