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Volvulus in git
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  • 2.  Gastric volvulus is a condition involving the stomach twisting upon itself Classified as one of two types organoaxial or mesenteroaxial  A combination of both types may occur in an individual.
  • 3.  Twist occurs along a line connecting the cardia and the pylorus--the luminal (long) axis of the stomach.  Most common type.  Usually associated with diaphragmatic defects.  Vascular compromise more common.
  • 4.  Organoaxial volvulus the rotation of the stomach along its long axis
  • 5.  Twist occurs around a plane perpendicular to the luminal (long) axis of the stomach from lesser to greater curvature.  Chronic symptoms are more common.  Diaphragmatic defects are less common.
  • 6.  Mesenteroaxial volvulus the stomach twisting along its short axis
  • 7. ◦ Abnormality of suspensory ligaments of stomach. ◦ Congenital defects of their diaphragm (Hiatal hernia). ◦ Weak Muscles (MND). ◦ Tumors of stomach.
  • 8.  Those with defects of the diaphragm commonly suffer with the common type (organoaxial volvulus), and it is the most serious form, needing urgent surgical intervention.  The mesenteroaxial type does not often lead to compromise of blood supply to the stomach speedily, and may run a chronic course.
  • 9. ◦ Unless acute, patients are frequently asymptomatic. ◦ When acute and obstructing  Abdominal pain  Attempts to vomit without results  Inability to pass an NG tube  Together, these three findings comprise the Borchardt triad which is diagnostic of acute volvulus .
  • 10.  In mesenteroaxial volvulus, distended stomach appears spherical on supine images.  Two air-fluid levels visible on upright film: in fundus and in antrum.  Upright image often demonstrates a beak where the esophagogastric junction is seen on normal images.
  • 11.  peanut sign- in a case of chronic gastric volvulus.  The ultrasonographic features consist of a constricted segment of stomach, with 2 dilated segments located above and below the constricted part, akin to a peanut.
  • 12.  .
  • 13.  Gastric ischemia ◦ Gastric emphysema ◦ Twisting of stomach may tear spleen from its normal attachments ◦ Perforation is rare
  • 14.  Torsion of the entire gut around superior mesenteric artery (SMA) due to a short mesenteric attachment of small intestine in malrotation.
  • 15.  AGE o Usually neonate or young infant o Occasionally older child and adult  ASSOCIATED WITH (IN 20%) o Duodenal atresia o Duodenal diaphragm o Duodenal stenosis o Annular pancreas
  • 16. o Degree of twisting is variable and determines symptomatology o Severe volvulus (twist of 3 ½ turns) result in bowel necrosis  Acute symptoms in newborn (medical emergency) o Bile-stained vomiting Intermittent, Postprandial, Projectile o Abdominal distension o Shock
  • 17. Dilated, air-filled duodenal bulb and paucity of gas distally "Double bubble sign" = air-fluid levels in stomach & duodenum o Isolated collection of gas-containing bowel loops distal to obstructed duodenum = gas- filled volvulus = closed-loop obstruction From non resorption of intestinal gas secondary to obstruction of mesenteric veins
  • 18. "Corkscrew" duodenum in malrotation with a midgut volvulus "Corkscrew" duodenum in malrotation with a midgut volvulus
  • 19. CT findings  Whirl-like pattern of small bowel loops and adjacent mesenteric fat converging to the point of torsion (during volvulus)  SMV to the left of SMA (NO volvulus)  Chylous mesenteric cyst (from interference with lymphatic drainage)
  • 20.  Clockwise whirlpool sign = color Doppler depiction of mesenteric vessels moving clockwise with caudal movement of transducer  Distended proximal duodenum with arrowhead- type compression over spine  Superior mesenteric vein to the left of SMA  Thick-walled bowel loops below duodenum and to the right of spine associated with peritoneal fluid
  • 21.  "Barber pole sign" = spiraling of SMA  Tapering / abrupt termination of mesenteric vessels  Marked vasoconstriction and prolonged contrast transit time  Absent venous opacification / dilated tortuous superior mesenteric vein
  • 22.  Intestinal ischemia and necrosis in distribution of SMA (bloody diarrhea, ileus, abdominal distension) DD:  Pyloric stenosis (same age group, no bilious vomiting)
  • 23.  Twisting of loop of intestine around its mesenteric attachment site may occur at various sites in the GI tract  Most commonly: sigmoid & cecum  Rarely: stomach, small intestine, transverse colon  Results in partial or complete obstruction  May also compromise bowel circulation resulting in ischemia
  • 24.  Sigmoid volvulus most common form of GI tract volvulus  Accounts for up to 8% of all intestinal obstructions  Most common in elderly persons (often neurologically impaired)  Patients almost always have a history of chronic constipation
  • 25.  Redundant sigmoid colon that has a narrow mesenteric attachment to posterior abdominal wall allows close approximation of 2 limbs of sigmoid colon à twisting of sigmoid colon around mesenteric axis  Other predisposing factors  Chronic constipation  High-roughage diet (may cause a long, redundant sigmoid colon)  Roundworm infestation  Megacolon (often due to Chagas)
  • 26.  20-25% mortality rate  Peak age > 50 years  Torsion usually counterclockwise ranging from 180 – 540 degrees  Luminal obstruction generally @ 180 degrees  Venous occlusion generally @ 360 degrees à gangrene & perforation
  • 27.  Diagnosis Abdominal plain films usually diagnostic Inverted U-shaped appearance of distended sigmoid loop  Largest and most dilated loops of bowel are seen with volvulus  Loss of haustra  Coffee-bean sign à midline crease corresponding to mesenteric root in a greatly distended sigmoid  Sigmoid volvulus – bowel loop points to RUQ
  • 28.  torsion of the caecum around its own mesentery which often results in obstruction  It accounts for 11% of all intestinal volvulus  can result in bowel perforation and faecal peritonitis
  • 29. Clinical presentation  Caecal volvulus presents with clinical features of proximal large bowel obstruction. This is usually with colicky abdominal pain, vomiting and abdominal distension.
  • 30. • Bowel loop points to LUQ • Dilated cecum comes to rest in left upper quadrant • Bird’s-beak or bird-of-prey sign à seen on barium enema as it encounters the volvulated loop • CT scan useful in assessing mural wall ischemia
  • 31. large, dilated loop of large bowel with an inverted U-shape with walls between two volvulated loops pointing from LLQ toward RUQ; same patient with decompressed sigmoid volvulus following insertion of rectal tube
  • 32. Differential Diagnosis  Large bowel obstruction due to other causes à sigmoid colon CA  Giant sigmoid diverticulum  Pseudoobstruction Complications  Colonic ischemia  Perforation  Sepsis
  • 33. Ba contrast enema contrast-filled rectum illustrates the "bird's beak" sign (white arrow), corresponding to the luminal narrowing at the site of sigmoid obstruction. This is the characteristic presentation of a sigmoid volvulus
  • 34.  20 year old woman presented to the ED with 12 hours of abdominal pain, nausea. and vomiting low grade fever.  No past surgical history  PMH: Polycystic ovarian disease
  • 35. Dilated cecum
  • 36. Cecum
  • 37. Contrast In Descending colon Cecum
  • 38. Barium Enema Point of Obstruction Ascending colon