A volvulus is when a loop of

intestine The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The tract is the largest of the body's systems, after the cardiovascular system. T ...

twists around itself and the

mesentery In human anatomy, the mesentery is an Organ (anatomy), organ that attaches the intestines to the posterior abdominal wall, consisting of a double fold of the peritoneum. It helps (among other functions) in storing Adipose tissue, fat and allowi ...

that supports it, resulting in a

bowel obstruction Bowel obstruction, also known as intestinal obstruction, is a mechanical or Ileus, functional obstruction of the Gastrointestinal tract#Lower gastrointestinal tract, intestines which prevents the normal movement of the products of digestion. Ei ...

. Symptoms include

abdominal pain Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Since the abdomen contains most of the body's vital organs, it can be an indicator of a wide variety of diseases. Given th ...

, abdominal bloating, vomiting,

constipation Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The Human feces, stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the ...

, and bloody stool. Onset of symptoms may be rapid or more gradual. The mesentery may become so tightly twisted that

blood Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood is com ...

flow to part of the intestine is cut off, resulting in ischemic bowel. In this situation there may be

fever Fever or pyrexia in humans is a symptom of an anti-infection defense mechanism that appears with Human body temperature, body temperature exceeding the normal range caused by an increase in the body's temperature Human body temperature#Fever, s ...

or significant pain when the abdomen is touched. Risk factors include a

birth defect A birth defect is an abnormal condition that is present at birth, regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities can range from mild to severe. Birth de ...

known as intestinal malrotation, an enlarged colon, Hirschsprung disease,

pregnancy Pregnancy is the time during which one or more offspring gestation, gestates inside a woman's uterus. A multiple birth, multiple pregnancy involves more than one offspring, such as with twins. Conception (biology), Conception usually occurs ...

, and abdominal adhesions. Long term

and a high fiber diet may also increase the risk. The most commonly affected part of the intestines in adults is the

sigmoid colon The sigmoid colon (or pelvic colon) is the part of the large intestine that is closest to the rectum and anus. It forms a loop that averages about in length. The loop is typically shaped like a Greek letter sigma (ς) or Latin letter S (thus ''s ...

, with the

cecum The cecum ( caecum, ; plural ceca or caeca, ) is a pouch within the peritoneum that is considered to be the beginning of the large intestine. It is typically located on the right side of the body (the same side of the body as the appendix (a ...

being the second most affected. In children the

small intestine The small intestine or small bowel is an organ (anatomy), organ in the human gastrointestinal tract, gastrointestinal tract where most of the #Absorption, absorption of nutrients from food takes place. It lies between the stomach and large intes ...

is more often involved. The stomach can also be affected. Diagnosis is typically with

medical imaging Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to revea ...

such as plain X-rays, a GI series, or

CT scan A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...

. Initial treatment for sigmoid volvulus may occasionally occur via sigmoidoscopy or with a barium enema. Due to the high risk of recurrence, a

bowel resection A bowel resection or enterectomy (''wikt:entero-#Prefix, enter-'' + ''wikt:-ectomy#Suffix, -ectomy'') is a surgery, surgical procedure in which a part of an intestine (bowel) is removed, from either the small intestine or large intestine. Often t ...

within the next two days is generally recommended. If the bowel is severely twisted or the blood supply is cut off, immediate surgery is required. In a cecal volvulus, often part of the bowel needs to be surgically removed. If the cecum is still healthy, it may occasionally be returned to a normal position and sutured in place. Cases of volvulus were described in

ancient Egypt Ancient Egypt () was a cradle of civilization concentrated along the lower reaches of the Nile River in Northeast Africa. It emerged from prehistoric Egypt around 3150BC (according to conventional Egyptian chronology), when Upper and Lower E ...

as early as 1550 BC. It occurs most frequently in Africa, the

Middle East The Middle East (term originally coined in English language) is a geopolitical region encompassing the Arabian Peninsula, the Levant, Turkey, Egypt, Iran, and Iraq. The term came into widespread usage by the United Kingdom and western Eur ...

, and India. Rates of volvulus in the United States are about 2–3 per 100,000 people per year. Sigmoid and cecal volvulus typically occurs between the ages of 30 and 70. Outcomes are related to whether or not the bowel tissue has died. The term volvulus is from the Latin "volvere"; which means "to roll".

Signs and symptoms

Regardless of cause, volvulus causes symptoms by two mechanisms: * Bowel obstruction manifested as abdominal distension and bilious vomiting. * Ischemia (loss of blood flow) to the affected portion of the intestine. Depending on the location of the volvulus, symptoms may vary. For example, in patients with cecal volvulus, the predominant symptoms may be those of small bowel obstruction (nausea, vomiting, and lack of stool or flatus), because the obstructing point is close to the ileocecal valve and small intestine. In patients with sigmoid volvulus, although abdominal pain may be present, symptoms of constipation may be more prominent. Volvulus causes severe pain and progressive injury to the intestinal wall, with accumulation of gas and fluid in the portion of the bowel obstructed. Ultimately, this can result in

necrosis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. The term "necrosis" came about in the mid-19th century and is commonly attributed to German pathologist Rudolf Virchow, who i ...

of the affected intestinal wall, acidosis, and death. This is known as a closed-loop obstruction because there exists an isolated ("closed") loop of bowel. Acute volvulus often requires immediate surgical intervention to untwist the affected segment of bowel and possibly resect any unsalvageable portion. Volvulus occurs most frequently in middle-aged and elderly men. Volvulus can also arise as a rare complication in persons with redundant colon, a normal anatomic variation resulting in extra colonic loops. Sigmoid volvulus is the most common form of volvulus of the gastrointestinal tract. and is responsible for 8% of all intestinal obstructions. Sigmoid volvulus is particularly common in elderly persons and constipated patients. Patients experience abdominal pain, distension, and absolute constipation. Cecal volvulus is slightly less common than sigmoid volvulus and is associated with symptoms of abdominal pain and small bowel obstruction. Volvulus can also occur in patients with

Duchenne muscular dystrophy Duchenne muscular dystrophy (DMD) is a severe type of muscular dystrophy predominantly affecting boys. The onset of muscle weakness typically begins around age four, with rapid progression. Initially, muscle loss occurs in the thighs and pe ...

due to smooth muscle dysfunction. Gastric volvulus causes nausea, vomiting, and pain in the upper abdomen. The Borchardt triad is a group of symptoms that help doctors identify gastric volvulus. The symptoms are intractable retching, pain in the upper abdomen, and inability to pass a nasogastric tube into the stomach.

Complications

* Strangulation * Gangrene * Perforation * Faecal peritonitis * Recurrent volvulus

Causes

Midgut volvulus occurs in people (usually babies) who are predisposed because of congenital intestinal malrotation. Segmental volvulus occurs in people of any age, usually with a predisposition because of abnormal intestinal contents (e.g., meconium ileus) or adhesions. Volvulus of the

transverse colon In human anatomy, the transverse colon is the longest and most movable part of the Large intestine#Structure, colon. Anatomical position It crosses the abdomen from the ascending colon at the right colic flexure (hepatic flexure) with a downward ...

, or

occurs, usually in adults, with only minor predisposing factors such as redundant (excess, inadequately supported) intestinal tissue and constipation.

Types

* volvulus neonatorum * Volvulus of the small intestine * midgut volvulus (due to intestinal malrotation) * volvulus of the caecum (

), also cecal volvulus * sigmoid colon volvulus (sigmoid volvulus) * Volvulus of the transverse colon * volvulus of the splenic flexure, the rarest * gastric volvulus * ileosigmoid knot

Diagnosis

After taking a thorough history, the diagnosis of colonic volvulus is usually easily included in the differential diagnosis. Abdominal plain x-rays are commonly confirmatory for a volvulus, especially if a coffee bean sign is seen. These refer to the shape of the air-filled closed loop of the colon, which forms the volvulus. Should the diagnosis be in doubt, a barium enema may demonstrate a "bird's beak" at the point where the segment of proximal bowel and distal bowel rotate to form the volvulus. This area shows an acute and sharp tapering and looks like a bird's beak. If a perforation is suspected, barium should not be used due to its potentially lethal effects when distributed throughout the free intraperitoneal cavity. Gastrografin, which is safer, can be substituted for barium. The differential diagnosis includes the much more common constricting or obstructing carcinoma. In approximately 80 percent of colonic obstructions, invasive carcinoma is found to be the cause. This is usually easily diagnosed with endoscopic biopsies.

Diverticulitis Diverticulitis, also called colonic diverticulitis, is a gastrointestinal disease characterized by inflammation of abnormal pouches—Diverticulum, diverticula—that can develop in the wall of the large intestine. Symptoms typically include lo ...

is a common condition with different presentations. Although diverticulitis may be the source of a colonic obstruction, it more commonly causes an ileus, which appears to be a colonic obstruction. Endoscopic means can be used to secure a diagnosis, although this may cause a perforation of the inflamed diverticular area. CT scanning is the more common method to diagnose diverticulitis. The scan will show mesenteric stranding in the involved segment of edematous colon, which is usually in the sigmoid region. Microperforations with free air may be seen. Ulcerative colitis or

Crohn's disease Crohn's disease is a type of inflammatory bowel disease (IBD) that may affect any segment of the gastrointestinal tract. Symptoms often include abdominal pain, diarrhea, fever, abdominal distension, and weight loss. Complications outside of the ...

may cause colonic obstruction. The obstruction may be acute or chronic, and after years of uncontrolled disease, it leads to the formation of strictures and fistulas. The medical history is helpful in that most cases of inflammatory bowel disease are well known to both the patient and doctor. Other rare syndromes, including Ogilvie's syndrome, chronic constipation, and impaction, may cause a pseudo-obstruction. *

Abdominal x-ray An abdominal x-ray is an x-ray of the abdomen. It is sometimes abbreviated to AXR, or KUB (for kidneys, ureters, and urinary bladder). Indications In adults, abdominal X-rays have a very low specificity and cannot rule out suspected obstructi ...

– tire-like shadow arising from the right iliac fossa and passing to the left * Upper GI series File:Sigmavolvulus - Coffee-bean-sign - LSL.jpg, Coffee bean sign in a person with sigmoid volvulus File:Sigmavolvulus - 91w - CT cor - 001 - Annotation.gif, Coronal view of sigmoid volvulus with "whirlpool sign" File:CT of small bowel volvulus (annotated).jpg,

of a small bowel volvulus. It shows two juxtaposed segments of narrowing, which is the spot of mesentery rotation. The other signs indicate strangulation. File:Voluculus.PNG, An x-ray of a person with a small bowel volvulus. File:CecalVolvulusXray.png, Plain X ray of a cecal volvulus File:CecalVolvulus.png, CT scan of a cecal volvulus

Treatment

Sigmoid

Treatment for sigmoid volvulus may include sigmoidoscopy. If the mucosa of the sigmoid looks normal and pink, a rectal tube for decompression may be placed, and any fluid, electrolyte, cardiac, kidney, or pulmonary abnormalities should be corrected. The affected person should then be taken to the operating room for surgical repair. If surgery is not performed, there is a high rate of recurrence. For people with signs of

sepsis Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage of sepsis is followed by suppression of the immune system. Common signs and s ...

or an abdominal catastrophe, immediate surgery and resection are advised.

Cecal

In a cecal volvulus, the cecum may be returned to a normal position and sutured in place, a procedure known as cecopexy. If identified early, before presumed intestinal wall ischemia has resulted in tissue breakdown and necrosis, the cecal volvulus can be detorsed laparoscopically. It has been associated to several diseases, including

Huntington's disease Huntington's disease (HD), also known as Huntington's chorea, is an incurable neurodegenerative disease that is mostly Genetic disorder#Autosomal dominant, inherited. It typically presents as a triad of progressive psychiatric, cognitive, and ...

Other

Laparotomy A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy. Origins and history The first successful laparotomy was performed without ...

for other forms of volvulus, especially anal volvulus.

References

External links

CT of an abdomen with sigmoid volvulus
{{Authority control Diseases of intestines Abdominal pain Wikipedia medicine articles ready to translate Wikipedia emergency medicine articles ready to translate