Volvulus

Volvulus is a gastrointestinal rotational irregularity which causes a bowel loop obstruction and occurs most commonly during infant development, in the elderly and in those with constipation or redundant colon.

What is volvulus?

Volvulus is abnormal twisting of the intestine around the peritoneum, which usually suspends the jejunum and ileum along the abdominal posterior wall (mesenteric base) and can occur along any part of the gastrointestinal tract. There are five types of volvulus depending on the site of intestinal twisting, which includes gastric volvulus, volvulus of the small intestine, volvulus caecum and volvulus sigmoid colon. Gastric volvulus is a 180-degree twisting of the stomach.

What causes volvulus?

There are a number of causes of volvulus depending on a patient's age and predisposing medical condition. Most common causes include:

• Congenital intestinal malrotation: this affects infants during the first eight weeks of gestation, as their midgut rotates and positions itself to the abdominal wall.  If the mesenteric base is too narrow and causes abnormal positioning and fixing to the abdominal wall, volvulus is likely to occur.
• Gastrointestinal irregularities can result in intestinal twisting and complete volvulus obstruction.
• Traverse or redundant colon, or excess intestinal tissue, can also cause complete blockage with volvulus.
• Smooth muscle dysfunction in patients with Duchenne Muscular Dystrophy.
• Absolute constipation causing a blockage in the colon and volvulus twisting.

The difference between malrotation and volvulus is that a complete obstruction occurs at the twisted mesenteric base in the gastrointestinal tract.

What medical conditions are associated with volvulus?

Volvulus can cause complications, such as mucosal necrosis, sepsis and intestinal ischemia. If left untreated, such conditions can cause rupturing within the gastrointestinal tract and infection, leading to a life threatening medical emergency. Metabolic processes can fail due to malabsorption. Medical attention should be sought immediately to untwist the volvulus intestine and eliminate the obstruction.

What are the symptoms of volvulus?

The main symptoms of volvulus are abdominal swelling and pain, with nausea and vomiting. As a result of bowel obstruction caused by the twisted intestine, an ischemic loss of blood flow affects the twisted intestinal area. Absolute constipation occurs where the individual is totally unable to pass faeces. If rupturing occurs blood may be present in vomit or stools.

How is volvulus diagnosed?

Initial diagnostic tests for volvulus will include physical examination and discussion of symptoms, followed by laboratory investigations, with blood test samples and stool samples where needed. Other diagnostic tests include X-rays and radiographic imaging. Gastrointestinal tract radiographic tests are most commonly used to diagnose volvulus and sometimes include barium contrast, and a barium enema may also be performed. To identify the exact mesenteric site of volvulus, abdominal ultrasound and computer tomography (CT) scans may be used.

How is volvulus treated?

Treatments may be non-surgical or surgical. Non-surgical treatments for patients with malrotation or at high risk of volvulus may include inserting a tube via the rectum called sigmoidoscopy, or a nasogastric or orogastric tube, to monitor the bowel obstruction and gastrointestinal decompression. The aim is to try and untwist the intestine to prevent absolute volvulus twisting and obstruction.

However, if volvulus is present surgery may be necessary. Two types of surgery are used:

• Laparotomy: involves surgically untwisting and sigmoid resectioning with primary anastomosis. This may be used in conjunction with the Ladd's procedure.
• Transduodenal Band of Ladd Procedure: surgery to untwist the small intestine and to rotate it anti-clockwise, so that the duodenum is separated downwards towards the paravertebral passage, away from the caecum in the left side of the abdomen.

Research suggests recovery from Ladd's Procedure is preferable due to faster recovery time of bowel functions and less pain that laparotomy surgery.

How can volvulus be prevented?

The amount of time that passes before diagnosis and treatment can signify life or death depending on how much blood flow loss (ischemia) occurs. Seeking immediate attention for symptoms and early treatment intervention is vital to prevent gastrointestinal damage and the need for surgery for volvulus complete obstruction.

Preventative measures for children also mean immediate medical care with monitoring and treatment as necessary. People predisposed to gastrointestinal irregularities, such as those with Duchenne Muscular Dystrophy, should also be monitored by a medical practitioner. When symptoms of frequent and long-lasting constipation occur, diagnostic testing and treatment can prevent volvulus from developing.