Reduction Of Volvulus Research Articles

Spontaneous, sub-acute right lung torsion: a case report

AbstractLung volvulus is a rare occurrence and is most commonly seen after thoracic surgery or trauma. They are generally associated with a long, thin hilum, with no parenchymal bridge between the lobes. In non-postoperative situations, pleural effusion or pneumothorax would appear to be mandatory. Spontaneous volvuli are not described, especially sub-acutely. We report the case of a patient with an apparently spontaneous lung volvulus. He presented with long prodromal symptoms of haemoptysis and increasing cough. The computed tomography scan showed a complete volvulus of the right lung with signs of non-perfusion of the upper and middle lobes. The patient was successfully treated with volvulus reduction and bi-lobectomy. Torsion is classically known to thoracic surgeons, but is rarely encountered by other specialists. We describe here a sub-acute lung volvulus, apparently spontaneous, easily treated by a simple surgical procedure.

S1968 Pregnancy With a Twist: A Case of Sigmoid Volvulus in the Third Trimester

Introduction: Sigmoid volvulus is a rare cause of bowel obstruction in the general population and particularly in pregnancy. Here, we present a case of a young woman in her third trimester presenting with acute sigmoid volvulus. Case Description/Methods: A 27-year-old woman with no prior medical history who was 31 weeks pregnant presented with 4 days of progressive abdominal pain and distension with associated obstipation, nausea, vomiting and decreased oral intake. Her surgical history was pertinent for prior cesarean section and right laparoscopic salpingectomy. Her vital signs are normal. Her abdomen is distended and tender to light palpation with guarding and rebound tenderness. CBC and CMP are within normal limits. A computed tomography (CT) scan of the abdomen and pelvis showed large bowel distension up to 10.5 cm with air fluid levels and twisting of the mesentery at the sigmoid colon. Based on these findings, she was diagnosed with sigmoid volvulus. The patient was emergently taken to the operating room for endoscopic sigmoid volvulus reduction. A therapeutic colonoscopy revealed a sigmoid volvulus with health appearing mucosa which was successfully traversed and detorsion was performed. A nasogastric tube was placed in the rectum with the proximal tip near the hepatic flexure for decompression.The patient’s abdominal pain improved significantly after colonic decompression. Three days later, she underwent definitive open sigmoidectomy with primary anastomosis. Three days later, the patient had vaginal bleeding along with contractions and had breech vaginal delivery of a male infant ( Figure). Discussion: Sigmoid volvulus in pregnancy is rare but should be included within the differential diagnosis for abdominal pain as a delay in diagnosis or late presentation can result in significant morbidity and mortality for mother and fetus. Delays in diagnosis are associated with high rates of morbidity and mortality for the mother and fetus. Maternal complications include sepsis, peritonitis, and bowel perforation. Fetal complications include pre-term delivery, intrauterine death, and neonatal sepsis. Endoscopic decompression is successful in 75-95% of cases. Elective surgery is recommended after endoscopic detorsion. Finally, it is important to have a multi-disciplinary approach with colorectal surgeons and obstetricians in the management of sigmoid volvulus in pregnancy.Figure 1.: Sagittal view of abdomen and pelvis CT Scan.

Gastric volvulus is a rare and life-threatening abdominal pain

Gastric volvulus is a rare and life-threatening abdominal pain condition resulting from the stomach twisting on its own longitudinal (organo-axial) or transverse (mesentero-axial) axis. Gastric volvulus can be primary or secondary. Secondary is most commonly related to para-esophageal hernia. Gastric volvulus can have an acute or chronic presentation, the acute form presents abdominal pain with a risk of gastric ischemia with subsequent perforation. Diagnosis is made by imaging studies such as barium contrast studies in the upper digestive tract or abdominal and chest computed tomography (CT). CT of the abdomen and thorax is very useful in the diagnosis as it can demonstrate the abnormal position and gastric torsion The goal in the definitive treatment of gastric volvulus is resolution of gastric obstruction and prevention of recurrence. Performing volvulus reduction, repair of the concomitant cause (para-esophageal hernia), fundoplication and/or gastropexy to the anterior abdominal wall. Gastropexy is considered safe and effective in elderly patients with high surgical risk.

Colonic volvulus and jejunal ischemia secondary to a congenital adhesive band

Abstract We report the case of a 7-year old Hispanic boy who presented with acute, severe intermittent diffuse abdominal pain. There was no previous significant medical or surgical history. Physical examination revealed a soft abdomen, normoactive bowel sounds, and epigastric tenderness. Initial blood tests and abdominal imaging were non-contributory, except for focal loops of dilated small bowel in the mid-abdomen. In less than 24 hours, the patient had worsening symptoms and physical findings. Emergent laparotomy revealed colonic volvulus with infarction and proximal jejunal ischemia secondary to a congenital adhesive band. Volvulus reduction, band release, extended right hemicolectomy, terminal ileostomy, and Hartman closure of the splenic flexure were performed. Recombinant tissue plasminogen activator (tPA) was infused into partially ischemic jejunum mesenteric vessels, and second look laparotomy planned. During the second laparotomy, nitroglycerin was topically applied on the ischemic jejunum, tPA infused into affected vessels, and third look laparotomy planned. Interval improvement of the affected proximal jejunum led to a shorter resection during the third laparotomy. Congenital adhesive bands are rare abnormalities that can cause bowel obstruction in children. A high index of suspicion in the absence of previous trauma or operations may prevent delays in diagnosis and treatment, allowing for improved outcomes.

360 Degree Twisted Transverse Colon in a Neurological Impaired Girl with a History of Chronic Constipation - A Case Report

Introduction: Transverse colon volvulus is an uncommon cause of bowel obstruction. Predisposing factors are mental retardation, dysmotility disorders, chronic constipation, and congenital megacolon. Case report: We presented a transverse colon volvulus in a 14-year-old girl with mental retardation. Chronic constipation in neurologically impaired patients was a risk factor predisposing to volvulus. The girl was admitted to our Clinic because of problems that last 4-5 days and was followed by abdominal pain, vomiting and lack of stool. Vomiting was once a day. She was sub febrile up to 37.6°C. On examination, the abdomen was distended, tense, diffusely painful. During the surgery, a 360° clockwise volvulus of the transverse colon was found. After the reduction of volvulus, an enormous transverse colon was resected and protective ileostomy was formed. In the postoperative period, ileostoma functioned a good. The definitive surgical treatment was done on the 20th postoperative day when the occlusion of the ileostomy and transanal biopsy of the rectum was done, which showed the presence of ganglia cells. The patient was discharged from our institution after 1 month. Conclusion: Pediatric patients with neurological conditions and mental retardation present an increased risk of colon transversum volvulus due to chronic obstruction.

2750 Acute Neck Pain Masquerading as Acute Gastric Volvulus

INTRODUCTION: Gastric volvulus is a rare cause of gastric outlet obstruction that if not recognized early can lead to ischemia, necrosis and death. Organoaxial is the most common type and is seen with secondary anatomic defects i.e. paraesophageal hernias, diaphragmatic hernias and diaphragm eventrations. It occurs in 60% of cases with 30% risk of strangulation. Risk factors include age >50 years, secondary anatomic defects, phrenic nerve paralysis and structural abnormalities of the stomach/spleen. Symptoms include abdominal pain, chest pain, retching and/or vomiting. Misdiagnosis occurs because of its nonspecific presentation. We describe a case of a patient who was admitted for suspect acute coronary syndrome and found to have an acute gastric volvulus. CASE DESCRIPTION/METHODS: 75 yo m with pmh of HTN, who p/w sudden onset neck pain radiating to L arm, with N/V during activity. He denied chest pain, SOB or diaphoresis. Vitals were T 98 F, HR 85, BP 156/69, and RR 18. On exam pt had decreased breath sounds LLL, NT abdomen, and left paraspinal neck tenderness. Pertinent labs: WBC: 11. Chemistry with hypokalemia. Normal troponins. CXR showed L hemidiaphragm elevation and hiatal hernia. Neck imaging was normal. EKG was normal without st changes. Overnight the pt became altered with intractable neck pain, nausea and vomiting. Repeat cxr showed widened mediastinum. A stat CTA chest/abd/pelvis showed organoaxial gastric volvulus with fluid filled esophagus. EGD abnormalities lead to an ex-lap with gastrostomy, gastropexy and volvulus reduction. Pt did well and went to a rehab facility. DISCUSSION: Gastric volvulus often manifests with abdominal pain in addition to nausea and vomiting rather than neck or chest pain. There have been reports of cases mimicking acute coronary syndrome. Intractable neck pain without abdominal pain is an extremely rare phenomenon in patients with acute gastric volvulus. In order to establish a diagnosis in our patient, a high index of suspicion was imperative for identifying an atypical presentation of acute gastric volvulus. This was illustrated by ordering a CT chest as soon as he became more ill-appearing. In retrospect, the intractable neck pain could have been considered as referred pain from the elevated left hemidiaphragm in the setting of a known hiatal hernia. Literature search was heterogeneous and scarce. Thus, we recommend high index of suspicion for acute gastric volvulus in the setting of intractable neck pain in order to intervene earlier and avoid worse outcomes.

A Large Hiatal Hernia: Atypical Presentation of Gastric Volvulus

Nasuea and vomiting are common side effects of chemotherapy, however, other serious conditions should be considered in order to provide immediate intervention. Gastric volvulus is as an abnormal rotation of the stomach and presents with Borchadt's triad of unproductive retching, epigastric pain, distention and the inability to pass a nasogastric tube. This can result in bowel obstruction, strangulation, ischemia, necrosis, perforation and abdominal sepsis which make it a medical emergency requiring urgent surgery. We report a 56-year-old female with history of non-small cell lung cancer status-post left lower lobectomy with partial diaphragmatic resection undergoing chemotherapy who presented to the ED with one month of worsening nausea, bilious emesis and epigastric pain radiating to the left chest. She was initially discharged home with antiemetics when she was simply noted to have a large hiatal hernia on CXR. A week later, the patient was admitted with the same symptoms along with severe hypokalemia and hypomagnesemia. Repeat CXR revealed marked elevation of the left hemi-diaphragm and thickwalled air-filled structure overlying the left lower thorax. Barium upper GI series showed the stomach antrum above the diaphragm in the left thorax while the antrum was cephelad to the gastric body. Oral contrast could not empty into the duodenum despite repositioning the patient. Contrast enhanced chest, abdomen and pelvis CT confirmed the diagnosis of mesenteroaxial gastric volvulus with gastric outlet obstruction. She underwent emergent exploratory laparotomy for volvulus reduction and diaphragmatic defect repair; no complications were noted. With mortality rates of 30-50%, gastric volvulus must not be missed. Unfortunately, the diagnosis was not made during the first ED visit, as her symptoms, laboratory testing and CXR finding of “a large hiatal hernia” did not raise enough concern for additional imaging studies to be pursued. Our patient did not present with the typical Borchadt's triad. Instead, she presented with migrating pain from the epigastrium to the left chest, likely corresponding to the stomach migrating through the diaphragmatic defect leading to the eventual volvulus. Risk factors include patient age over 50, diaphgragmatic defects, gastric ligament laxity and gastroduodenal tumors. Fortunately, gastric volvulus was identified on the second visit with the appropriate diagnostic modalities of Barium UGI series and CT scan.Figure 1Figure 2Figure 3

Intestinal Volvulus: A Life-Threatening Disease.

A male infant was delivered at 40th week gestational age with a birth weight of 3.2 kilogram via cesarean section to a 29-year-old primiparous woman. The mother had normal antenatal care. The infant was admitted into neonatal intensive care unit with bilious vomiting and rectal bleeding at the age of 4 days. Physical examination revealed sick baby. He is tachycardiac (Heart rate: 170) and hypotensive (Blood pressure 45/20). There is abdominal distension, otherwise systemic examinations were normal. The baby was rapidly resuscitated with normal saline and intravenous antibiotics were started. Blood transfusion was given because hemoglobin dropped to 6.1 (normal value: 12. 2-15.3 gm/dL). An Upper Gastrointestinal Barium Swallow showed dilated duodenum (bold arrow) and “Corkscrew” of contrast projecting away from the posterior abdominal wall suspecting malrotation with midgut volvulus (narrow arrow) [Table/Fig-1]. [Table/Fig-1]: An Upper Gastrointestinal Barium Swallow showing dilated duodenum (bold arrow) and “Corkscrew” of contrast projecting away from the posterior abdominal wall suspecting malrotation with midgut volvulus (narrow arrow). An emergency laparotomy was performed, which confirmed twisting of superior mesenteric artery. Volvulus occurred at the duodenojejunal junction. There was 360 degree rotation of volvulus. The diagnosis of small-bowel volvulus was confirmed and Ladd’ procedure was performed [Table/Fig-2]. The bowel was not resected because of intestinal viability and no necrotic tissues in the second-look operation at 24 hours. [Table/Fig-2]: Twisting of superior mesenteric artery on laparotomy. During fetal development the intestinal volvulus is twisted because of malrotation of the intestine [1]. When the normal embryologic sequence of bowel development and fixation is interrupted, malrotation of the intestine occurs [1]. The pathogenesis of volvulus occurs because the narrow mesenteric base, which develops as a result of malrotation, allows the small bowel to twist around the superior mesenteric artery. This leads to vascular compromise of large portions of the midgut [1]. In neonates, malrotation with midgut volvulus classically presents with bilious vomiting and intestinal obstruction. Abdominal tenderness and hemodynamic deterioration (hematemesis, hematochezia and shock) are associated symptoms [2]. If the volvulus is missed, it can lead to vascular compromise, which can cause intraluminal bleeding evidenced by melena and/or hematemesis and worsening intestinal ischemia can lead to signs of shock [2]. The best diagnostic choice to diagnose malrotation, with or without midgut volvulus, is an upper GI series. The Ladd procedure remains the cornerstone of surgical treatment for malrotation [3]. Ladd procedure is described as reduction of volvulus (if present), division of mesenteric bands, placement of small bowel on the right and large bowel on the left of the abdomen. When intestinal malrotation is complicated by volvulus especially if the child has signs of systemic decompensation (hematochezia, abdominal distension, peritonitis and shock), it is a potentially life-threatening condition and requires emergent evaluation and treatment. The child should be rapidly resuscitated and immediately taken to surgery for exploration because quick surgical intervention, not prolonged medical management, is associated with the best results if midgut volvulus is suspected [3].

Successful Gastric Volvulus Reduction and Gastropexy Using a Dual Endoscope Technique

Gastric volvulus is a life threatening condition characterized by an abnormal rotation of the stomach around an axis. Although the first line treatment of this disorder is surgical, we report here a case of gastric volvulus that was endoscopically managed using a novel strategy. An 83-year-old female with a history of pancreatic cancer status postpylorus-preserving Whipple procedure presented with a cecal volvulus requiring right hemicolectomy. Postoperative imaging included a CT scan and upper GI series that showed a gastric volvulus with the antrum located above the diaphragm. An upper endoscopy was advanced through the pylorus into the duodenum and left in this position to keep the stomach under the diaphragm. A second pediatric endoscope was advanced alongside and used to complete percutaneous endoscopic gastrostomy (PEG) placement for anterior gastropexy. The patient's volvulus resolved and there were no complications. From our review of the literature, the dual endoscopic technique employed here has not been previously described. Patients who are poor surgical candidates or those who do not require emergent surgery can possibly benefit the most from similar minimally invasive endoscopic procedures as described here.

Successful Gastric Volvulus Reduction and Gastropexy Using a Dual Endoscope Technique

Successful Gastric Volvulus Reduction and Gastropexy Using a Dual Endoscope Technique

Treatment of Recurrent Sigmoid Volvulus with Percutaneous Endoscopic Sigmoidopexy

Purpose: In the United States, sigmoid volvulus is second only to cancer and diverticulitis as a cause of colonic obstruction. Prompt endoscopic decompression followed by surgical correction has become the accepted treatment method in most patients. There is, however, a small subset of patients in which comorbidities preclude the possibility of surgical intervention. Recurrence rates in these patients after nonoperative reduction are as high as 70%, with a resultant mortality rate of 21%. Percutaneous endoscopic sigmoidopexy has been proposed as a safe and effective treatment option in this population. We present a case of one such patient. Methods: A 93 year old female nursing home patient with a history of advanced Alzheimer's dementia, Parkinson's disease, CHF, PEG tube, and eight previous episodes of sigmoid volvulus within the prior year presented with a two day history of abdominal pain and distention. Abdominal X-ray confirmed the presence of sigmoid volvulus. The patient underwent directly visualized endoscopic reduction of volvulus with no evidence of gangrenous bowel wall or other pathology. As the patient was deemed a poor surgical candidate (ASA score 4), percutaneous endoscopic sigmoidopexy was considered as an alternative therapy. The patient received intensive bowel prep, conscious sedation and premedication with IV antibiotics prior to the procedure. On colonoscopy, a massively dilated rectum and sigmoid colon were noted. An area of the sigmoid with good 1:1 and transillumination was identified as the likely apex of the volvulus. Two 16 French PEG tubes were placed via pull technique per rectum and confirmed endoscopically at 40 cm and 55 cm from the anal verge. There were no immediate complications noted. Results: Diet was advanced after two days. The patient remained afebrile, and was subsequently transferred back to her nursing home with instructions on tube maintenance. No further episodes of confirmed revolvulus have occurred 12 months post procedure. Conclusion: A small number of reports of percutaneous endoscopic sigmoidopexy have appeared in the literature, most notably from the U.K., where the National Health Service has issued guidelines for its use in the treatment of sigmoid volvulus. To our knowledge, PES use has only been reported once prior in the United States. As surgical correction is the accepted modality in the majority of patients, PES is suggested as an alternative to expectant management in patients too ill to undergo general anesthesia or surgical intervention. As so few cases have thus been reported, many questions pertaining to methodology and outcomes must be answered prior to this procedure becoming a well accepted tool in the treatment of sigmoid volvulus.

Volvulus gastrique : diagnostic et prise en charge thérapeutique

Gastric volvulus is defined as an abnormal rotation of all or part of the stomach around one of its axes. It is a diagnostic emergency and therapeutic challenge because in acute forms it may lead to gastric strangulation with a high risk of ischemia and necrosis. Organoaxial and mesentericoaxial volvulus are distinguished according to the direction of rotation. The most common cause of gastric volvulus is hiatal hernia, but the principal predisposing factor is ligamentous laxity. The diagnosis is suspected when erect chest radiograph images show a high air-fluid level in the chest. Moreover a barium swallow is essential to confirm the diagnosis. Nonetheless, a computed tomography (CT) scan now provides a comprehensive description of the thoracic lesion, including stomach vitality. Gastric volvulus requires surgical treatment, specifically volvulus reduction, reintegration of the stomach into the abdominal cavity in cases of intrathoracic migration, and correction of causal factors. Resection of the hernial sac and the role of gastropexy for preventing recurrence remain controversial. Advances in laparoscopic surgery have made possible a laparoscopic approach to most cases of chronic gastric volvulus.

Endosonography probe-guided endoscopic mucosal resection of gastric neoplasms

the stomach following endoscopic volvulus reduction in a poor surgical candidate. This novel approach resulted in persistence of normal gastric position as documented by UGI series 1 year later. Further data is needed on the long-term follow-up of patients with various types of symptomatic volvulus managed endoscopically in regards to the significance and frequency of recurrence. In conclusion, we have described a new maneuver, the alpha-loop technique, for endoscopic reduction of gastric volvulus. We used this technique to successfully reduce gastric volvulus in 7 out of 8 patients with no procedural complications. The major benefit of endoscopic volvulus reduction was to allow time for elective surgical repair of abdominal pathology (paraesophageal hernia) predisposing to volvulus formation. The role of the alpha-loop technique as a definitive therapy in poor surgical candidates and in patients with idiopathic volvulus requires further evaluation.

Sigmoid volvulus in elderly patients

We reviewed the records of 51 patients over 65 years of age admitted for an initial episode of sigmoid volvulus, and adequate information about their subsequent course was obtained in 92 percent. Nonoperative reduction of the initial volvulus was attempted in 43 patients and was successful in 39 (91 percent). Eleven patients required emergency operations, with a mortality rate of 36 percent. Six patients had elective resections with no deaths. Thirty-three patients, 32 after nonoperative reduction of a volvulus and 1 after operative reduction, were discharged without definitive treatment. Twenty-three of the 33 patients (70 percent) managed by expectant observation had one or more episodes of recurrent volvulus. Five of the 23 patients died from the recurrence without operation, and 16 were operated on either emergently (3 patients) or electively (13 patients) after nonoperative reduction. The mortality rate related to recurrent volvulus or its treatment in the 33 patients observed was 21 percent. The mortality rate for 18 elective resections (6 for initial volvulus and 12 for recurrent volvulus) was 5.6 percent. After successful nonoperative reduction of a sigmoid volvulus in elderly patients, maximal survival is achieved by early elective resection. Age alone is not an adequate reason for adopting a nonoperative approach.

The colonoscope in volvulus of the transverse colon

A case of volvulus of the transverse colon in a patient with dystrophia myotonica is reported in which the volvulus was reduced during colonoscopy. Indications for colonoscopy in patients with volvulus of the transverse colon are discussed, and it is suggested that colonoscopic reduction of volvulus of the transverse colon might have a place as emergency treatment in patients with other severe complications.

Cicatricial stenosis of jejunum after reduction of volvulus

An unusual case of jejunal cicatricial stenosis after reduction of a volvulus is presented. Probable etiologic factors and methods of diagnosis, treatment, and prevention are discussed.

Volvulus of the midgut in the adult due to nonrotation of the intestine.

Although volvulus of the midgut due to nonrotation of the intestine is most frequently seen in infants, it may occur in the adult, producing definite symptoms and surgical emergencies. Recognition and treatment depend on an understanding of the embryology, careful history taking with respect to repeated transient attacks of abdominal pain, the unusual position of the cecum as revealed by barium enema and the presenting position of the intestine on opening of the abdomen. Reduction of volvulus is the necessary therapy.