The document discusses different types of intestinal volvulus including gastric, small bowel, large bowel, and combinations. Gastric volvulus is classified as organoaxial or mesenteroaxial depending on the axis of rotation. Small bowel volvulus often occurs due to midgut malrotation. Large bowel volvulus commonly affects the cecum or sigmoid colon. Sigmoid volvulus is the most common type of large bowel volvulus and presents as an inverted U-shape on imaging. Cecal volvulus results from torsion of the cecum around its own mesentery.

2.  GASTRIC VOLVULUS
 SMALL BOWEL VOLVULUS (MIDGUT MALROTATION)
 LARGE BOWEL VOLVULUS (CECAL VOLVULUS,
SIGMOID VOLVULUS)
 LARGE AND SMALL BOWEL VOLVULUS (
ILEOSIGMOID KNOT)

3.  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.

4.  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.

5.  Organoaxial volvulus the rotation of the stomach
along its long axis

6.  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.

7.  Mesenteroaxial volvulus the stomach twisting along its
short axis

8. ◦ Abnormality of
suspensory ligaments of
stomach.
◦ Congenital defects of their
diaphragm (Hiatal hernia).
◦ Weak Muscles (MND).
◦ Tumors of stomach.

9.  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.

10. ◦ 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 .

11.  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.

12.  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.

19.  .

22.  Gastric ischemia
◦ Gastric emphysema
◦ Twisting of stomach may tear spleen from its
normal attachments
◦ Perforation is rare

23.  Torsion of the entire gut around superior
mesenteric artery (SMA) due to a short
mesenteric attachment of small intestine in
malrotation.

24.  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

25. 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

26. 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

27. "Corkscrew" duodenum in malrotation with a midgut volvulus
"Corkscrew" duodenum in malrotation
with a midgut volvulus

28. 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)

29.  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

30.  "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

31.  Intestinal ischemia and necrosis in
distribution of SMA (bloody diarrhea, ileus,
abdominal distension)
DD:
 Pyloric stenosis (same age group, no bilious
vomiting)

32.  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

33.  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

34.  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)

35.  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

36.  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

37.  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

38. Clinical presentation
 Caecal volvulus presents with clinical features
of proximal large bowel obstruction. This is
usually with colicky abdominal pain, vomiting
and abdominal distension.

39. • 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

42. 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

44. Differential Diagnosis
 Large bowel obstruction due to other causes
à sigmoid colon CA
 Giant sigmoid diverticulum
 Pseudoobstruction
Complications
 Colonic ischemia
 Perforation
 Sepsis

48. 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

49.  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

50. Dilated cecum

51. Cecum

52. Contrast
In Descending colon
Cecum

53. Barium Enema
Point of Obstruction
Ascending colon