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Volvulus

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Overview

Volvulus describes when the intestine twists around itself and the mesentery supplying it, leading to bowel obstruction. It is an emergency that requires urgent treatment as twisting and obstruction can lead to bowel ischaemia, perforation, peritonitis, sepsis, and death.

This section primarily covers sigmoid and caecal volvulus. For midgut volvulus, click here.

Types

Some notable types of volvulus include:

  • Sigmoid volvulus – around 80% of cases
  • Caecal volvulus – around 20% of cases
  • Midgut volvulus (due to midgut malrotation) in neonates

Epidemiology

  • Sigmoid volvulus is the most common type of volvulus overall in adults
  • Sigmoid volvulus tends to be common in older adults
  • Caecal volvulus tends to be more common in younger adults
  • In neonates and infants, midgut volvulus is more common

Risk Factors

Sigmoid volvulus

Risk factors for sigmoid volvulus include:

  • Advanced age
  • Chronic constipation
  • Excessive colon mobility – frequent laxative use/high-fibre diet
  • Neurological disorders – Parkinson’s disease, multiple sclerosis muscular dystrophy
  • Antipsychotic use
  • Reduced mobility

Caecal volvulus

Risk factors for caecal volvulus include:

  • Advanced age
  • Chronic constipation
  • Pregnancy
  • Adhesions

Presentation

Overview

The site of volvulus can affect its presentation. In general:

Most patients with sigmoid or caecal volvulus present acutely with:

  • Abdominal pain – typically colicky
  • Constipation – severity depends on if it is a sigmoid or caecal volvulus
    • In sigmoid volvulus, constipation is more severe and tends to be absolute
  • Nausea and vomiting – may be bilious
  • Features of Peritonitis may be present if perforation occurs

Investigations

Overview

Key investigations include:

  • Abdominal X-ray:
    • Often performed first identifies volvulus characterised by dilated bowels
    • Sigmoid volvulus – may show a ‘coffee-bean’ sign arising from the left lower quadrant, haustra tend to be absent
    • Caecal volvulus – arising from the right iliac fossa and extending towards the left upper quadrant, haustra tend to remain
  • CT abdomen:
    • Identifies volvulus and may identify the underlying cause

Management

Overview

The initial management of all patients with bowel obstruction includes:

  • Nil-by-mouth – to reduce the amount of material entering an obstructed bowel
  • IV fluids
  • Nasogastric tube with free drainage (‘drip and suck’) to remove stomach contents and decompress the bowel

After initial management, the following may be performed:

  • Sigmoid volvulus:
    • May be managed conservatively via flexible sigmoidoscopy and rectal tube insertion to decompress the bowel
  • Caecal volvulus:
    • Often managed surgically with a right hemicolectomy

Complications

If untreated, blood flow to the bowel decreases, leading to ischaemia, necrosis, and perforation, followed by the leakage of bowel contents into the peritoneum, which can result in peritonitis, sepsis, shock, and death.

Prognosis

  • Delaying treatment increases mortality rates significantly
  • Mortality rates tend to be higher in caecal volvulus compared to sigmoid volvulus
  • There is an up to 60% recurrence rate in sigmoid volvulus managed conservatively

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