Observations on a Giant Sigmoid Volvulus with Unusual Clinical Presentation and Challenging Postoperative Course: Case Report

Giuseppe Pisano,Enrico Erdas,Stefano Piras,Pietro Giorgio Calò

doi:10.4236/ss.2015.611072

Abstract

Introduction: The present report describes a case of a giant sigmoid volvulus (SV) where acute respiratory distress was associated with toxic megacolon. Clinical features, surgical treatment and postoperative course deserved our attention and discussion. Presentation of Case: A 67-year-old man with psychiatric disturbances was admitted to our Department with severe respiratory distress due to an enormous abdominal distension caused by a sigmoid volvulus. Endoscopic derotation was unsuccessful and surgery immediately performed. After a wide colonic resection the patient underwent a prolonged treatment in the Intensive Care Unit. Death occurred 34 days after the operation for secondary infection of peritoneal effusion. Discussion: Main clinical features of SV pertain to abdominal compartment while in the present case acute respiratory distress was the prominent symptom; in the same time the severity of the case was due to the association of high abdominal pressure together with a toxic megacolon. Postoperative treatment consisted in ventilatory support, with a progressive shift from asssisted to spontaneous ventilation; repeated sessions of haemodialysis were necessary to manage renal failure up to recovery of the urine output. Bacterial trans location due to toxic megacolon was responsible of late infection of ascitic fluid. In spite of multiple antibiotic association according to bacterial cultures, intra-abdominal abscesses eventually developed causing fatal outcome 34 days after the first intervention. Conclusion: Severe clinical presentation required a prolonged and demanding postoperative course which was focused on the recovery of respiratory, cardiac and renal function even if fatal outcome was due to septic complications. Suspicion of late infection of ascitic fluid could arise from persistently high values of inflammation indexes and drive to an earlier drainage of the abdominal abscesses.

Highlights

The present report describes a case of a giant sigmoid volvulus (SV) where acute respiratory distress was associated with toxic megacolon
Common complaints of sigmoid volvulus (SV) are usually represented by sudden abdominal pain, distension and arrested flatus passage, while physical examination reveals abdominal tenderness and asymmetrical abdominal distension [1]-[4]. If these are the most frequent findings, sometimes clinical presentation may change towards a frank peritonitic syndrome or an abdominal compartment syndrome (ACS), where the increased abdominal pressure compromises the functions of visceral organs [2] [5]-[8]
The present paper describes a case where an acute SV presented with such a massive distension to cause a severe respiratory distress and renal flow impairment; in the same time colonic ischemia due to bowel strangulation was already responsible of a condition evolving towards a septic shock

Summary

Introduction

Common complaints of sigmoid volvulus (SV) are usually represented by sudden abdominal pain, distension and arrested flatus passage, while physical examination reveals abdominal tenderness and asymmetrical abdominal distension [1]-[4]. If these are the most frequent findings, sometimes clinical presentation may change towards a frank peritonitic syndrome or an abdominal compartment syndrome (ACS), where the increased abdominal pressure compromises the functions of visceral organs [2] [5]-[8]. The unusual clinical presentation and the challenging postoperative course made this case worth of the present report

Case Presentation

Findings

Discussion

Conclusions