 GASTRIC VOLVULUS
 SMALL BOWEL VOLVULUS (MIDGUT MALROTATION)
 LARGE BOWEL VOLVULUS (CECAL VOLVULUS,
SIGMOID VOLVULUS)
...
 Gastric volvulus is a condition involving the
stomach twisting upon itself
Classified as one of two types
organoaxial or...
 Twist occurs along a line connecting the
cardia and the pylorus--the luminal (long)
axis of the stomach.
 Most common t...
 Organoaxial volvulus the rotation of the stomach
along its long axis
 Twist occurs around a plane perpendicular to
the luminal (long) axis of the stomach from
lesser to greater curvature.
 ...
 Mesenteroaxial volvulus the stomach twisting along its
short axis
◦ Abnormality of
suspensory ligaments of
stomach.
◦ Congenital defects of their
diaphragm (Hiatal hernia).
◦ Weak Muscles ...
 Those with defects of the diaphragm
commonly suffer with the common type
(organoaxial volvulus), and it is the most
seri...
◦ Unless acute, patients are frequently
asymptomatic.
◦ When acute and obstructing
 Abdominal pain
 Attempts to vomit wi...
 In mesenteroaxial volvulus, distended
stomach appears spherical on supine images.
 Two air-fluid levels visible on upri...
 peanut sign- in a case of chronic gastric
volvulus.
 The ultrasonographic features consist of a
constricted segment of ...
 .
 Gastric ischemia
◦ Gastric emphysema
◦ Twisting of stomach may tear spleen from its
normal attachments
◦ Perforation is ...
 Torsion of the entire gut around superior
mesenteric artery (SMA) due to a short
mesenteric attachment of small intestin...
 AGE
o Usually neonate or young infant
o Occasionally older child and adult
 ASSOCIATED WITH (IN 20%)
o Duodenal atresia...
o Degree of twisting is variable and determines
symptomatology
o Severe volvulus (twist of 3 ½ turns)
result in bowel necr...
Dilated, air-filled duodenal bulb and paucity of
gas distally
"Double bubble sign" = air-fluid levels in
stomach & duodenu...
"Corkscrew" duodenum in malrotation with a midgut volvulus
"Corkscrew" duodenum in malrotation
with a midgut volvulus
CT findings
 Whirl-like pattern of small bowel loops and
adjacent mesenteric fat converging to the point
of torsion (duri...
 Clockwise whirlpool sign = color Doppler
depiction of mesenteric vessels moving clockwise
with caudal movement of transd...
 "Barber pole sign" = spiraling of SMA
 Tapering / abrupt termination of mesenteric
vessels
 Marked vasoconstriction an...
 Intestinal ischemia and necrosis in
distribution of SMA (bloody diarrhea, ileus,
abdominal distension)
DD:
 Pyloric ste...
 Twisting of loop of intestine around its
mesenteric attachment site may occur at
various sites in the GI tract
 Most co...
 Sigmoid volvulus most common form of GI
tract volvulus
 Accounts for up to 8% of all intestinal
obstructions
 Most com...
 Redundant sigmoid colon that has a narrow
mesenteric attachment to posterior abdominal
wall allows close approximation o...
 20-25% mortality rate
 Peak age > 50 years
 Torsion usually counterclockwise ranging
from 180 – 540 degrees
 Luminal ...
 Diagnosis
Abdominal plain films usually diagnostic
Inverted U-shaped appearance of distended
sigmoid loop
 Largest and ...
 torsion of the caecum around its own
mesentery which often results in obstruction
 It accounts for 11% of all intestina...
Clinical presentation
 Caecal volvulus presents with clinical features
of proximal large bowel obstruction. This is
usual...
• Bowel loop points to LUQ
• Dilated cecum comes to rest in left upper
quadrant
• Bird’s-beak or bird-of-prey sign à seen ...
large, dilated loop of large bowel with an inverted U-shape
with walls between two volvulated loops pointing from LLQ towa...
Differential Diagnosis
 Large bowel obstruction due to other causes
à sigmoid colon CA
 Giant sigmoid diverticulum
 Pse...
Ba contrast enema
contrast-filled rectum
illustrates the "bird's beak"
sign (white arrow),
corresponding to the
luminal na...
 20 year old woman presented to the ED with
12 hours of abdominal pain, nausea. and
vomiting low grade fever.
 No past s...
Dilated cecum
Cecum
Contrast
In Descending colon
Cecum
Barium Enema
Point of Obstruction
Ascending colon
Volvulus in git
Volvulus in git
Volvulus in git
Volvulus in git
Volvulus in git
Volvulus in git
Volvulus in git
Volvulus in git
Volvulus in git
Volvulus in git
Volvulus in git
Volvulus in git
Volvulus in git
Volvulus in git
Volvulus in git
Volvulus in git
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Volvulus in git

  1. 1.  GASTRIC VOLVULUS  SMALL BOWEL VOLVULUS (MIDGUT MALROTATION)  LARGE BOWEL VOLVULUS (CECAL VOLVULUS, SIGMOID VOLVULUS)  LARGE AND SMALL BOWEL VOLVULUS ( ILEOSIGMOID KNOT)
  2. 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. 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. 4.  Organoaxial volvulus the rotation of the stomach along its long axis
  5. 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. 6.  Mesenteroaxial volvulus the stomach twisting along its short axis
  7. 7. ◦ Abnormality of suspensory ligaments of stomach. ◦ Congenital defects of their diaphragm (Hiatal hernia). ◦ Weak Muscles (MND). ◦ Tumors of stomach.
  8. 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. 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. 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. 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. 12.  .
  13. 13.  Gastric ischemia ◦ Gastric emphysema ◦ Twisting of stomach may tear spleen from its normal attachments ◦ Perforation is rare
  14. 14.  Torsion of the entire gut around superior mesenteric artery (SMA) due to a short mesenteric attachment of small intestine in malrotation.
  15. 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. 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. 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. 18. "Corkscrew" duodenum in malrotation with a midgut volvulus "Corkscrew" duodenum in malrotation with a midgut volvulus
  19. 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. 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. 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. 22.  Intestinal ischemia and necrosis in distribution of SMA (bloody diarrhea, ileus, abdominal distension) DD:  Pyloric stenosis (same age group, no bilious vomiting)
  23. 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. 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. 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. 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. 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. 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. 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. 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. 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. 32. Differential Diagnosis  Large bowel obstruction due to other causes à sigmoid colon CA  Giant sigmoid diverticulum  Pseudoobstruction Complications  Colonic ischemia  Perforation  Sepsis
  33. 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. 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. 35. Dilated cecum
  36. 36. Cecum
  37. 37. Contrast In Descending colon Cecum
  38. 38. Barium Enema Point of Obstruction Ascending colon
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