VOLVULUS

**VOLVULUS **

1. Definition – Volvulus is a condition in which a loop of intestine twists around its mesenteric attachment, thereby obstructing the lumen and compromising its blood supply.

2. Types –
   a. Sigmoid volvulus – most common, accounts for about 50‑70 % of cases.
   b. Cecal volvulus – second most common type.
   c. Ileal (small‑bowel) volvulus – rare, often associated with congenital malrotation.
   d. Gastric volvulus – rare, involves twisting of the stomach.

3. Causes / risk factors –
   • Redundant colon with long mesentery (especially sigmoid).
   • Chronic constipation, high‑fiber diet, megacolon.
   • Adhesions or previous abdominal surgery.
   • Congenital malrotation (ileal).
   • Pregnancy, distal obstruction, heavy meals.

4. Clinical features –
   • Sudden onset of severe abdominal pain.
   • Vomiting (may be bilious).
   • Marked abdominal distension.
   • Constipation or obstipation.
   • Abdominal tenderness and guarding.
   • Diminished or absent bowel sounds in advanced obstruction.

5. Investigations –
   • Plain abdominal X‑ray – “coffee bean” or “bent inner‑tube” sign in sigmoid; “kidney‑shaped” loop in cecal volvulus.
   • CT abdomen – twisted bowel loop with whirl sign of mesentery; assesses bowel viability.
   • Contrast enema (sigmoid) – shows “bird’s‑beak” tapering at the point of twist.

6. Complications –
   • Bowel ischemia → necrosis.
   • Perforation → peritonitis.
   • Sepsis, electrolyte imbalance, shock.

7. Initial management – fluid resuscitation → nasogastric decompression → broad‑spectrum antibiotics if perforation suspected.

8. Definitive management –
   a. Sigmoid volvulus –
   • Endoscopic detorsion (flexible sigmoidoscopy) → if successful, plan elective sigmoid resection later.
   • If endoscopic reduction fails or bowel is gangrenous → emergency laparotomy → sigmoid resection with primary anastomosis or Hartmann’s procedure.
   b. Cecal volvulus –
   • Endoscopic reduction rarely effective → emergency right hemicolectomy or cecopexy.
   c. Ileal or gastric volvulus –
   • Prompt surgical reduction → resection of non‑viable segment → fixation (e.g., gastropexy for gastric volvulus).

9. Post‑operative care – monitor for anastomotic leak, maintain fluid/electrolyte balance, early ambulation, gradual diet advancement.

10. Key exam points –
    • Volvulus becomes a surgical emergency when there is evidence of ischemia or necrosis.
    • “Coffee bean” sign on plain X‑ray is characteristic of sigmoid volvulus.
    • First‑line treatment for uncomplicated sigmoid volvulus is endoscopic reduction.
    • Right hemicolectomy is the treatment of choice for cecal volvulus.