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 GI tract contains all the major organs of the digestive system, in humans an ...

twists around itself and the

mesentery The mesentery is an organ that attaches the intestines to the posterior abdominal wall in humans and is formed by the double fold of peritoneum. It helps in storing fat and allowing blood vessels, lymphatics, and nerves to supply the intesti ...

that supports it, resulting in a bowel obstruction. Symptoms include

abdominal pain Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Common causes of pain in the abdomen include gastroenteritis and irritable bowel syndrome. About 15% of people have a more ...

, abdominal bloating, vomiting,

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

, and

bloody stool Blood in stool looks different depending on how early it enters the digestive tract—and thus how much digestive action it has been exposed to—and how much there is. The term can refer either to melena, with a black appearance, typically origi ...

. Onset of symptoms may be rapid or more gradual. The mesentery may become so tightly twisted that blood flow to part of the intestine is cut off, resulting in ischemic bowel. In this situation there may be

fever Fever, also referred to as pyrexia, is defined as having a temperature above the normal range due to an increase in the body's temperature set point. There is not a single agreed-upon upper limit for normal temperature with sources using val ...

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

birth defect A birth defect, also known as a congenital disorder, 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 ...

known as

intestinal malrotation Intestinal malrotation is a congenital anomaly of rotation of the midgut. It occurs during the first trimester as the fetal gut undergoes a complex series of growth and development. Malrotation can lead to a dangerous complication called volvulus. ...

, an enlarged colon,

Hirschsprung disease Hirschsprung's disease (HD or HSCR) is a birth defect in which nerves are missing from parts of the intestine. The most prominent symptom is constipation. Other symptoms may include vomiting, abdominal pain, diarrhea and slow growth. Symptoms usu ...

pregnancy Pregnancy is the time during which one or more offspring develops ( gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins. Pregnancy usually occurs by sexual intercourse, but can ...

, 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 or caecum 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, to which it is joined). The w ...

being second most affected. In children the

small intestine The small intestine or small bowel is an organ in the gastrointestinal tract where most of the absorption of nutrients from food takes place. It lies between the stomach and large intestine, and receives bile and pancreatic juice through the ...

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 rev ...

such as plain X-rays, a GI series, or CT scan. Initial treatment for sigmoid volvulus may occasionally occur via

sigmoidoscopy Sigmoidoscopy (from the Greek term for letter " s/ς" + "eidos" + "scopy": namely, to look inside an "s"/"ς"-like object) is the minimally invasive medical examination of the large intestine from the rectum through to the nearest part of the co ...

or with a barium enema. Due to the high risk of recurrence, a bowel resection 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 as early as 1550 BC. It occurs most frequently in Africa, the

Middle East The Middle East ( ar, الشرق الأوسط, ISO 233: ) is a geopolitical region commonly encompassing Arabia (including the Arabian Peninsula and Bahrain), Asia Minor (Asian part of Turkey except Hatay Province), East Thrace (Europea ...

, 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 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 Cell (biology), cells in living Tissue (biology), tissue by Autolysis (biology), autolysis. Necrosis is caused by factors external to the cell or tissue, such as infec ...

of the affected intestinal wall,

acidosis Acidosis is a process causing increased acidity in the blood and other body tissues (i.e., an increase in hydrogen ion concentration). If not further qualified, it usually refers to acidity of the blood plasma. The term ''acidemia'' describes ...

, 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 that primarily affects boys. Muscle weakness usually begins around the age of four, and worsens quickly. Muscle loss typically occurs first in the thighs and pelvis follow ...

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 to identify gastric volvulus. The symptoms are intractable retching, pain in the upper abdomen and inability to pass nasogastric tube into the stomach.

Complications

* Strangulation *

Gangrene Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. If the ga ...

Perforation A perforation is a small hole in a thin material or web. There is usually more than one perforation in an organized fashion, where all of the holes collectively are called a ''perforation''. The process of creating perforations is called perfor ...

* Faecal peritonitis * Recurrent volvulus

Causes

Midgut volvulus occurs in people (usually babies) that are predisposed because of congenital

. Segmental volvulus occurs in people of any age, usually with a predisposition because of abnormal intestinal contents (e.g.

meconium ileus Meconium is the earliest stool of a mammalian infant resulting from defecation. Unlike later feces, meconium is composed of materials ingested during the time the infant spends in the uterus: intestinal epithelial cells, lanugo, mucus, amnio ...

) or

adhesions Adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connects tissues not normally connected. Pathophysiology Adhesions form as a natura ...

. Volvulus of the

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

, 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

) * 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 Gastric volvulus or volvulus of stomach is a twisting of all or part of the stomach by more than 180 degrees with obstruction of the flow of material through the stomach, variable loss of blood supply and possible tissue death. The twisting can oc ...

* 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 "bent inner tube" sign or a "coffee bean" sign are seen. These refer to the shape of the air-filled closed loop of colon which forms the volvulus. Should the diagnosis be in doubt, a barium enema may be used to 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 Diatrizoate, also known as amidotrizoate, is a contrast agent used during X-ray imaging. This includes visualizing veins, the urinary system, spleen, and joints, as well as computer tomography (CT scan). It is given by mouth, injection into a v ...

, 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 of the obstruction. This is usually easily diagnosed with endoscopic biopsies.

Diverticulitis Diverticulitis, specifically colonic diverticulitis, is a gastrointestinal disease characterized by inflammation of abnormal pouches—diverticula—which can develop in the wall of the large intestine. Symptoms typically include lower abdomina ...

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. Micro perforations 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 (which may be bloody if inflammation is severe), fever, abdominal distension, ...

may cause colonic obstruction. The obstruction may be acute or chronic after years of uncontrolled disease 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 patient and doctor. Other rare syndromes, including Ogilvie's syndrome, chronic constipation and impaction may cause a pseudo obstruction. * Abdominal x-ray – tire-like shadow arising from right iliac fossa and passing to left *

Upper GI series An upper gastrointestinal series, also called a barium swallow, barium study, or barium meal, is a series of radiographs used to examine the gastrointestinal tract for abnormalities. A contrast medium, usually a radiocontrast agent such as bari ...

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, CT scan 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 The small intestine or small bowel is an organ in the gastrointestinal tract where most of the absorption of nutrients from food takes place. It lies between the stomach and large intestine, and receives bile and pancreatic juice through th ...

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, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...

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 a neurodegenerative disease that is mostly inherited. The earliest symptoms are often subtle problems with mood or mental abilities. A general lack of coordination and an unst ...

Other

Laparotomy for other forms of volvulus, especially anal volvulus.

References

External links

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