Presented at National Acadamy of Medical Sciences (NAMS). On 12th October 2020.

1. Volvulus of Colon
Moderator :
Dr. Sundar Shrestha
Department of Gen.
Surgery
National Academy of Medical
Studies(NAMS)
Dr. Kiran Pandey
MS General Surgery
Resident
National Academy of
Medical Studies(NAMS)

2. Volvulus of Colon
Introduction
Epidemiology
Types of Volvulus of colon
Etiology
Presentation
Investigation
Treatment

3. Introduction :Volvulus of Colon
• Condition where the bowel becomes twisted
on its mesenteric axis,
• Results in partial or complete obstruction of
the bowel lumen
• Variable degree of impairment of its blood
supply.

4. Introduction :Volvulus of Colon
The rotation causes
 obstruction to the lumen (>180° torsion)
 vascular occlusion in the mesentery (>360° torsion)
 Bacterial fermentation adds to the distention and
increasing intraluminal pressure impairs capillary
perfusion.
Mesenteric veins become obstructed as a result of the
mechanical twisting, thrombosi and contributes to the
ischaemia.

5. Introduction :Volvulus of Colon
• Volvuli may be primary or secondary.
The primary Volvuli:
 Secondary to congenital malrotation of the gut
 Abnormal mesenteric attachments or congenital bands.
 Volvulus neonatorum, caecal volvulus and sigmoid volvulus.
Secondary volvulus,
Due to rotation of a segment of bowel around an acquired
adhesion or stoma

6. Introduction :Volvulus of Colon
Compound volvulus
• Rare condition referred as ileosigmoid knotting.
• The long pelvic mesocolon allows the ileum to
twist around
• the sigmoid colon, resulting in gangrene of either
or both segments of bowel.
• The patient presents with acute intestinal
obstruction, but distension is comparatively mild.
• Plain radiography reveals distended ileal loops in
a distended sigmoid colon.

7. Volvulus of Colon
• Volvulus
• Twist of the bowel around its own mesentery)
• Closed loop obstruction
• (obstruction of the bowel at 2 points in 1 location)
• Strangulation
• obstruction of the bowel with interruption of its blood
supply

8. Epidemiology
 In North America less common
4% of cases of large bowel obstruction.
 Common in area of volvulus belt
50% of all cases of colonic obstruction.
South America, Africa, the Middle East, India, and Russia
(diet high in fiber and vegetables)
 Transverse colon is involved in 2 to 4% versus 43 to 80% and
15 to 43% respectively for the sigmoid colon and the cecum.

9. Epidemiology
Mortality or morbidity more often than cecal or sigmoid
volvulus
The mortality rate
transverse colon volvulus :33%,
Sigmoid Colon volvulus: 21%
Cecal volvulus: 10%.

10. Etiology
Congenital
I. Redundancy
II. Non fixation
III. Long mesentery
PHYSIOLOGICAL
I. High roughage Diet
II. Elongation and distension 2
o
Constipation
III. Megacolon from
IV. Hirschsprung disease

11. Etiology
MECHANICAL
I. Previous volvulus of the colon,
II. Distal colonic obstruction,
III. Adhesions
IV. Malposition of the colon following previous surgery,
V. Mobility of the right colon,
VI. Inflammatory strictures,
VII. Carcinoma.

12. Types
• Sigmoid colon Volvulus
• Caecal and ileocecal Volvulus
• Transverse colon Volvulus

13. Sigmoid volvulus Cecal volvulus
sigmoid volvulus can only move
upwards and usually goes to the
right upper quadrant.
Cecal volvulus however can go
almost anywhere and can even be
located in the pelvis.
Sigmoid volvulus Vs cecal volvulus
A volvulus always extends away from the area of bowel twist.

14. Sigmoid volvulus Cecal volvulus
Associated with large bowel
dilatation.
Associated with small bowel
dilatation.
Sigmoid volvulus Vs cecal volvulus

15. Types of cecal volvulus
Type I cecal bascule Type II Axial cecal
volvulus
Folding of the cecum anterior to
the ascending colon
Rotation of the distended
cecum around the longitudinal
axis of the ascending colon.

16. Sigmoid Volvulus
• Two thirds of all cases of colonic volvulus.
• Elongated segment of bowel with lengthy
mesentery , narrow parietal attachment, two
ends of the mobile segment to come together to
twist around the narrow mesenteric base.
• Associated factors include chronic constipation,
aging, treated with psychotropic drugs affecting
intestinal motility.
• Average age at presentation: seventh to eighth
decade of life.

17. Types of sigmoid volvulus
180 degree of rotation 360 degree of rotation 540 degree of rotation
Most common
Mesenterico axial Organo-axial
Twist around
mesenteric axis
Twist around
longitudinal axis
Closed loop obstruction No closed loop
obstruction (one
transition point)

18. Clinical Presentation
May present as acute or subacute intestinal
obstruction, with signs and symptoms
indistinguishable from those caused by cancer of
the distal colon.
sudden onset of severe abdominal pain,
vomiting
Obstipation.
markedly distended and tympanitic abdomen
.

19. Clinical Presentation
Usually associated with ischemia caused by mural
ischemia resulting from
 Increased tension of the distended bowel wall
 Arterial occlusion caused by torsion of the mesenteric
arterial supply.
 Severe abdominal pain, rebound tenderness, and
tachycardia are ominous signs.
History of previous episodes of acute volvulus that
spontaneously resolved. In this case, marked
abdominal distention may occur with minimal
tenderness

20. Clinical Presentation
Fulminant:
sudden onset, severe pain, early vomiting,
rapidly deteriorating clinical course;
Indolent:
Insidious onset, slow progressive course, less
pain, late vomiting.

21. Laboratory Studies
• Laboratory tests include
• Complete blood count (CBC) with differential
• Comprehensive metabolic profile.
 An elevated white blood cell (WBC) count and
left shift indicate bowel ischemia, peritoneal
infection, or systemic sepsis.
Bowel obstruction may cause significant changes
in electrolyte levels.

22. Other diagnostic studies include
• Plain Abdominal Radiography,
• Computed Tomography (CT),
• Barium Enema,
• Sigmoidoscopy Or Colonoscopy

23. Sigmoid Volvulus

24. Sigmoid Volvulus
Bird Beck Sign

25. Sigmoid Volvulus
• Bird Beck sign

26. Sigmoid Volvulus

27. Sigmoid Volvulus

28. Sigmoid Volvulus

29. Sigmoid Volvulus

30. Sigmoid Volvulus

31. Sigmoid Volvulus

32. Sigmoid Volvulus

33. Sigmoid volvulus

34. Clinical indicators of ischaemic bowel
in sigmoid volvulus
Mucosal discoloration seen in colonoscopy
Haematochezia
Failure to negotiate colonoscope past the obstruction
Fever
Leukocytosis
Tenderness of abdomen
Hypotension/shock
Postmorbid alteration in sensorium
Metabolic acidosis

35. Management of Sigmoid Volvulus

36. Management of Sigmoid Volvulus
THE GOAL OF TREATMENT:
1. Reduce the SigmoidVolvulus
2. Prevent Recurrent Episodes
Initial Flexible Sigmoidoscopy
• To Reduce the SigmoidVolvulus
Definitive Surgery
• For RecurrentVolvulus
Immediate Laparotomy if:
 Endoscopic Detorsion IsUnsuccessful
 Signs & Symptoms SuggestiveOf Peritonitis.

37. Clinical Practice Guidelines for Colon Volvulus and Acute ColonicPseudo-
Obstruction Jon D. Vogel, M.D. etAl
Diseases of the Colon & Rectum Volume 59: 7 (2016)
1. Rigid or flexible endoscopy should be performed to assess
sigmoid colon viability & to allow initial detorsion &
decompression of the
colon
(Grade of Recommendation:Strong)
2. Urgent sigmoid resection is generally indicated when
endoscopic detorsion of the sigmoid colon is not possible & in
cases of nonviable or perforated colon
(Grade of Recommendation: Strong)
3. Sigmoid colectomy should be considered after resolution of the
acute phase of sigmoid volvulus to prevent recurrent volvulus
(Grade of Recommendation: Strong).
AMERICAN SOCIETY OF COLON AND RECTALSURGEONS

38. Management of Sigmoid Volvulus
Decompression
Achieved by placement of a rectal tube through a rigid
proctoscope, or flexible sigmoidoscope
 Decompression results in a sudden gush of gas and
fluid, with a decrease in the abdominal distention.
 The reduction should be confirmed with an abdominal
radiograph.
 The rectal tube should be taped to the thigh and left in
place for 1 or 2 days to allow continued decompression
and to prevent immediate recurrence of the volvulus.
 The bowel can then be cleansed with cathartics and a
complete colonoscopic examination performed.

39. Management of Sigmoid Volvulus
Resection of sigmoid colon
If detorsion of the volvulus cannot be
accomplished with a rectal tube or flexible
sigmoidoscope, laparotomy with resection of
the sigmoid colon (Hartmann operation) is
required
Even if detorsion of the sigmoid is successful,
elective sigmoid resection is indicated
As extremely high recurrence rate of 70%.

40. Management of Sigmoid Volvulus
Resection of sigmoid colon
Colonoscopy should be performed before elective
resection to exclude an associated neoplasm.
Conducted through a small left lower quadrant
incision or by a laparoscopic approach.
Because the elongated colon and mesentery
require almost no mobilization, resection with
primary anastomosis is easily accomplished.

41. Management of Sigmoid Volvulus
Resection of sigmoid colon
For patients with signs of colonic necrosis or in
whom endoscopic detorsion has failed, the
traditional treatment has been a sigmoid
colectomy with closure of the rectum and end
colostomy (Hartmann procedure).
Resection with primary anastomosis, with or
without protection from a proximal ostomy
(transverse colostomy or ileostomy), may be
accomplished in the acute setting.

42. Cecal Volvulus
 Characterised anatomically by the axial twisting that occurs
involving the caecum, terminal ileum, and ascending colon
 True volvulus of the cecum never occurs.
 Cecal bascule refers to cecum folding in a cephalad
direction anteriorly over a fixed ascending colon.
 Gangrene is rare as no major vessel obstruction.
 Causes intermittent bouts of abdominal pain
Since the mobile cecum permits intermittent episodes of
isolated cecal obstruction that are spontaneously relieved

43. Cecal Volvulus
• Cecal volvulus is actually a cecocolic volvulus.
• Consisting an axial rotation of the terminal ileum,
cecum, and ascending colon, with concomitant
• twisting of the associated mesentery.
• Due to lack of fixation of the cecum to the
retroperitoneum.
• 11% and 22% have a right colon that is
sufficiently mobile to allow a volvulus to occur.
•

44. Cecal Volvulus
Average age of patients
Indian subcontinent is 33 years
Western countries 53 years.
23%–53% have a history of prior abdominal
surgery,
People with incomplete intestinal rotation
generally develop inadequate right colon fixation
associated with the potential for caecal volvulus
formation

45. Cecal Volvulus
Factors
• Surgery,
• Pregnancy,
• Malrotation
• Obstructing lesions of the left colon.

47. Clinical presentation
Broadly categorised as
Recurrent intermittent,
Acute obstruction, and
Acute fulminant patterns

48. Clinical presentation
Recurrent intermittent pattern
Referred to as the mobile caecum syndrome.
occur in 50% of patients before the onset of acute volvulus.
Recurrent symptoms of
 Generalised or localised right lower quadrant pain,
 Abdominal distension
 Pain resolution after the passage of flatus.
Physical findings during symptomatic episodes
 High pitched bowel sounds
 Right lower quadrant abdominal tenderness
 Disappear as the patients’ symptoms resolve

49. Clinical presentation
Acute obstructive pattern:
 Cramping abdominal pain and vomiting that do not
resolve spontaneously
 Indistinguishable from acute, uncomplicated small
bowel obstruction.
 Tender and dilated caecum maybe palpable in thin
patients
 Recommended undergo early radiological evaluation.
 Untreated acute volvulus intestinal strangulation and
perforation (acute fulminant)

50. Clinical presentation
Acute fulminant patterns
severe abdominal pain,
peritoneal irritation
dehydration, and haemodynamic instability

51. Radiological Evaluation
Dilated cecum that is usually displaced to the left side of the abdomen.
The distended cecum generally assumes a gas-filled comma shape, the concavity
of which faces inferiorly and to the right.

52. Radiological Evaluation
Barium enema
• Bird Beck Sign

53. Radiological Evaluation

54. Radiological Evaluation
Computed Tomography Cecal volvulus

55. Radiological Evaluation

56. Radiological Evaluation

57. Radiological Evaluation

58. Radiological Evaluation

59. Radiological Evaluation

60. Radiological Evaluation

61. Treatment
Barium enema
 Sporadic reports of reduction after barium enema.
 The success rate is unknown.
 Usually recommended as a therapeutic option
Colonoscopy
 Reduction of volvulus by endoscopic approach;
 Success rate is about 30% and the recurrence rate is unknown
 risks of increasing distention because of insufflation of air
Operative detorsion
 Manual reduction of volvulus by caeliotomy.
 Mortality 0%– 25%; recurrence 0%–70%

62. Treatment
Colectomy
 Resection of involved intestinal segment. Mortality 0%–
39% .
 No recurrence has been reported after resection.
Right colectomy is the procedure of choice.
Primary anastomosis is usually preferred unless frankly
gangrenous bowel, in which case resection of the
gangrenous bowel with ileostomy is a safer approach.
• The recurrence rates are high with cecopexy, and right
colectomy remains the procedure of choice for most
surgeons.
• Volvulus of the transverse colon is extremely rare

63. Treatment
Caecopexy
 Fixation of right colon by suturing of caecum and/or
ascending colon to lateral parietal peritoneum.
 Operative mortality 0%–30%; recurrence 0%–40%.
 Avoid the complication associated with an
anastomosis.
Caecostomy tube placement
 Fixation of right colon by tube placement into caecum.
 Operative mortality 0%–40%; recurrence 0%–33%.

64. Transverse colon volvulus
 Involved in 2 to 4% of all colon volvulus
Most often occurs in the second and third decades
Additional Peak in seventh decade
Women outnumber men 2:1
 Mortality or morbidity more often than cecal or sigmoid
volvulus

65. Endoscopic colopexy:
For patients who have had successful
endoscopic detorsion but have significant
comorbidities, may also be an option.
For Compound Volvulus
At operation, decompression, resection and
anastomosis are required.

66. Transverse colon volvulus
Twisting in volvulus usually occurs along the mesenteric axis
of the bowel, resulting in venous obstruction and eventually
arterial compromise.
Compression of the duodenojejunal junction, at the root of its
mesentery may cause severe vomiting in this condition.
Clinical features are indistinguishable from other causes of
large bowel obstruction

67. Transverse colon volvulus
• Radiologic examination is not particularly
useful because many cases are misdiagnosed
as sigmoid volvulus.
• A contrast study may show
a bird’s beak deformity,
indicating a volvulus.

68. Colonic Volvulus Radiograph

69. Transverse Colon
Ascending colon
Descending Colon
and Sigmoid
Colonic Volvulus Radiograph

70. Treatment
 Colonoscopic reduction may result in detorsion and relief of
obstruction.
 Volvulus of the transverse colon usually has to be detorsed
surgically.
 Elective resection
 Resection of the affected segment constitutes the treatment
of choice to prevent recurrence.

71. References
 Sabiston Textbook of Surgery, vol II, 20th edition
 Schwartz's Principles of Surgery, 11e.
 Bailey & Love's Short Practice of Surgery, 27th edition
 https://emedicine.medscape.com/article/2048554-overview#a6
 Clinical Practice Guidelines for Colon Volvulus and Acute
ColonicPseudo-Obstruction Jon D. Vogel, M.D. etAl
Diseases of the Colon & Rectum Volume 59: 7 (2016)
 Frizelle FA, Wolff BG. Colonic volvulus. Advances in Surgery. 1996
;29:131-139.
 Diagnosis and treatment of caecal volvulus E T Consorti, T H Liu,
Postgrad Med J 2005;81:772–776. doi: 10.1136/pgmj.2005.035311
 Volvulus of the sigmoid colon, V. Raveenthiran, T. E. Madiba , S. S.
Atamanalp , U. De

72. Thank You