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• Volvulus = rotation of the gut on its own mesenteric axis
• Produces partial or complete intestinal obstruction
• Blood supply compromised resulting in intestinal ischaemia
• Venous congestion leading to infarction can occur
• Arterial supply rarely compromised
• Long narrow based mesentery predisposes to volvulus

Sigmoid volvulus

• Sigmoid is commonest site of colonic volvulus
• Accounts for 5% of large bowel obstruction in UK
• Usually seen in elderly or those with psychiatric disorders
• Commonest cause of obstruction in Africa / Asia
• >Incidence is 10 times higher than in Europe or USA

Clinical features

• Large bowel obstruction – pain, constipation and vomiting
• Disproportionate abdominal distension
• 50% patients have had a previous episode
• Severe pain and tenderness suggests ischaemia
• Plain abdominal x-ray may show a large ‘bean’ shaped loop of large bowel arising from pelvis

• If diagnostic doubt consider a water soluble contrast enema
• Will demonstrate site of obstruction

Management

• Resuscitation with intravenous fluids is essential
• Conservative management can be attempted if so clinical features of ischaemia
• Sigmoidoscopy can be both diagnostic and therapeutic
• Obstruction usually at 15 cm which when advanced passed produces release of flatus
• Flatus tube can be inserted and left for 2-3 days
• 80% of patients will settle with conservative management
• If decompression occurs no emergency treatment required
• 50% further episode of volvulus within 2 years
• If decompression fails or features of peritonitis
• Options are:
  • Sigmoid colectomy and primary anastomosis
  • Hartmann’s procedure
  • Paul Mickulicz Colostomy

• Sigmoidopexy best avoided

Picture provided by Shanker Sathappan, Hospital Alor Setar, Kedah State, Malaysia

Caecal volvulus

• Incidence is less than that of sigmoid volvulus
• Accounts for about 25% cases of colonic volvulus
• Incomplete midgut rotation is a predisposing factor
• Results in inadequate fixation of caecum to posterior abdominal wall
• Volvulus usually occurs clockwise around ileocolic vessels
• Usually also involves terminal ileum and ascending colon

Clinical features

• Presents with clinical features of proximal large bowel obstruction
• Colicky abdominal pain and vomiting are common
• Abdominal distension may occur
• Plain abdominal x-ray shows a 'comma-shaped' caecal shadow in mid abdomen
• Small bowel loops may lie to the right of the caecum

• If diagnostic doubt consider a water soluble contrast enema
• Will show beaked appearance in ascending colon

Management

• Colonoscopic decompression may be appropriate if patient unfit for surgery
• It is successful in only about 30% patients
• Laparotomy is normally required
• If colon is ischaemic then right hemicolectomy should be performed
• Primary anastomosis may be inappropriate
• Exteriorisation of both ends of the bowel might be the safest option
• If the caecum is viable and the volvulus reduced the following can be considered
  • Reduction alone is associated with high recurrence rate
  • Right hemicolectomy
  • Caecostomy
  • Caecopexy

Bibliography

Consorti E T,  Liu T H.  Diagnosis and treatment of caecal volvulus.  Postgrad Med J 2005;  81:  772-776

Madiba T E,  Thompson S R.  The management of sigmoid volvulus.  J R Coll Surg Ed 2000;  45:  74-80.

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