Volvulus and intestinal malrotation

Volvulus is defined as the twisting of a loop of bowel on its mesentery and is one of the most common causes of intestinal obstruction. The sigmoid colon, and less frequently, the cecum, are the common sites of volvulus in adults. Volvulus in a neonate or infant almost always presents as a midgut volvulus secondary to intestinal malrotation. Patients typically show features of bowel obstruction (abdominal pain, distension, bilious vomiting) or of bowel ischemia and gangrene (tachycardia, hypotension, hematochezia, peritonitis) in severe cases. The whirl sign and a grossly dilated loop of bowel on an abdominal CT scan establish the diagnosis of volvulus in adults. Upper GI series is the investigation of choice in infants with suspected midgut volvulus, which is seen as a cork-screw duodenum. Sigmoid volvulus without peritonitis is initially managed with endoscopic detorsion, followed by a semi-elective surgery (sigmoid colectomy). Sigmoid volvulus with peritonitis, and all cases of cecal volvulus, require emergency surgery. Endoscopic detorsion should not be attempted in a patient with cecal volvulus because of the high risk of perforation. The Ladd procedure (laparotomy and detorsion of the volvulus) is indicated in all patients with intestinal malrotation since it is impossible to predict if volvulus of the midgut will occur in an asymptomatic patient or not.

• Incidence
  • Volvulus: 3^rd most common cause (∼ 10–15%) of intestinal obstruction in the United States
  • Intestinal malrotation: symptomatic malrotation (midgut volvulus) in 1:6000 live births in the United States
• Age ^[1][2]
  • Sigmoid volvulus: ∼ 70 years
  • Cecal volvulus: 40–60 years
  • Intestinal malrotation and midgut volvulus: neonates and infants
• Sex ^[1][2]
  • Sigmoid volvulus: ♂ > ♀
  • Cecal volvulus: ♀ >♂

SigmOid volvulus is more common in Older individuals while Midgut volvulus and Malrotation are more common in Minors.

Epidemiological data refers to the US, unless otherwise specified.

• Torsion of bowel on its axis ^[3]
  • Closed-loop mechanical bowel obstruction → accumulation of gas and feces within the loop → increased intraluminal pressure → impaired capillary perfusion of bowel → bowel strangulation, ischemia, and gangrene
  • Torsion of the mesenteric vascular pedicle → occlusion/thrombosis of mesenteric vessels → bowel strangulation, ischemia, and gangrene
• Location: may affect all parts of the bowel ^[4]
  • Sigmoid volvulus (most common, 80%)
  • Cecal volvulus (15%)
  • Transverse colon volvulus (3%)
  • Splenic flexure volvulus (2%)

• Long mesentery ^[5]
  • Acquired (sigmoid volvulus): chronic constipation , high-fiber diet resulting in bulky stools → chronic overloading of the sigmoid colon → lengthening of the sigmoid colon and its mesentery → increased risk of torsion
  • Congenital (cecal volvulus): abnormally mobile cecum → predisposition of the cecum to rotate on its axis (axial torsion) or fold upwards (cecal bascule)
• Intestinal malrotation: abnormal rotation of the bowel with abnormal fixation of mesentery to the posterior abdominal wall
• Megacolon (Hirschsprung disease, Chaga disease)
• Intestinal bands/adhesions
• Decreased pelvic space: pregnancy or pelvic mass
• Previous history of volvulus

Clinical features

• Previous episodes of abdominal pain, which decreased after explosive passage of stool/gas
• Slowly (most common) or rapidly progressive symptoms of bowel obstruction
• If bowel ischemia occurs → tachycardia, hypotension, peritonitis (rebound tenderness), hematochezia or blood on DRE may be present
• If bowel perforation occurs → obliteration of liver dullness on percussion

Differential diagnoses

• Acute megacolon
• Toxic megacolon
• Other causes of mechanical bowel obstruction (e.g., colon cancer, strictures, cecal volvulus)

Treatment ^[6][7]

• Initial resuscitation: IV fluids; acid-base and electrolyte imbalance correction; NPO; placement of a nasogastric tube
• Evaluation
  • No signs of peritonitis ; : rigid/flexible sigmoidoscopic detorsion of the volvulus → inspection of the mucosa for signs of ischemia ^[8]
    • No signs of mucosal ischemia → placement of a soft rectal tube (for bowel decompression) → semi-elective surgery within 72 hours of detorsion
    • Signs of mucosal ischemia → emergency surgery (see below)
  • Signs of peritonitis/unsuccessful endoscopic detorsion → broad-spectrum IV antibiotics and emergency surgery ^[8]
• Surgery
  • Sigmoid colectomy and primary anastomosis : indicated in hemodynamically stable patients with viable bowel ^[7]
  • Hartmann procedure: indicated in hemodynamically unstable patients or those with ischemic/gangrenous bowel

References:^{[3][6][7][8][9][10][11]}

Types ^[12]

• Axial torsion of the cecum (90% of cases): the cecum rotates on its mesenteric axis → bowel obstruction with vascular compromise
• Cecal bascule (10%): the cecum folds upwards onto the ascending colon → bowel obstruction often without vascular compromise

Clinical features

• Acute presentation: features of small bowel obstruction
• Insidious onset: recurrent episodes of right lower abdominal pain

Differential diagnoses

• Sigmoid volvulus
• Small bowel obstruction (e.g., adhesions, tumors, intussusception)

Treatment ^[10]

• Initial resuscitation (See “Treatment” of sigmoid volvulus above.)
• Surgery
  • Hemodynamically stable patients: ileocecal resection or right colectomy with ileocolic anastomosis
  • Hemodynamically unstable patients
    • Cecostomy ^[5][11]
    • Detorsion with cecopexy ^[13]

Definition

• Intestinal malrotation: arrest in the normal rotation of the gut in utero, resulting in an abnormal orientation of the bowel and mesentery within the abdominal cavity
• Normal intestinal rotation: the midgut starts to elongate in utero (4^th week) → herniation of the midgut out of the umbilicus (6^th week) → 90° counter-clockwise rotation of the midgut → re-entry of the midgut into the abdominal cavity(10^th week) → 180° rotation inside the abdominal cavity (a total of 270°) → fixation of the duodenojejunal flexure and cecum to the posterior abdominal wall

• Midgut volvulus: torsion of a malrotated midgut causing mechanical bowel obstruction, mostly in neonates and infants

Clinical presentation

• Malrotation: mostly asymptomatic
• Midgut volvulus
  • Bilious vomiting with abdominal distension in a neonate/infant
  • Signs of bowel ischemia: hematochezia, hematemesis, hypotension, and tachycardia
• Features of duodenal obstruction: bilious vomiting without abdominal distension
• Variable presentation in older children/adults: recurrent episodes of abdominal pain and vomiting; failure to gain weight; malabsorption ^[15][16]
• Abdominal examination is unreliable in neonates/infants because abdominal tenderness/rebound tenderness is difficult to assess in this population.
• Features of associated congenital anomalies
  • Commonly associated anomalies: congenital diaphragmatic hernia (∼ 100%) ; congenital heart defects (up to 90%); omphalocele (up to 45%)
  • Less commonly associated anomalies: gastroschisis; Meckel diverticulum; esophageal atresia; biliary atresia

Differential diagnoses ^[17][18]

• In neonates/infants with recurrent vomiting: duodenal atresia and stenosis; , hypertrophic pyloric stenosis
• In neonates with features of bowel ischemia/gangrene: necrotizing enterocolitis (NEC)
• In older children with abdominal pain and vomiting: intussusception
• In older children/adults with nonspecific symptoms: GERD; chronic mesenteric ischemia; food allergy

Treatment

• Midgut volvulus with/without peritonitis
  • Initial resuscitation: NPO; nasogastric tube insertion; IV fluids; correction of electrolyte imbalance; broad-spectrum IV antibiotics
  • Emergency surgery (Ladd procedure) ^[14]
• Incidentally detected/asymptomatic intestinal malrotation: elective surgery (Ladd procedure) ^[19]

References:^{[14][15][18][19][20]}

Volvulus

• Work-up follows the same protocol as that for bowel obstruction.
• Abdominal x-ray (erect and supine)
  • Sigmoid volvulus: coffee bean sign (bent inner tube sign/inverted U sign)
  • Cecal volvulus: kidney bean sign
  • Cecal bascule: dilated cecum in the center of the abdominal cavity; an air-distended appendix may also be seen
  • Bowel perforation: air under diaphragm ^[21]
• CT scan
  • Whirl sign: pathognomonic for volvulus ^[22]
  • Specific features of sigmoid/cecal volvulus are similar to those seen in x-rays
  • Demonstrates bowel ischemia , or perforation , if present
• Barium enema: : bird's beak sign (tapering of the dye column at the site of the twist)
  • In cecal bascule, the end of the barium column is rounded, rather than tapered (teardrop sign).
  • Cecal volvulus: normal-sized colon with bird's beak sign at the cecum; dye does not enter the small bowel
  • Sigmoid volvulus: normal-sized rectum with bird's beak sign at the sigmoid; dye does not enter the sigmoid colon

Intestinal malrotation and midgut volvulus

• Laboratory studies: complete blood count; electrolyte levels; arterial blood gas analysis ^[23][24]

References:^{[15][21][22][23][24][25][26][27][28]}

See “Differential diagnosis of lower gastrointestinal bleeding in children.”

The differential diagnoses listed here are not exhaustive.

1. Atamanalp SS, Ozogul B, Kisaoglu A. Cecal volvulus: a rare cause of intestinal obstruction. Eurasian J Med. 2012; 44 (2): p.115-116. doi: 10.5152/eajm.2012.25 . | Open in Read by QxMD
2. Yeo CJ, Matthews JB, McFadden DW, Pemberton JH, Peters JH . Shackelford's Surgery of the Alimentary Tract. Elsevier Saunders ; 2012
3. Corman ML. Colon and Rectal Surgery. Lippincott Williams & Wilkins ; 2004
4. Laparoscopic Treatment of Volvulus of the Colon, In: Laparoscopic Surgery, Saunders Co, 1994. http://www.lapsurgery.com/volvulus.htm. Updated: September 11, 2010. Accessed: March 28, 2017.
5. Ortega PM, Rotellar F, Arredondo J, et al. Minimal invasive management of acute cecal volvulus: colonoscopy followed by laparoscopic cecopexy. Rev Esp Enferm Dig. 2014; 106 (7): p.497-499.
6. Lou Z, Yu ED, Zhang W, Meng RG, Hao LQ, Fu CG. Appropriate treatment of acute sigmoid volvulus in the emergency setting. World J Gastroenterol. 2013; 19 (30): p.4979-4983. doi: 10.3748/wjg.v19.i30.4979 . | Open in Read by QxMD
7. Steele SR, Hull TL, Read TE, Saclarides TJ, Senagore AJ, Whitlow CB. The ASCRS Textbook of Colon and Rectal Surgery. Springer ; 2016
8. Chalya PL, Mabula JB. Sigmoid volvulus and ileo-sigmoid knotting: a five-year experience at a tertiary care hospital in Tanzania. World J Emerg Surg. 2015; 10 : p.10. doi: 10.1186/s13017-015-0001-1 . | Open in Read by QxMD
9. Halabi WJ, Jafari MD, Kang CY, et al. Colonic volvulus in the United States: trends, outcomes, and predictors of mortality. Ann Surg. 2014; 259 (2): p.293-301. doi: 10.1097/SLA.0b013e31828c88ac . | Open in Read by QxMD
10. Gingold D, Murrell Z. Management of colonic volvulus. Clin Colon Rectal Surg. 2012; 25 (4): p.236-244. doi: 10.1055/s-0032-1329535 . | Open in Read by QxMD
11. Katsikogiannis N, Machairiotis N, Zarogoulidis P, et al. Management of sigmoid volvulus avoiding sigmoid resection. Case Rep Gastroenterol. 2012; 6 (2): p.293-299. doi: 10.1159/000339216 . | Open in Read by QxMD
12. Sigmoid Volvulus: An Update. http://www.ptolemy.ca/members/archives/2009/Sigmoid/. Updated: March 28, 2017. Accessed: March 28, 2017.
13. Williams NS, Bulstrode C, O'Connell PR. Bailey & Love's Short Practice of Surgery. CRC Press ; 2013
14. Coffee-bean sign (sigmoid colon). https://radiopaedia.org/articles/coffee-bean-sign-sigmoid-colon. Updated: March 28, 2017. Accessed: March 28, 2017.
15. Hodin RA. Cecal volvulus. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/cecal-volvulus.Last updated: March 2, 2016. Accessed: March 28, 2017.
16. Kim SH, Shin SS, Jeong YY, Heo SH, Kim JW, Kang HK. Gastrointestinal tract perforation: MDCT findings according to the perforation sites. Korean J Radiol. 2009; 10 (1): p.63-70. doi: 10.3348/kjr.2009.10.1.63 . | Open in Read by QxMD
17. Khurana B. Signs in Imaging: The whirl sign. Radiology. 2003; 226 (1): p.69-70. doi: 10.1148/radiol.2261011392 . | Open in Read by QxMD
18. Gennari FJ, Weise WJ. Acid-Base Disturbances in Gastrointestinal Disease. Clin J Am Soc Nephrol. 2008; 3 (6): p.1861-1868. doi: 10.2215/​CJN.02450508 . | Open in Read by QxMD
19. Van den heijkant TC, Aerts BA, Teijink JA, Buurman WA, Luyer MD. Challenges in diagnosing mesenteric ischemia. World J Gastroenterol. 2013; 19 (9): p.1338-1341. doi: 10.3748/wjg.v19.i9.1338 . | Open in Read by QxMD
20. Applegate KE, Anderson JM, Klatte EC. Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series. Radiographics. 2006; 26 (5): p.1485-1500. doi: 10.1148/rg.265055167 . | Open in Read by QxMD
21. Tackett JJ, Muise ED, Cowles RA. Malrotation: Current strategies navigating the radiologic diagnosis of a surgical emergency. World J Radiol. 2014; 6 (9): p.730-736. doi: 10.4329/wjr.v6.i9.730 . | Open in Read by QxMD
22. Rokade ML, Yamgar S, Tawri D. Ultrasound “Whirlpool Sign” for Midgut Volvulus. J Med Ultrasound. 2011; 19 (1): p.24–26. doi: 10.1016/j.jmu.2011.01.001 . | Open in Read by QxMD
23. Yigit M, Turkdogan KA. Coffee bean sign, whirl sign and bird's beak sign in the diagnosis of sigmoid volvulus. Pan Afr Med J. 2014; 19 : p.56. doi: 10.11604/pamj.2014.19.56.5142 . | Open in Read by QxMD
24. Jaffe T, Thompson WM. Large-Bowel Obstruction in the Adult: Classic Radiographic and CT Findings, Etiology, and Mimics. Radiology. 2015; 275 (3): p.651-663. doi: 10.1148/radiol.2015140916 . | Open in Read by QxMD
25. Strouse PJ. Disorders of intestinal rotation and fixation ("malrotation"). Pediatr Radiol. 2004; 34 (11): p.837-851. doi: 10.1007/s00247-004-1279-4 . | Open in Read by QxMD
26. Buchmiller T. Intestinal malrotation in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/intestinal-malrotation-in-adults.Last updated: February 2, 2016. Accessed: March 28, 2017.
27. Brandt ML. Intestinal malrotation in children. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/intestinal-malrotation-in-children.Last updated: January 3, 2017. Accessed: March 28, 2017.
28. Midgut volvulus. https://radiopaedia.org/articles/midgut-volvulus. Updated: March 28, 2017. Accessed: March 28, 2017.
29. Malrotation. https://www.sages.org/wiki/malrotation/. Updated: March 28, 2017. Accessed: March 28, 2017.
30. Fischer JE, Bland KI. Mastery of Surgery. Lippincott Williams & Wilkins ; 2006