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290 M.D. Hellinger and R.M. Steinhagen
countries, it may comprise 30%–40% of cases. This form of
volvulus tends to occur more often in the young, with most
series showing a peak incidence in the second through fourth
decades of life. There is a two- to threefold female predomi-
4,18,20,27–29
nance.
Pathogenesis/Etiology
Although anatomic factors are key to the development of
transverse colon volvulus, physiologic, rather than congenital,
factors seem to have a crucial role in the development. These
patients frequently have a history of chronic constipation
and/or laxative abuse, previous abdominal surgery, a diet high
in fiber, recurrent distal obstruction, and institutionalization.
There are also reports, however, of an association with malrotation, Hirschsprung’s disease, and Chilaiditi’s syndrome.
Finally, adhesive bands, frequently reported in these patients,
may act as a fulcrum around which the bowel can twist.
Specific factors that may increase the risk of occurrence are a
redundant or elongated transverse colon with narrow mesenteric attachments, narrowed distance between the flexures,
and an absence or paucity of fixation of the mesentery. These
factors increase the likelihood of an axial rotation of the transverse colon about its mesentery.
4,18,20,27–31
recurrence, and may therefore be best reserved for those highrisk individuals who show no signs of compromised
12,14,18
bowel.
However, colonoscopy may serve to confirm
intestinal viability and allow for a less emergent definitive
procedure to be performed.
30
Operative procedures include detorsion with or without
colopexy, and resection. Most authors recommend either segmental transverse colectomy or extended right colectomy as
definitive treatment. Clearly, in the presence of nonviable
bowel, resection is mandatory.
12,14,18,30–32
As in cecal volvulus, the decision regarding primary anastomosis versus diversion is made during surgery, taking into account the severity
of the disease process and the patient’s overall condition.
When viable bowel is encountered, several different
colopexy procedures have been reported. These include
suture of the greater omentum, transverse mesocolon, or
transverse colon itself to the anterior abdominal wall and/or
18,30,32
pelvis,
and the U colopexy reported by Mortensen.31In
this procedure, after reduction and needle decompression of
the volvulus, the redundant U-shaped loop of transverse
colon is sutured to the adjacent limbs of ascending and
descending colon (Figure 19-5).
Recurrence from either detorsion or colopexy has been
reported to range from 30% to 75%, whereas resection eliminates virtually all risk of recurrence.
25,32
Mortality, however,
Clinical Presentation
Transverse colon volvulus presents as a large bowel obstruction. Presentation may be as a subacute recurring process or
may take a more fulminant course. The subacute form is associated with repetitive episodes, each with gradual onset.
Although associated with significant abdominal distension,
pain is mild to moderate, and vomiting is usually absent. Up
to 50% of patients admit to previous episodes. The fulminant
form is associated with less distension, but marked pain and
vomiting. Clinical deterioration is rapid in these
4,17,27–29,31
cases.
Although diagnosis may be suspected on clinical presentation, plain films are rarely diagnostic. The diagnosis is therefore usually made at the time of exploration. Plain films may
reveal a distended proximal colon with decompressed distal
bowel and two distinct air-fluid levels representing two limbs
of the volvulized transverse colon. This has been described as
a bent inner-tube appearance with the apex pointing inferiorly. Barium contrast studies, if performed, will demonstrate
a bird’s beak deformity at the distal transverse colon.
However, awaiting these studies only leads to a delay in definitive management.
4,17,27–30
Treatment/Outcome
Although successful endoscopic decompression has been
reported, surgical intervention is the recommended treatment
modality. Based on literature from surgical detorsion, it is
assumed that endoscopic treatment will lead to a high rate of
FIGURE 19-5. Parallel coloplasty as described by Mortensen.
31
19. Colonic Volvulus 291
from resection has been reported to be as high as 33%. This
is primarily in the setting of gangrene or perforation.
18,27
In
these cases, mortality may be decreased by construction
of an end stoma or extended resection with ileocolic anasto-
30
mosis.
Splenic Flexure Volvulus
Incidence and Epidemiology
Having been described in fewer than 50 patients in the
English literature, volvulus of the splenic flexure of the colon
is the rarest form of colonic volvulus. It is estimated to represent 1%–2% of all cases of colonic volvulus. It seems to be
more common in women and occurs at a younger age than
cecal or sigmoid volvulus.
Pathogenesis/Etiology
The infrequency of this form of volvulus is believed to be the
result of multiple attachments of the splenic flexure, and the
retroperitoneal position of the descending colon. Three ligaments, the gastrocolic, splenocolic, and phrenocolic, are
responsible for fixation of the splenic flexure. Congenital
absence, laxity, or iatrogenic disruption of these ligaments
may lead to excessive mobility of the splenic flexure. In
addition, an intraperitoneal descending colon and adhesive
bands from previous surgery may further predispose to the
development of this form of volvulus. In fact, up to twothirds of patients have had prior abdominal surgery. Finally,
it has been speculated that chronic constipation may lead to
redundancy of the colon and elongation of the mesentery.
This may possibly create laxity of the ligamentous attach-
4,13,25,33,34
ments.
Clinical Presentation
As in transverse colon volvulus, the presentation may be
acute and fulminant, or a more chronic or subacute event.
Many patients have a history of severe chronic constipation,
with longstanding laxative abuse. At presentation, the majority of patients have significant abdominal distention and pain.
Although nausea and vomiting are common, obstipation is
rare. Very few patients present with strangulation, gangrene,
or findings of an acute surgical abdomen.
Four features have been described radiographically that
may suggest splenic flexure volvulus. They are: 1) a markedly
dilated air-filled colon with an abrupt termination at the
splenic flexure; 2) two widely spaced air-fluid levels, one in
the cecum and the other in the transverse colon; 3) an empty
descending and sigmoid colon; and 4) a bird’s beak obstruction at the splenic flexure on contrast enema examination
(Figure 19-6). An additional sign is a crescenteric gas shadow
in the left upper quadrant of the abdomen.
4,13,25,33,34
4,33,34
13,33
FIGURE 19-6. Barium enema study of a chronic splenic flexure volvu-
lus. Arrows indicate the point of rotation and bird’s beak deformity.
Treatment/Outcome
Although colonoscopic and fluoroscopic decompression have
been reported, most reports have identified surgery as the primary mode of management. Surgical options include resection with or without stoma formation, or detorsion with or
without colopexy. Segmental resection may be considered;
however, the majority of these patients will have an associated
redundant, dilated colon and a history of chronic constipation.
Therefore, these patients may be better served by undergoing
an extended resection with an ileosigmoid or ileorectal anastomosis. Stomas should be reserved for cases involving gangrenous bowel with perforation and peritoneal contamination,
or for other high-risk cases.
4,13,25,34
No mortality has been reported with either form of surgical
management. The complication rate, excluding recurrence, is
in the range of 10%. Resection carries a 0% recurrence rate.
However, the recurrence rate after detorsion alone, whether
performed surgically, endoscopically, or fluoroscopically, is
approximately 20%–25%. As a result of these high recurrence
rates, nonoperative decompression/detorsion should be
reserved for extremely high-risk patients who are not candidates for surgical intervention, or as a temporizing measure
before a semi-elective definitive resection.
4,13,34
Sigmoid Volvulus
Incidence and Epidemiology
Although it is the most common form of volvulus seen,
volvulus of the sigmoid colon is not very common in the
United States and Western Europe, accounting for less than
10% of all cases of large bowel obstruction.
regions of Asia, Africa, and other less-developed portions of
the world, however, the situation is significantly different. In
these areas, sigmoid volvulus accounts for 20%–50% of the
5,6,19,35
In some
292 M.D. Hellinger and R.M. Steinhagen
cases of intestinal obstruction. Overall, there is a substantial
male predominance, especially in developing nations.
However, sigmoid volvulus is the most common cause of
intestinal obstruction in pregnancy, accounting for nearly
45% of all intestinal obstructions in this group of
women.
3,4,5,19
The reasons for geographic differences in incidence are thought to be primarily related to diet. In the West,
relatively lower amounts of fiber are consumed, resulting in a
much higher incidence of colorectal cancer and diverticular
disease, which are the more common etiologies for colonic
obstruction in these areas. In less-developed regions of Asia
and Africa, extremely high fiber diets result in significantly
elongated colons, and lead to development of sigmoid volvulus,
in relatively young patients.
Pathogenesis/Etiology
Any condition that results in an elongated colon predisposes
to the development of volvulus. In order for volvulus of any
part of the intestinal tract to occur, there must be a long redundant, mobile segment, with a relatively narrow mesenteric
attachment, such that the sites of fixation at each end are relatively close together. The sigmoid colon is the ideal location
for this configuration: the sigmoid can be extremely redundant and mobile and the sites of fixation at the descendingsigmoid junction and the rectosigmoid junction are often in
close proximity to each other.
Although a single etiology has not been identified, several
theories do exist. In 1849, in his Manual of Pathological
Anatomy, Von Rokitansky proposed that the primary
causative factor was a “congenital or acquired long, loose,
and floppy mesentery.” Thirty-five years later, in his text of
intestinal obstruction, Treves indicated that the loop in sigmoid volvulus “must be of considerable length, the mesocolon must be long and very narrow at its parietal attachment,
so that two ends of the loop may be brought as close together
as possible.”
3
In the West, the typical patient with sigmoid volvulus is an
elderly institutionalized male, often receiving psychotropic
medications, who is usually extremely constipated. Other factors that have been implicated are laxative abuse, previous
abdominal surgery, and diabetes.
world, the patients are significantly younger.
Megacolon from any etiology, but especially Hirschsprung’s
disease or Chagas’ disease, predisposes to volvulus.
Gross features of the sigmoid colon include progressive
widening and eventual loss of taenia coli, absence of appendices epiploicae, and a thickened narrowed fibrous mesentery.
The scarring forms patches and bands coined “shrinking
mesosigmoiditis” by Brusgaard, and is believed to be the
result of previous episodes of volvulus.
be either clockwise or counterclockwise. Once the rotation
has reached 360 degrees, a closed loop obstruction occurs.
Hyperperistalsis and fluid secretion into the closed loop add
to increased pressure and tension. Eventually, as blood flow is
3,19
3,5,18
In other parts of the
9,19,38
The rotation may
24,36,37
3,8,19
compromised, ischemia and necrosis develop. Additionally,
the diminished blood flow may lead to arterial and venous
thrombosis. Three patterns of necrosis have been described:
1) at the neck of the volvulus, 2) any location within the
closed loop, and 3) in the proximal descending colon or distal rectum because of retrograde mesenteric thrombosis.
Because the sigmoid loop is usually chronically thickened, it
is unlikely for a perforation to occur in this location. In the
face of a competent ileocecal valve, perforation is more common in the cecum.
39
Clinical Presentation
As previously described, the patient is typically a male nursing home resident, on psychotropic medications, with a history of chronic constipation. These patients may not complain
of pain, but rather a caregiver notices an extremely long interval between bowel movements, associated with significant
abdominal distension. In younger patients, constipation, distension, and abdominal pain are the predominant symptoms.
Before arrival at the hospital, the patient may have been given
enemas or laxatives, without relief. This therapy may have, in
fact, made the distension worse. There is often significant
delay between onset and evaluation.
that 40%–60% of patients will give a history of having had
similar episodes.
4,38
On presentation, the distension is often dramatic. Unlike
the patient with fecal impaction, the rectal ampulla is empty.
Plain abdominal films typically show massive colonic distension, with or without small bowel dilatation (depending on the
competence of the ileocecal valve). The very large sigmoid
loop will be orientated toward the right upper quadrant. The
adjacent walls of the sigmoid will appear to be thickened,
arising out of the left lower quadrant, giving the classical
“bent inner tube” sign (Figure 19-7A).
cases, plain radiographs are sufficient to establish the diagno-
40
sis.
In fact, plain abdominal X-rays alone are diagnostic in
60%–75% of cases.
39,42
However, the massive distension may,
occasionally, make the diagnosis difficult to establish with
certainty. In those cases, a contrast enema should be obtained.
This study will show the obstruction at the rectosigmoid junction, with the classical bird’s beak configuration (Figure 19-
5,39
7B).
The addition of barium enema to the plain abdominal
X-rays may increase the diagnostic yield to near 100%.
The major diagnosis from which sigmoid volvulus must be
distinguished is colonic obstruction caused by neoplasm.
Usually the abdominal X-rays can distinguish one from the
other; however, in the presence of truly massive distension,
differentiation may be difficult. At the time of attempted sigmoidoscopic detorsion, the obstructing neoplasm will hopefully be visualized and the true diagnosis will be apparent.
The other condition that may cause clinical confusion is
colonic megacolon associated with abnormal colonic motility.
This condition also presents in elderly, constipated nursing
home patients. The X-rays can look remarkably similar.
40,41
It has been reported
38
In the majority of
42
38
19. Colonic Volvulus 293
FIGURE 19-7. A Plain abdominal X-ray of a sigmoid volvulus indicating the “bent inner tube” sign. B Barium enema study of a sigmoid
volvulus indicating the bird’s beak deformity and complete obstruction to retrograde flow of contrast.
Because rectal tube decompression will generally rapidly and
successfully relieve the distension associated with this form
of megacolon, distinction from volvulus can be difficult. It is
important to make the distinction, however, because this condition is also associated with a high incidence of recurrence,
but will not be successfully treated by sigmoid resection. In
one series, a 37% incidence of recurrent “volvulus” was seen
after sigmoid resection and anastomosis. However, virtually
all of these patients had megacolon-associated abnormal
colonic motility.
43
passage of a rectal tube, and use of a column of barium during barium enema examination.
7,9,10,14,15,24
Successful decompression using one of these techniques is generally reported in
the range of 70%–80%.
18,39–41,44
A significant concern is that the sigmoid may already be
gangrenous. Several authors in Asia and Africa have noted an
incidence of gangrene approaching 50%, as well as a significant incidence of double volvulus (ileosigmoid knotting)
rarely seen in the West, and have therefore recommended
emergency laparotomy without attempts at detorsion.
36,37,45–47
If ischemic mucosa is visualized, attempts at detorsion should
Treatment/Outcome
The patient with sigmoid colon volvulus should be hydrated
and resuscitated. Since 1947, when Bruusgaard
90% success rate with sigmoidoscopic detorsion, the mainstay of emergency therapy has generally been detorsion and
decompression. Detorsion of sigmoid volvulus has been
described using several techniques, including rigid proctoscopy, flexible sigmoidoscopy or colonoscopy, blind
9
reported a
be immediately abandoned and operative intervention should
be undertaken emergently. For this reason, we strongly recommend using only those detorsion techniques that visualize
the mucosa before detorsion. Attempts at detorsion via blind
passage of a rectal tube should be avoided. Attempted detorsion of nonviable bowel will lead to a high incidence of perforation and peritonitis. The presence of nonviabilty should
be suspected by the presence of signs and symptoms of
compromised bowel and/or systemic sepsis, such as fever,
294 M.D. Hellinger and R.M. Steinhagen
leukocytosis, and especially localized tenderness over the sigmoid loop. If these are present, decompression should not
even be attempted. The patient should be taken for emergent
surgery. In approximately 25% of cases, the site of the twist
will be more proximal than can be reached with a rigid proctoscope.
14
Use of flexible scopes can obviate this problem.
The major complication associated with attempted detorsion
is inadvertent perforation. This is more likely in the presence
of gangrene, but can occur with viable bowel as well.
Once decompression has been accomplished, there is usually forceful evacuation of flatus and stool (frequently all over
the clothes and shoes of an unsuspecting novice) and visible
deflation of the patient’s abdominal distension. A rectal tube
should then be gently inserted into the colon to a point proximal to the site of the twist (which is usually within 20 cm of
the anus). The tube should then be fixed in place, to allow
continued decompression and prevention of recurrence. A
plain abdominal film should be obtained to document decompression and the patient should be admitted to the hospital.
Successful detorsion provides the advantage of converting a
surgical emergency to an elective situation.
Over the next several days, bowel function is likely to
return to normal. Medical conditions (cardiac, pulmonary,
renal, etc.) should be addressed, electrolyte abnormalities
should be corrected, and the patient’s condition optimized.
Colonoscopy, to rule out a proximal lesion, should be performed, and then a decision must be made. The rectal tube
can be safely removed and the patient could be discharged
from the hospital; however, it is well established that the rate
of recurrent sigmoid volvulus is in excess of 25%.
48,49
In fact,
most authors document a recurrence rate of greater than 50%,
and some report recurrences as high as 80%–90%.
18,21
However, one report notes that 15 of 29 patients (52%) with
sigmoid volvulus never required surgery. Twenty-three of 26
successfully decompressed patients were observed. Twelve
recurred, six of whom were again decompressed and
observed. Four of these patients had no further recurrence.
Whereas none of the conservatively treated patients developed a complication, 43% of the surgical patients died.
35
The
overall condition of the patient, the ease with which the
volvulus was untwisted, and whether or not there were previous episodes of volvulus, are all factors that must be considered in the decision to perform definitive surgery.
The standard elective surgical procedure is sigmoid resection with primary anastomosis; however, a number of nonresective techniques have been described, including nonsurgical
endoscopic sigmoidopexy with or without tube fixation,
17,50,51
extraperitoneal sigmoidopexy,52sigmoidopexy to the transverse colon and/or the parieties,
17
mesosigmoplasty,
53,54
colopexy with banding,55mesenteric fixation,7and laparoscopic fixation.
excellent results using pexy without resection,
have reported recurrence rates in excess of 25%.
56
Although several authors have reported
52–54
38
Whereas
others
recurrence after resection approaches zero, resection with
anastomosis was historically accompanied by relatively
42
substantial morbidity and mortality,
prompting a number of
investigators to seek less risky alternatives.
Bhatnagar and Sharma
52
reported a series of 84 patients
treated by sigmoidopexy with extraperitonealization. They
reported a mortality of 9%. Patients were followed for a mean
of 6.7 years with no evidence of recurrence (48 patients were
followed for more than 5 years). Salim,
55
however, reported
on a technique of percutaneous deflation, followed by tube
detorsion and decompression, and finally intraperitoneal sigmoidopexy. He conducted a prospective, randomized trial of
this nonresectional technique compared with resection and
primary anastomosis. Of the initial 21 patients randomized to
the decompression followed by surgical arm, six required
emergency surgery. The remaining 15 were able to undergo
an elective resection. Of note, he reported no recurrences and
a mortality of 0% in the colopexy group as opposed to 13% in
the group undergoing resection.
55
Finally, the technique of mesosigmoidoplasty deserves discussion. This procedure is performed by incising the elongated sigmoid mesentery vertically along its axis. Peritoneal
flaps are then created which are then approximated transversely (Figure 19-8). This procedure thereby creates a shortened, broad mesentery precluding future bowel rotation.
Although one author has reported a recurrence of 28%, most
report recurrences of less than 2%. Mortality ranges from 0%
53,54
to 7%.
Modern surgical and anesthetic techniques, including the
use of surgical staplers, have reduced operative complications
substantially. Resection with anastomosis, therefore, should
currently be considered the standard of care for elective cases.
However, in circumstances in which continence is an issue, an
end stoma may be a better alternative. Colostomy via a
FIGURE 19-8. Mesosigmoidoplasty. A A longitudinal peritoneal incision is made in the elongated, narrow mesentery. B The incision is
then closed transversely, broadening the mesenteric base and shortening the height of the sigmoid loop.
19. Colonic Volvulus 295
minimal left lower quadrant incision has been suggested for
debilitated patients, too sick to undergo formal laparotomy.
Laparoscopic techniques have also been applied,
58–60
57
but in
general, because the redundant distended colon obscures the
working space and the incision required to deliver the specimen is also large enough to exteriorize the redundant sigmoid
colon and perform an adequate resection and anastomosis,
there is little to be gained by the use of laparoscopy.
60
In fact,
the entire resection and anastomosis can often be performed
via a limited left lower quadrant muscle splitting incision, a
very small midline incision, or via a Pfannenstiel incision.
If decompression is not possible, if the patient has signs
and symptoms of peritonitis or colonic ischemia, or if gangrenous mucosa is visualized during attempted decompression, the situation becomes a surgical emergency. The patient
should be rehydrated, electrolyte abnormalities and anemia
should be corrected, the patient should be given intravenous
antibiotics, and emergency surgery should be undertaken. The
patient should be explored via a midline laparotomy, the
volvulus should be manually reduced if the bowel is viable,
and the redundant, twisted sigmoid should be resected.
However, when gangrenous bowel is encountered during
laparotomy, detorsion should not be performed. Accumulated
toxins and bacteria may be released into the circulation,
resulting in sepsis and cardiovascular collapse. Maintenance
of the volvulus is therefore paramount as one obtains early
vascular control. Inspection of the proximal colon must be
performed, because in the face of a competent ileocecal valve,
the closed loop obstruction produces rapid cecal ischemia and
perforation.
21,38
Obviously, avoidance of fecal contamination
is paramount. With the use of 90-mm linear staplers, even
though the bowel proximal to the volvulus may be enormously dilated, resection without spillage is usually possible.
Generally, an anastomosis should be avoided if the proximal
colon is massively dilated and loaded with feces. Some
authors have applied the technique of intraoperative colonic
lavage to facilitate primary anastomosis.
61
In most cases, the
proximal sigmoid should be exteriorized as an end-sigmoid
colostomy; the distal end can be treated with a Hartmann-type
closure, or a mucus fistula. A single prospective, randomized
trial comparing primary anastomosis to the Hartmann’s procedure in 14 patients with gangrenous bowel, revealed a 50%
anastomotic leak rate. In addition, mortality was more than
double in those patients in whom an anastomosis was performed (33% versus 13%).
36
Although the colostomy can
generally easily be reversed in an elective manner, it must be
recognized that because of the age and infirmity of many
of these patients, in actual practice, the colostomy is often
permanent.
Overall mortality rates for the treatment of sigmoid volvulus range from 14% to 45%. Emergency surgery without preoperative detorsion is associated with mortality rates of
20%–45%. If nonviable bowel is encountered, these rates may
exceed 50%. In fact, several studies report mortality of
60%–80% in these cases.
9,17,21,35,36,38–41,62
Elective surgery,
after detorsion, is currently associated with mortality rates
below 10%, despite the fact that these are generally patients
with multiple comorbidities. However, older data reveal this
mortality was as high as 25%.
7,9,17,21,35,36,38–41,62
Paradoxically, outcomes in developed nations tend to be far
worse than those in developing countries. This is presumed to
be attributable to the older age and presence of significant
comorbidities of the patients in the Western nations.
4,38
Ballantyne,42in a review of 67 series of sigmoid volvulus
worldwide before 1981, compared mortality of nongangrenous and gangrenous bowel in the United States as compared with the rest of the world. He noted that the overall
mortality in the United States was 25% and internationally
18%. When gangrenous bowel was present, the United States
mortality further exceeded the international rate (80% versus
48%). However, for the nongangrenous, elective procedures,
the United States mortality was somewhat less than the worldwide rate (10.6% versus 12.6%).
It has been suggested that a nonresectional approach may be
safer in these ill patients. However, nonoperative decompression alone carries 0%–12% mortality. This may be related to
attempted detorsion in the presence of ischemic bowel.
Finally, operative detorsion with or without pexy carries a similar mortality to elective resection and anastomosis (8%–14%).
Therefore, one must consider the overall risk of recurrence as
well as the risk of mortality. As expected, any nonresectional
procedure carries a substantial risk of recurrence. For decompression alone it ranges from 25% to 70%, whereas detorsion,
with or without pexy, has been associated with recurrence rates
of 23%–40%. Most authors indicate that the risk of recurrence
after resection approaches zero; it has been reported to be as
high as 5% in some series.
17,9,21,35,36,38–41,62
This is usually
attributed to concomitant megacolon and/or megarectum.
The only prospective randomized trial comparing elective
resection and primary anastomosis with mesosigmoidoplasty
confirms these findings. None of the resected patients and 29%
of the plastied patients experienced recurrence. However, there
was no mortality in the plasty group as compared with 10% in
the resection group.
36
Ileosigmoid Knotting
Incidence and Epidemiology
Ileosigmoid knotting, also called compound volvulus, is a
rare form of volvulus uncommon in the West. It is, however,
comparatively more common in certain areas of Africa, Asia,
and the Middle East. In particular, large series are reported
from Turkey, Russia, Scandinavia, Uganda, and India. It is
more common in males than females, and presents at a
younger age than sigmoid volvulus. In fact, it has rarely been
reported in individuals older than 50 years of age.
The geographic distribution corresponds with regions of
the world where diets high in bulk and carbohydrates are
3,63–67
48
296 M.D. Hellinger and R.M. Steinhagen
consumed with large volumes of liquid. The incidence is
highest in groups in which one single large meal is consumed
daily. It has been reported to peak in the followers of Islam
during Ramzan when a single large meal is consumed at sunset after a full day’s fast.
3,63–67
Pathogenesis/Etiology
Theories of the pathogenesis of ileosigmoid knotting focus on
a large volume diet high in bulk and carbohydrates, associated
with large volumes of concomitant liquid ingestion. This may
lead to an elongated abnormally mobile small intestinal
mesentery, in addition to a long narrow pedicled sigmoid
mesentery. The simultaneous consumption of a large meal
combined with a large volume of fluid may then initiate an
acute knot formation. As the bolus empties into the jejunum,
the bowel becomes hyperperistaltic, and the weight acts to
pull it into the left paracolic gutter. The empty distal loops of
small bowel are then displaced around a narrow-based sigmoid. Continued peristalsis leads to further rotation of the
loop, internal herniation, and knot formation (Figure 19-9).
The fact that this entity usually occurs in the early morning
hours lends further credence to the theory that dietary and
dining habits of certain populations are causative.
3,63–67
Alver et al.,64in a review of 68 cases, described four different patterns of ileosigmoid knot formation which differentiate between an active or passive segment of bowel and the
direction of rotation. Usually, the ileum is the active component and wraps around the sigmoid in either a clockwise or
counterclockwise manner. Alternatively, the sigmoid may
wrap around a passive segment of ileum, either clockwise or
counterclockwise.
Clinical Presentation
The presentation of ileosigmoid knotting is one of acute
onset, often with a fulminant course. There is a dramatic
absence of prior similar attacks that are frequently seen in
other forms of volvulus. Patients usually present in shock
with signs of an intraabdominal catastrophe. The patient may
complain of severe colicky abdominal pain, which begins in
the periumbilical region. Nausea and vomiting, as well as distension, are early findings. At surgery, gangrenous intestine is
found in 70%–100% of cases. As the result of the severity of
the condition at presentation, acidosis, hypovolemia, oliguria,
hypotension, and tachycardia are common findings.
Preoperative diagnosis is extremely difficult because of the
confusing nature of the presentation and unfamiliarity with
3,63–67
FIGURE 19-9. Ileosigmoid knotting: these schematic illustrations indicate the four forms of knotting. The active ileum may rotate around the
sigmoid colon in either a clockwise A or counterclockwise B direction. Much more infrequently, the sigmoid colon may act as the active
loop and rotate in either a clockwise C or counterclockwise D direction around the ileum.
19. Colonic Volvulus 297
this entity. Clinically, the patient’s condition presents as a
small bowel obstruction, but radiographic evaluation is more
consistent with a large intestinal obstruction. In fact, X-rays
are often atypical, and the diagnosis is correctly made in
fewer than 20% of patients preoperatively. However, several
characteristic radiographic features of ileosigmoid knotting
have been identified. These include a double obstruction, with
an obstructed distended sigmoid loop pulled to the right and a
proximal small bowel obstruction on the left. A diagnostic
triad has been proposed consisting of a clinical small bowel
obstruction, a radiographic large bowel obstruction, and the
inability to pass a sigmoidoscope to decompress a suspected
sigmoid volvulus.
3,64–67
Treatment/Outcome
Because of the high incidence of ischemia and gangrene at the
time of presentation, after an initial period of rapid resuscitation and antibiotic administration, patients should be taken for
emergent abdominal exploration. Controversy clearly exists
regarding the preferred surgical approach. Treatment recommendations have ranged from simple detorsion to double
resection. Because of the high likelihood of gangrenous
bowel, most authors advocate en bloc resection of both segments of intestine without attempts to untwist the bowel.
They state that untying the knot may be time consuming, difficult, hazardous, and may lead to systemic release of endotoxin and propagation of shock. Finally, perforation may
ensue, leading to peritoneal contamination.
others have recommended detorsion if one or both segments
of bowel are thought to be viable. Deflation of the torsed segments had been shown to assist in untying the knot and diminishing the risk of rupture. There are conflicting data on
recurrence after detorsion alone.
3,63–66
resection of the sigmoid in all cases because of the possibility
of recurrent knotting or eventual sigmoid volvulus.
Although most perform a primary ileoileal or ileocolic
anastomosis in patients with gangrenous small bowel, a
Hartmann’s procedure is usually performed when the sigmoid
is found to be nonviable. When the sigmoid is viable, despite
the lack of bowel preparation, some authors have reported
safe colorectal anastomoses. Because of the risk of inferior
mesenteric artery or superior rectal artery thrombosis, most
authors also advocate resection of the sigmoid well past the
areas of twisting and/or gangrene to ensure adequate blood
3,63–67
supply.
Overall surgical mortality generally ranges from 30% to
50%. One review of seven patients reported no mortality,
despite finding gangrenous colon in all seven patients, and
gangrenous ileum in three.
63–67
Mortality for nongangrenous
bowel is generally less than that for gangrenous bowel.
Reports range from 10% to 30% for nongangrenous intestine,
and 40% to 50% for gangrenous bowel.
however, noted a paradoxic relationship between duration of
symptoms and mortality. Those patients who presented within
3,63–66
However,
Some authors advise
62,64–66
3,64–66
Alver et al.,
24 hours had a mortality of 42%, whereas those that presented
later had a much lower mortality rate of 20%. Additionally, he
noted that the rate of gangrene was 91% in the early presenters but only 57% in the late presenters. This reflects the more
rapid fulminant course of the patients that present earlier.
addition, when extensive gangrene of the small bowel is
found, leaving the patient with less than 60 cm of residual
bowel, mortality has been shown to be 100%.
64
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20
Lower Gastrointestinal Hemorrhage
Frank G. Opelka, J. Byron Gathright, Jr., and David E. Beck
Lower gastrointestinal hemorrhage refers to a spectrum of
intestinal bleeding that arises distal to the ligament of Treitz. It
may range from occult bleeding or occasional spotting of
blood to massive lower intestinal hemorrhage. Massive lower
intestinal hemorrhage is difficult to define. Patients often
describe massive bleeding into their commode even when a
small amount of blood discolors the water. True massive intestinal hemorrhage typically involves hemodynamic compromise or symptomatic anemia. Multiple sources define massive
bleeding to include patients with a hematocrit less than 30%,
patients with transfusion requirements (up to 3–5 units of
blood/blood products), or orthostasis requiring resuscitation.
Primarily, lower intestinal hemorrhage arises from within
the colon. Billingham
orrhage as a conundrum with five key concerns. First, the condition may arise from bleeding throughout the gastrointestinal
tract. Second, intermittent bleeding precludes a prompt identification of the site of hemorrhage. Third, patients requiring
surgery may undergo a procedure without a specific preplanned site of resection and with considerable morbidity and
mortality. Fourth, despite aggressive surgical management,
persistent bleeding may occur. And finally, there is no consensus about the precise diagnostic and therapeutic pathways
for patients.
From the perspective of the emergency room care, massive
lower gastrointestinal hemorrhage is a relatively uncommon
emergency. Longstreth
organization (HMO)-based population in San Diego,
California, noting an annual incidence rate of 20.5/100,000
patients with a male predominance. His study reflected a retrospective survey and chart review defining incidence. The
incidence of significant bleeding increases with age. The
association with aging may suggest senescent changes associated with the small intestine and colon. Certainly aging
reflects the surging prevalence of colonic diverticulosis and
intestinal angiodysplasia in the elderly. It is of interest to note
that the California HMO group had a high incidence of diverticulosis (41.6%) and infrequent angiodysplasia (2.7%).
1
described lower gastrointestinal hem-
2
studied a large health maintenance
However, Longstreth admits the limitations of the study
design may not precisely determine the true etiologies of
lower gastrointestinal hemorrhage.
Lower gastrointestinal bleeding presents with varying
degrees of hemorrhage. Patients may experience minor bleeding when they describe the passage of 100–250 mL of blood,
possibly a few clots, and often mixed with mucous. Other
patients experience brisk, copious bleeding with major, selflimited hemorrhage. Finally, certain patients present with
massive and continuous hemorrhage associated with hypovolemia. The hemorrhage may present as melena or hematochezia. Melena typically suggests bleeding from a more
proximal source in the colon or small intestine. Hematochezia
suggests left colonic, rectal, or anal sources. It is wise to note
that upper gastrointestinal hemorrhage may present with the
rectal bleeding given blood’s cathartic effect and rapid intestinal transit. Jensen and Machicado
emergency panendoscopy in patients with hematochezia and
negative nasogastric lavage. His 1988 study provided additional insights in demonstrating an upper source for bleeding
in 11% of patients.
may present with lower gastrointestinal bleeding symptoms in
10%–15% of cases.
Most often the intestinal bleeding resolves spontaneously
with supportive hospital care. Once it resolves, investigations
should begin to identify the potential sources. Actual bleeding
sources are not so frequently identified by the current limitations of our diagnostic tools. In clinical scenarios in which the
bleeding resolved spontaneously, the diagnostic evaluation may
only unmask potential sources. Without associated attached
clot or active bleeding, the true site of hemorrhage may never
be elucidated. On occasion, the intestinal hemorrhage does not
resolve. It continues, creating hemodynamic compromise.
Ongoing hemorrhage demands aggressive medical and surgical
management. Oftentimes, patients with massive hemorrhage
are plagued with significant comorbidities that complicate their
individual resuscitation. Their comorbidities must be considered in the diagnostic and therapeutic phases of the care plan.
4
Overall, it is believed that upper sources
3
outlined the safety of
299
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