Hospital Medicine

Volvulus

I. What every physician needs to know.

Volvulus refers to torsion of a segment of the alimentary tract, which often leads to bowel obstruction.The most common sites of volvulus are the sigmoid colon and the cecum.Volvulus of other portions of the alimentary tract, such as the stomach, gallbladder, small bowel, splenic flexure, and transverse colon, are rare.

Midgutvolvulus is a well-recognized surgical emergency in children, but it is rarely found in adults. It usually manifests as congenital midgut malrotation but may also be acquired from postoperative adhesion bands, tumors, persistent omphalomesenteric duct, and mesenteric cysts. Volvulus has also been reported in the setting of Crohn's disease, pregnancy, post-colonoscopy, Hirschsprung's disease, mobile cecum syndrome, and Chagas disease. It may also be a delayed complication of blunt trauma to the abdomen resulting from post-traumatic cyst development. The causes of sigmoid volvulus are primarily acquired so it is usually seen in elderly, institutionalized, or chronically constipated persons.

Anatomical risk factors for volvulus are rotation abnormalities (intestinal malrotation and non-rotation). Although these conditions usually cause volvulus at a much earlier age, they are sometimes seen in adults. Rotation abnormalities are conditions that develop as a result of an arrest of normal rotation of the embryonic gut. These abnormalities occur in 1/200 to 1/500 live births. Non-rotation is not as dangerous as malrotation since risk of volvulus is lower in non-rotation.

In malrotation, the cecum is abnormally fixated by bands of peritoneum known asLadd bands,which can cause extrinsic compression of the intestine. Additionally, in malrotation the narrow mesenteric base of the small bowel further predisposes the gut to volvulus. Volvulus as a result of non-rotation and malrotation usually occurs after birth (with up to 40% of patients presenting within the first week of life and up to 75% to 85% having been diagnosed by age one year)and is rare in older children and adults. The literature is not clear concerning whether the risk for volvulus(among those with malrotation), decreases with advancing age.

II. Diagnostic Confirmation: Are you sure your patient has volvulus?

Patients with volvulus usually present with nonspecific complaints. Abdominal imaging (discussed in detail below) usually confirms the diagnosis. Plain abdominal X-ray picks up volvulus in about 60 percent of cases.

A. History Part I: Pattern Recognition:

Clinical symptoms of volvulus are non-specific but most commonly includecolicky abdominal painand vomiting. Accompanying signs may also includeabdominal distension andbloody stool. Blood in the stool is a worrisome sign since it usually implies bowel ischemia and necrosis.

Fever, hypotension,and signs ofperitonitis usually indicate bowel gangrene.

Gastric volvulus, which is uncommon, is characterized by theBorchardt triad,which consists of sudden epigastric pain, intractable retching, and inability to pass a nasogastric tube in to the stomach.

B. History Part 2: Prevalence:

Volvulus in adults accounts for only 2 percent of all cases of mechanical intestinal obstruction(Ballantyne et al.). Adult sigmoid volvulus usually occurs in the debilitated elderly patient.

Rotation abnormalities significantly increase risk for volvulus; however, their incidence in the population is difficult to estimate since most patients go through life without any symptoms.Kapfer et al.noted that, according to barium enema series and autopsy results, 0.2-1 percent of the population may harbor such abnormalities.

C. History Part 3: Competing diagnoses that can mimic volvulus.

The majority of patients present with features of small bowel obstruction, which can mimic almost any other cause of obstruction. It is important to identify volvulus as the underlying etiological mechanism for obstruction, which can be achieved by means of abdominal imaging (as detailed below).

D. Physical Examination Findings.

Patients with volvulus may initially present with nonspecific physicalabdominal pain, nausea, vomiting,andtachycardia. In some cases, amass can be palpated. As necrosis sets in, patients may developperitoneal signs, fevers,andhematochezia.

E. What diagnostic tests should be performed?

The diagnosis of volvulus can be established onby imaging (discussed below).

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

There are no diagnostic laboratory tests for volvulus; however, some commonly found nonspecific laboratory abnormalities are leukocytosis, lactate elevation, and metabolic acidosis.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

Abdominal plain film has about 60 percent sensitivity and may pick up dilated loops of bowel in midgut volvulus. It offers the advantage of a rapid test without the need for contrast and is the test of first choice. In sigmoid volvulus, a "coffee bean" sign may be seen, which is formed by closely apposed, dilated loops of bowel.

CT of the abdomen has high sensitivity and specificity for this diagnosis. A "whirlpool" sign, which refers to SMA wrapped by coils of intestine, may be seen. Some authors believe that this sign is diagnostic of midgut volvulus.

Upper gastrointestinal series with small bowel follow-through is the most specific radiological exam for the diagnosis of midgut volvulus; however, it is time-consuming and poorly tolerated by patients with acute abdominal pain. In midgut volvulus, a "corkscrew" appearance and "beak-like" stenosis may be seen.

Angiography may reveal the "barber pole" sign in midgut volvulus, which represents rotation of the small intestine around the root of the mesentery. However, this test is invasive and not the test of choice.

Ultrasonography:The "whirlpool: sign (noted under CT) may be seen on ultrasound, which has a similar high specificity for diagnosing volvulus.

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

None notable.

III. Default Management.

Once volvulus is diagnosed, it is important to keep in mind that a volvulated gut is at risk for ischemia and should undergo emergent surgical intervention.

If the patient is found to have underlying malrotation, the Ladd surgical procedure is performed. This procedure involves division of the Ladd bands, widening of the base of the mesentery, placing viable bowel in a position of nonrotation, and appendectomy.

If sigmoid volvulus is found, a flexible or rigid sigmoidoscope may be advanced to untwist the segment. However, if mucosa is found to be gangrenous, this procedure should be stopped immediately, and the patient should undergo surgery. Because of high recurrence rates (55-90%) and high mortality rates (40%), some authors advise that non-operative measures be used only to move the patient from emergent surgery status to elective surgery status.

A. Immediate management.

Volvulus is a surgical emergency. Once diagnosis is suspected, a surgical consult while obtaining appropriate imaging is the next step.

Preoperatively, the goals of treatment include cardiopulmonary and circulatory resuscitation. Doing so involves obtaining appropriate intravenous access (may need a central line if the patient is at risk for hypotension), generous intravenous fluids, placement of a nasogastric decompression tube, and broad-spectrum antibiotics.

B. Physical examination tips to guide management.

Signs of peritonitis and blood in the stool usually indicate onset of gangrene and acute decline in the patient's status so they should prompt an immediate surgical evaluation and appropriate abdominal imaging. If surgical services are already involved, these signs may indicate that patient should go to the operating room sooner than later.

C. Laboratory tests to monitor response to and adjustments in management.

Worsening lactic acidemia and leukocytosis usually indicate worsening disease.

D. Long-term management.

The definitive management of volvulus is surgical correction. In some cases of sigmoid volvulus, endoscopic correction may be considered; however, because of the high rate of recurrence, endoscopic correction should be only a temporary measure. Surgery should still be considered electively at some point.

E. Common pitfalls and side effects of management

Outcome in the management of this condition is dependent on early diagnosis. Unfortunately, these patients usually present with signs of acute bowel obstruction and need quick intervention to avoid bowel necrosis. Delay in making the diagnosis or getting surgical service involved may have lethal complications.

IV. Management with Co-Morbidities

No change in standard management.

A. Renal insufficiency.

No change in standard management.

B. Liver insufficiency.

No change in standard management.

C. Systolic and diastolic heart failure.

No change in standard management.

D. Coronary artery disease or peripheral vascular disease

No change in standard management.

E. Diabetes or other endocrine issues

No change in standard management.

I. Gastrointestinal or nutrition issues

No change in standard management.

J. Hematologic or coagulation issues

No change in standard management.

K. Dementia or psychiatric illness/treatment

No change in standard management.

V. Transitions of Care

A. Sign-out considerations while hospitalized.

Volvulus frequently presents with acute abdominal pain and is often a surgical emergency. Ideally, a plan for surgical evaluation should be in place prior to sign-out. In addition, sign-out should include detailed instructions to follow up on surgical consult recommendations and frequent bedside visits to ensure that the patient is stable. If the patient is unstable in any way, sign-out should include a discussion about the threshold for transfer to the intensive care unit.

B. Anticipated length of stay.

Length of stay is variable and determined by surgical outcome and perioperative complications.

C. When is the patient ready for discharge?

Discharge readiness is determined by operative outcome and complications. The surgical service will weigh in on discharge readiness.

D. Arranging for clinic follow-up

Patients should follow up with surgical services and primary care.

1. When should clinic follow-up be arranged and with whom?

Follow-up should be arranged with surgical service and primary care. Timing of follow up is varaible and will be determined by surgical outcome and perioperative complications.

2. What tests should be conducted prior to discharge to enable best clinic first visit?

None notable.

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit?

None notable.

E. Placement considerations

No diagnosis specific placement considerations.

F. Prognosis and patient counseling

This condition is rare in adults, hence prognosis will be determined by surgical outcome and complications.

VI. Patient Safety and Quality Measures

A. Core indicator standards and documentation

Surgical care improvement measures will apply. The hospitalist should work with surgical teams to ensure appropriate peri-operative antibiotics (if indicated) along with foley catheter management post surgery.

B. Appropriate prophylaxis and other measures to prevent readmission

Appropriate wound care as advised by the surgical team and surgical follow up (as discussed above). If discharged home, patient will likely benefit from 'visiting nurse' care.

VII. What's the evidence?

McVay, MR, Kokoska, ER, Jackson, RJ, Smith, SD. "Jack Barney Award The changing spectrum of intestinal malrotation: diagnosis and management.". Am J Surg. vol. 194. 2007. pp. 712-7.

Liao, WI, Lin, YY, Ko, KH, Chu, SJ, Tsai, SH. "Midgut volvulus as a delayed consequence of posttraumatic mesenteric pseudocyst.". Am J Emerg Med. vol. 27. 2009. pp. 1025.e3-6.

Peterson, CM, Anderson, JS, Hara, AK, Carenza, JW, Menias, CO. "Volvulus of the gastrointestinal tract: appearances at multimodality imaging.". Radiographics. vol. 29. 2009. pp. 1281-93.

Hsieh, TM, Sheen-Chen, SM, Lin, CC. "Combination of adult intussusception and intestinal malrotation: an unusual presentation.". Dig Dis Sci.. vol. 53. 2008. pp. 3037-9.

Bozlar, U, Ugurel, MS, Ustunsoz, B, Coskun, U. "CT angiographic demonstration of a mesenteric vessel "whirlpool" in intestinal malrotation and midgut volvulus: a case report.". Korean J Radiol. vol. 9. 2008. pp. 466-9.

Burke, MS, Glick, PL. "Gastrointestinal malrotation with volvulus in an adult.". Am J Surg. vol. 195. 2008. pp. 501-3.

Taylor, HO, Barish, M, Soybel, D. "Unraveling intestinal malrotation with 3-dimensional computed tomography". Clin Gastroenterol Hepatol. vol. 4. 2006. pp. xxix.

Kapfer, SA, Rappold, JF. "Intestinal malrotation-not just the pediatric surgeon's problem.". J Am Coll Surg. vol. 199. 2004. pp. 628-35.

Kuzu, MA, Alar, AK, Soran, A, Polat, A, Topcu, O, Hengirmen, S. "Emergent resection for acute sigmoid volvulus: results of 106 consecutive cases.". Dis Colon Rectum. vol. 45. 2002. pp. 1085-90.

Shimanuki, Y, Aihara, T, Takano, H, Moritani, T, Oguma, E, Kuroki, H, Shibata, A, Nozawa, K, Ohkawara, K, Hirata, A, Imaizumi, S. "Clockwise whirlpool sign at color Doppler US: an objective and definite sign of midgut volvulus". Radiology. vol. 199. 1996. pp. 261-4.

Rowsom, JT, Sullivan, SN, Girvan, DP. "Midgut volvulus in the adult: A complication of intestinal malrotation". J Clin Gastroenterol. vol. 9. 1987. pp. 212-6.

Ballantyne, GH, Brandner, MD, Beart RW, Jr, Ilstrup, DM. "Volvulus of the colon: Incidence and mortality.". Ann Surg. vol. 202. 1985. pp. 83-92.

Buranasiri, SI, Baum, S, Nusbaum, M, Tumen, H. "The angiographic diagnosis of midgut malrotation with volvulus in adults.". Radiology. vol. 109. 1973. pp. 555-6.

Berdon, WE, Baker, DH, Bull, S, Santulli, TV. "Midgut malrotation and volvulus: Which films are most helpful?". Radiology. vol. 96. 1970. pp. 375-84.

Devlin, HB, Williams, RS, Pierce, JW. "Presentation of midgut malrotation in adults.". Br Med J. vol. 1. 1968. pp. 803-7.

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