Sigmoid Volvulus
Where Sigmoid Colon twists on its mesentery. Luminal obstruction at 180 degree twist and decreased vascular supply at 360 degree twist.
Risk factors:
- Long redundant sigmoid colon
- Narrow mesenteric attachment
- Higher incidence in older institutionalised adults with constipation
Two presentations:
- Insidious: with abdominal pain, nausea, abdominal pain and constipation
- Acute: acute abdo pain, obstipation, vomiting, peritonitis (or sepsis)
XR has 60% sensitivity for sigmoid volvulus. U-shaped distended
sigmoid colon. Absence of rectal gas.
CT can rule out other causes. Can see a whirl pattern.
1. How would you manage a sigmoid volvulus? clinical interview
1.1. Back
Principle are to reduce the volvulus in the acute setting and long term, to prevent recurrence.
If there are signs of peritonism, you should perform surgery. Options include:
- Sigmoid resection with primary anastamosis. Done when no gangrene or perforation, and the patient is stable.
- Hartmanns procedure Done when evidence of ischaemic bowel, perforation, faecal soiling, or HD stability.
After the second episode, recurrence rates are much higher (50% of patients will not have a recurrence after the first episode). In this situation, surgery should be recommended to the patient.
Non-operative management is ideally with
- Flexible sigmoidoscopy - decreased complication rate cf rigid sig. Consent, arrange emergency theatre, find spiral mucosa at 25cm, gently advance scope with minimal insufflation. Visualise dilated prox bowel and suction gas or stool. Inspect mucosa. Stop if gangrene. Insert rectal tube beyond torsion area.
- Consent, left lateral, knees to chest, check light, attach stylet, lubricate the tip. Perform PR. Empty rectum with enema if full. Insert stylet 4cm. Remove stylet and advance under vision. Examine at 15-20cm, gentle pressure at spiral mucosa, insert rectal tube.
2. Interview Question interview scenario
2.1. Front
You are called to review a 60 year old man with motor neurone disease from a high level care nursing home how has presented with abdominal distension. This is his XR:
What is your approach to management?
How does it change if this was his second presentation?
2.2. Back
CCrISP principles. Assuming stable and no peritonism - reduce volvulus with flexible sigmoidoscopy. Second presentation, much more likely to reoccur. Would advocate for sigmoid resection.
3. Associated Notes