INDEX

    Volvulus

    Cardinal Presentations / Presenting Problems, Gastrointestinal

    Last Updated Feb 19, 2019
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    Context

    • Volvulus is a rare disease process but has a high morbidity/mortality if not diagnosed in a timely fashion.
    • The small bowel, stomach, and colon are all subject to volvulus. There are a variety of risk factors including intestinal malrotation, an enlarged colon, Hirschsprung disease, pregnancy, and abdominal adhesions. Long term constipation and a high fiber diet may also increase the risk.
    • The most commonly affected part in adults is the sigmoid colon with the cecum being second most affected.
    • In children, the small intestine is more often involved. The stomach can also be affected.

    COLONIC VOLVULUS

    • Most commonly present in the sigmoid colon (60%–75% of all cases), followed by the cecum (25%–40% of all cases), and rarely in the transverse colon (1%–4% of all cases) and splenic flexure (1% incidence).
    • Sigmoid volvulus preferentially affects elderly men (age > 70 years), which vastly contrasts countries in the “volvulus belt” in which sigmoid volvulus is more common in younger men (fourth decade of life) at a male to female ratio of 4:1.

    SMALL BOWEL VOLVULUS (SBV)

    • Typically thought to be a diagnosis in newborns. Small bowel rotates around its mesenteric axis.
    • Approximately 1 in 500 live births have intestinal malrotation with roughly 80% of these patients presenting with SBV within the first month of life. As a result, SBV secondary to intestinal malrotation is most common in children and young adults.
    • Adult patients, however, can present with SBV.

    GASTRIC VOLVULUS (GV)

    • Although rare, is recognized to be a life-threatening condition, thus prompt diagnosis and treatment is imperative.
    • It is defined as abnormal rotation of the stomach by more than 180 degrees.
    • The exact prevalence of GV is unknown. Peak incidence is in the fifth decade of life comprising 10% to 20% of cases. No association with either sex or race has been identified.
    • Risk factors for GV in adults include:
      • age greater than 50,
      • diaphragmatic abnormalities, diaphragm eventration,
      • phrenic nerve paralysis,
      • other anatomic gastrointestinal or splenic abnormalities and
    • Acute GV is a surgical emergency, with mortality rates ranging anywhere from 30% to 50%: necrosis, perforation, and septic shock. A high index of suspicion for GV with early diagnosis is essential for a good outcome.

    Recommended Treatment

    • High suspicion for volvulus is required given its rare nature and often vague abdominal pain in elderly, demented, institutionalized patients as well as pregnancy.
    • Abdominal XR has mediocre sensitivity.
    • US might be useful.
    • Low threshold for CT in these patients.
    • Definitive therapy = endoscopy +/- surgery with the goals being: reduction of the volvulus, removal of a septic source, restoration of bowel continuity if possible, and prevention of recurrence.

    Criteria For Hospital Admission

    All patients with volvulus need referral & admission.

    Criteria For Transfer To Another Facility

    Resource availability.

    Criteria For Close Observation And/or Consult

    All need general surgical or gastroenterological consult.

    Quality Of Evidence?

    Justification

    Moderate

    Related Information

    Reference List

    1. Bauman ZM and Evans CH.  Volvulus. Surg Clin N Am 98 (2018) 973–993


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