Sigmoid Volvulus Case Presentation 2019 التواء ألقولون

SIGMOID VOLVULUS
CASE PRESENTATION
DR. MOHAMAD AL-GAILANI FRCS
‫الكيالني‬ ‫محمد‬ ‫الدكتور‬
CONSULTANT SURGEON
CHIEF OF SURGERY
AL HAMMADI HOSPITAL, NUZHA
RIYADH, KSA

ER
Presentatio
n:
23 Year Old
Female
• 7 day history increasing abdominal
distention, upper abdominal and
back pain, vomiting, constipation
and obstipation.
• No blood per rectum
• No previous bowel complaint
• No previous operations
• No family history of bowel problems
• Fit otherwise
• On no regular medications
SIGMOID VOLVULUS CASE PRESENTATION
DR. M. AL-GAILANI AHH NUZHA
2

On Exam
• T 37 Degree C, PR 88/Minute,
BP110/80 mm Hg
• Abdomen: Gaseous Distention, Soft,
No Guarding, No Localized
Tenderness
• No Groin Hernia
• Bowel SoundsTinkling
• PR Empty (Collapsed) Rectum, No
Blood
3

Investigation
s
• HB 13.7 , WCC 8.77, PLAT315
• Lactic Acid 1.5 mmol/L
• Urea 8, Creatinine 0.57, Na 137, K 3.3
• ALT 13, AST 15, Bilirubin 1, Lipase 15,
Glucose 93
• PH 7.2, PCO2 35.8, PO2 213, HCO3
17.9
• SO2 99.5
• Ultrasound Abdomen: Obvious Bowel
Gaseous Distention, No Free Fluid,
Otherwise Normal
4

PLAINABDOMINALX RAY
5
(BENT INNER
TUBE)
SIGN

ERECT CHEST X RAY
6

Provisional
Diagnosis
Managemen
t
• Large Bowel Obstruction:
SigmoidVolvulus
Ogilvie Syndrome
• Admit
o Nil by mouth
o NasogastricTube
o IV Fluids
o Arrange Urgent CT with Contrast
7

CT ABDOMEN
12 CM
8

9

10
(WHIRL
PATTERN)
SIGN
DYNAMIC CT ABDOMEN

Sigmoid
Volvulus
Management
:
Rectal Tube
Deflation
• Diameter of Distended Colon 12 Cm
• Fear of Perforation
Attempt at Deflation:
Bedside RectalTube Deflation
Attempt Failed!
Arrange for Urgent Surgery
11

Operation:
On-Table
Rigid
Sigmoidoscop
y
Laparotomy
:
Findings
Foleys Catheter
Prophylactic Antibiotic
TED Stocking
• OnTable Rigid Sigmoidoscopy-Failed to
Deflate!
PROCEEDTO LAPAROTOMY
• Midline Laparotomy
• Findings:
o Hugely Distended Long Sigmoid Colon on a
Narrow Mesentery Root
o Rest of Bowel Normal
12

DR. AL-GAILANI
13

Sigmoid
Colectom
y
• No Attempt at Deflation in Fear
of Spillage and Contamination
• Sigmoid Colectomy
• End-to-End Interrupted Sero-
Submucosal Anastomosis of
Descending Colon to Rectum
• 18 F Redivac Drain Left in Pelvis
14

15
SIGMOID
COLECTOMY

16
SIGMOID
COLECTOMY

Postoperative
Histopatholog
y
• Day 1 Passed Flatus
• Day 2 Passed Motion
• Day 3 Discharged Home Well
• 2 Weeks Postoperative Follow up
Outpatients- Well
• Discharged from Follow-Up
• HISTOPATHOLOGY- Mild to
Moderate Congestion and Mild
Ischaemic Changes Consistent with
SigmoidVolvulus
17

SIGMOID VOLVULUS
18

Sigmoid
Volvulus
• Torsion of the sigmoid colon which often
leads to bowel obstruction.
• Mean age of 70 years at presentation
• Reported in younger patients and in
children in association with abnormal
colonic motility
• Obstruction of the intestinal lumen occur
when the degree of torsion exceeds 180
degrees
• Impairment of vascular perfusion occur
when the degree of torsion exceeds 360
degrees with the threat of gangrene.
19

Risk
Factors
• A long redundant sigmoid colon with
a narrow mesenteric attachment.
• Chronic faecal overloading from
constipation may cause elongation
and dilatation of the sigmoid
• Large bowel motility disturbance
manifested by chronic constipation,
recurrent obstipation or laxative
dependency
20

Clinical
Features
• Slowly progressive abdominal pain, nausea,
abdominal distension & constipation.
• Vomiting several days after the onset of pain.
• Pain is continuous & severe with a superimposed
colicky component during peristalsis.
• Present 3 to 4 days after onset of symptoms.
• Variants:
• Recurrent attacks of abdominal pain with resolution
due to spontaneous detorsion
• Acute abdomen due to gangrene or perforation
21

Investigation
s
• Abdominal X-ray: (Bent InnerTube) sign
U-shaped distended sigmoid colon
extending from the pelvis to the right upper
quadrant as high as the diaphragm
• Contrast enema: (Bird's Beak) sign
A twisted taper or a configuration where
contrast tapers to the point of obstruction.
• Abdominal CT scan: (Whirl Pattern) sign
Caused by the dilated sigmoid colon around
its mesocolon and vessels, and a (Bird-
Beak) appearance of the afferent and
efferent colonic segments
22

Differential
Diagnosis
Toxic Megacolon
o Due to Fulminant Ulcerative Colitis
ShowingTypical (Thumbprinting)
Pattern
Ogilvie Syndrome
o Pseudo- Obstruction
Faecal Impaction
o Intestinal Motility Disorders
23

Managemen
t of Sigmoid
Volvulus
THE GOAL OF TREATMENT:
1. Reduce the SigmoidVolvulus
2. Prevent Recurrent Episodes
 Initial Flexible Sigmoidoscopy To
Reduce the SigmoidVolvulus
 Definitive Surgery to Follow, to Prevent
RecurrentVolvulus
 Immediate Laparotomy if:
 Endoscopic Detorsion Is Unsuccessful
 Signs & Symptoms Suggestive Of
Peritonitis.
24

Endoscopic
Detorsion
• A Sigmoidoscope can detort the sigmoid
volvulus when advanced through the
twisted segment of the colon
• It also allows for an assessment of the
viability of the colon
• Successful in 75 to 95% of cases
• A well lubricated RectalTube is an
alternative to Sigmoidoscopic deflation
• Post successful deflation, the rectal tube
connected to a bag can be left in for 24
hours to allow for the passive passage of
gas and stool.
25

AMERICAN SOCIETY OF COLON AND RECTAL SURGEONS
Clinical Practice Guidelines for Colon Volvulus and Acute Colonic Pseudo-Obstruction
Jon D. Vogel, M.D. et Al
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).
26

SURGERY
• The Surgical Management of Sigmoid
Volvulus Includes:
Resection with Primary Anastomosis in
Patients Who Have Not Developed Gangrene
Hartmann's Procedure
o Initial Sigmoidoscopic Reduction ofThe
Volvulus is Advantageous
o It Converts An Emergency Procedure Into A
Semi-urgent One Performed 24To 72 Hours
After Endoscopic Reduction ofTheVolvulus
Percutaneous Endoscopic Colostomy has
Been Associated with Significant Morbidity
27

Recurrence
&
Prognosis
• Recurrence of an Initial Episode of Sigmoid
Volvulus that is NotTreated With Surgery
Occurs in UpTo 60%
• Surgery is Almost Always Recommended
After Repeated Episodes of Sigmoid
Volvulus
• TheTime to Recurrence CanVary From
Hours to Weeks or Months
• The Mortality Related to SigmoidVolvulus
is Highest in Patients Who Have Developed
Gangrene & Ranges From 11To 60%.
28

CONCLUSION • SigmoidVolvulus Causes Mechanical
Intestinal Obstruction & Can Lead to
Ischaemic Gangrene ofThe Colon.
• Initial Detorsion With Sigmoidoscopy
is Indicated.
• Surgery is Indicated When Detorsion
Fails, When Gangrene is Suspected &
to Prevent Recurrence.
• Sigmoid Colectomy or Hartmann’s
Procedure areThe Operative Options.
29

CONSULTANT BREAST & GENERAL SURGEON
CHIEFOF SURGERY
MEDICAL EDUCATION &TRAINING DIRECTOR
AL HAMMADI HOSPITAL, NUZHA
‫الحمادي‬ ‫مستشفى‬,‫النزهة‬
RIYADH, KSA
‫الرياض‬,‫السعودية‬ ‫العربية‬ ‫المملكة‬

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Sigmoid Volvulus Case Presentation 2019 التواء ألقولون