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AnastomosisThe Colon Ring

Clinical Training Team

BENIGN PATHOLOGYBENIGN PATHOLOGYVolvulusVolvulus

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Sigmoid and Cecal Volvulus – Introduction

• Volvulus - rotation of the gut on its own mesenteric axis.

• Produces partial or complete intestinal obstruction.

• Blood supply is compromised, resulting in intestinal ischemia.

• Venous congestion leading to infarction can occur.

• Arterial supply is rarely compromised.

• Long narrow-based mesentery predisposes to volvulus.

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Sigmoid Volvulus

• The sigmoid is the commonest site of colonic volvulus.

• Accounts for 5% of large bowel obstruction.

• Usually seen in elderly or those with psychiatric disorders.

• Commonest cause of obstruction in Africa / Asia.

• Incidence is 10 times higher than in Europe or USA.

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Clinical Features

• Large bowel obstruction – – Pain– Constipation– Vomiting

• Disproportionate abdominal distension.

• 50% patients have had a previous episode.

• Severe pain and tenderness suggest ischemia.

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Clinical Features

• Plain abdominal x-ray may show a large ‘bean’ shaped loop of large bowel arising from pelvis.

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Sigmoid Volvulus

• Gangrenous loop—

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Management

• Conservative management can be attempted.

• Resuscitation with intravenous fluids is essential.

• Sigmoidoscopy and/or Barium enema can be both diagnostic and therapeutic.

• Obstruction is usually at ~15 cm which, when passed, produces release of flatus and decompression.

• Flatus tube can be inserted and left in place for 2-3 days.

• 80% of patients will resolve with conservative management.

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Management

• If decompression occurs, no emergency treatment is required.

• 50% will develop a further episode of volvulus within 2 years.

• If decompression fails or features of peritonitis occur, the options are:

– Sigmoid colectomy and primary anastomosis.

– Hartmann’s procedure.

– Sigmoidopexy best avoided.

Cecal Volvulus

• Less common than sigmoid volvulus.

• Less likely to result in complete obstruction.

• Usually “flops” upward on its mesentery rather than undergoing a complete rotation (such as with the sigmoid).

• Rarely requires resection.

• May usually be treated with cecopexy (to right gutter).

• Less likely to recur after cecopexy.