Cardinal Presentations / Presenting Problems, Gastrointestinal
- 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.
- 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.
- 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
Criteria For Close Observation And/or Consult
All need general surgical or gastroenterological consult.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Bauman ZM and Evans CH. Volvulus. Surg Clin N Am 98 (2018) 973–993
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Feb 19, 2019
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