Sigmoid Volvulus: A Case Series, Review of the Literature and Current Treatment | Biomedgrid llc

Abstract

A sigmoid volvulus occurs when a loop of the sigmoid colon twists around the mesentery, often leading to bowel obstruction and constipation. Patients with sigmoid volvulus can either present with insidious or an acute onset of abdominal pain, abdominal distension, nausea and constipation. Imaging is imperative to facilitate a timely sigmoid volvulus and radiologists and emergency physicians have to be aware of the apparent and subtler findings. A small case series is presented on sigmoid volvulus, which failed decompressive sigmoidoscopy and were successfully managed with a modified Paul Mikulicz operation.

Introduction

A volvulus in simple terms refers to torsion of a segment of the gastrointestinal tract (most commonly the caecum and sigmoid colon), often resulting in bowel obstruction [1, 2]. A sigmoid volvulus (SV) occurs when a loop of the sigmoid colon (containing air) twists around the mesentery — the sigmoid mesocolon [3]. When the degree of torsion exceeds 180 and 360 degrees, then obstruction of the bowel lumen and impairment of bowel perfusion occur, respectively [4]. The exact cause of a SV is unknown, however, risk factors include: a family history, high fibre diet, institutionalisation, chronic faecal loading, psychiatric disease, colonic dysmotility, previous abdominal surgeries, diabetes and Hirshprung’s disease [5, 6].

Case Series

Case 1

Discussion

SV is the most common type of colonic volvulus, accounting for 50–80 per cent [7]. In the developed world (including the United States of America, Australia and Europe), it accounts for approximately 10 per cent of all intestinal obstructions. However, SV is in the top three causes (3–5 per cent) of acute large bowel obstruction [3, 7]. In contrast, in countries where high fibre diets are consumed (such as Africa, India, Latin America and the Middle East), the incidence of acute bowel obstructions from sigmoid volvuli are up to 54 per cent [8]. The geographical distribution is thought to be linked to the ingestion of a high fibre diet, leading to lengthening of the sigmoid colon and its mesentery, resulting in a predisposition to volvulize [9]. The mean age of presentation for a SV is 70 years [10]. Patients are typically male, instutionalised, have a history of constipation and often have neurological or psychiatric disease [11, 12, 13]. In contrast, some studies found that there were no difference in the incidence by gender [13, 14].

Conclusion

Acute sigmoid volvulus is a diagnosis to exclude in patients presenting with acute abdominal pain. Clinical management can be improved through an accurate and timely diagnosis. Failure to recognise the condition can lead to sigmoid perforation, sepsis, peritonitis and death. Imaging is imperative to facilitate a timely sigmoid volvulus and radiologists and emergency physicians have to be aware of the apparent and subtler findings. If uncomplicated, sigmoid volvulus is best initially treated with flexible sigmoidoscopy and rectal tube placement. If this fails, or if the patient has complicated acute sigmoid volvulus, then emergency surgery is required. Research is consistent for technique in unstable patients, recommending an emergency midline laparotomy surgery. Favourable outcomes can be achieved through the use of a modified Paul Mikulicz operation.

Conflicts of Interest

No financial interest or any conflicts of interest.

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