No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Apport du scanner multidetecteur dans la prise en charge des volvulus du sigmoide
Abstract
Objectifs
Evaluer l’intérêt du scanner multi-détecteurs dans la prise en charge des volvulus du côlon sigmoïde.
Matériel et méthode
Vingt-trois examens TDM de volvulus du sigmoïde ont été étudiés rétrospectivement, et analysés en fonction de leur type (mésentérico-axial ou organo-axial), de leur degré de rotation (180° ou 360°), du diamètre maximal de l’anse volvulée, de la présence ou non d’un Northern Exposure sign, de signes pariétaux de souffrance ischémique et d’un épanchement intrapéritonéal. Une étude statistique a été conduite afin de déterminer la corrélation entre les caractéristiques de la population, la sémiologie TDM, le type de prise en charge, et les données histologiques le cas échéant.
Résultats
Dans notre étude, le volvulus de type organo-axial survenait dans une population plus âgée (p = 0,047), présentait un risque de récidive plus élevé (p = 0,015) et nécessitait un recours plus fréquent à la chirurgie en urgence que le volvulus mésentérico-axial. Un degré de rotation élevé était lié à une distension plus importante de l’anse volvulée (p = 0,033) et entraînait un recours plus fréquent à la chirurgie.
Conclusion
Au-delà du diagnostic positif de volvulus du sigmoïde et de la recherche de signes de souffrance ischémique, l’examen TDM permet d’analyser le type du volvulus et son degré de rotation, éléments qui semblent conditionner la gravité du processus et peuvent orienter vers un traitement optimal, endoscopique ou chirurgical.
... Our patient presented with the classical triad of acute abdominal pain which includes acute abdominal pain, abdominal distention and failure to pass faeces and gas. Whilst this triad is not specific to sigmoid volvulus it is present in 52.4% of cases [18,[21][22][23]26]. However, radiological imaging is necessary to confirm the diagnosis [1]. ...
... The success rate with endoscopic rectal tube decompression has been reported to be between 77% to 98% [1,5,6]. Rectal tube detorsion can be performed without anaesthesia and is a simple technique [26]. The disadvantages of rectal tube detortion are failure to identify mucosal ischaemia and the risk of colonic perforation. ...
... The immediate recurrence rate has been reported between 10.2% to 11.2% (Dieme E et al. 2016). Studies have shown that a failure of rectal tube detorsion is mainly due to the degree of torsion being ≥720 0 or due to the presence of bowel necrosis [26]. Within 2 days to 15 days following rectal tube detorsion, elective sigmoid colectomy should be performed and a 90% recurrence rate has been reported without performing sigmoid colectomy [6,14,29,30]. ...
The purpose of this study was to report the presentation and management of a case of uncomplicated sigmoid volvulus in a referral hospital in East Africa. Sigmoid volvulus occurs due to torsion of a dilated loop of sigmoid colon around its mesenteric axis resulting in acute colonic obstruction and eventually colonic strangulation. A 46-year-old male presented with a seven-day history of stomach pain, inability to pass stool, and flatus. His abdomen was tympanic, bloated, and nontender. Following resuscitation, a laparotomy was conducted, which revealed sigmoid volvulus with no bowel ischaemia or gangrene. A one-stage sigmoid colectomy and primary anastomosis was carried out and the patient made an uneventful recovery. Endoscopic decompression is not available in the emergency scenario in East Africa. Our patient was brought for an emergency laparotomy since he had straightforward sigmoid volvulus and no endoscopic detortion or rectal tube insertion. There was no morbidity following sigmoid colectomy and primary anastomosis. He made an uneventful recovery. One-stage sigmoid colectomy was reported to have a 7.7% mortality rate in East Africa. Septic shock is the leading cause of death in people who present to the hospital with sigmoid volvulus. To reduce morbidity and mortality in a patient with sigmoid volvulus bowel obstruction, an early diagnosis and prompt care are required.
... Our patient presented with the classical triad of acute abdominal pain which includes acute abdominal pain, abdominal distention and failure to pass faeces and gas. Whilst this triad is not specific to sigmoid volvulus it is present in 52.4% of cases [18,[21][22][23]26. However, radiological imaging is necessary to confirm the diagnosis [1]. ...
... The success rate with endoscopic rectal tube decompression has been reported to be between 77% to 98% [1,5,6]. Rectal tube detorsion can be performed without anaesthesia and is a simple technique [26]. The disadvantages of rectal tube detortion are failure to identify mucosal ischaemia and the risk of colonic perforation. ...
... The immediate recurrence rate has been reported between 10.2% to 11.2%. Studies have shown that a failure of rectal tube detorsion is mainly due to the degree of torsion being ≥7200 or due to the presence of bowel necrosis [26]. Within 2 days to 15 days following rectal tube detorsion, elective sigmoid colectomy should be performed and a 90% recurrence rate has been reported without performing sigmoid colectomy [6,14,29,30]. ...
Introduction: In the developing world in Sub-Saharan Africa, sigmoid volvulus is the commonest cause of large bowel obstruction and constitutes 50% of all large bowel obstructions. Sigmoid volvulus occurs due to torsion of a dilated loop of sigmoid colon around its mesenteric axis resulting in acute colonic obstruction and eventually strangulation. The objective of this study was to describe the presentation and management of a case of uncomplicated sigmoid volvulus in our referral hospital in East Africa. Presentation of Case: A 46-year old gentleman presented with a 7-day history of abdominal pain associated with inability to pass stool and flatus. His abdomen was distended, tympanic and nontender. After resuscitation, laparotomy was performed which showed evidence of sigmoid volvulus with no bowel ischaemia or gangrene. A one-stage sigmoid colectomy and primary anastomosis was carried out and the patient made an uneventful recovery. Discussion: In the emergency setting in East Africa, endoscopic decompression is not available. Since our patient presented with uncomplicated sigmoid volvulus and had no endoscopic detortion or rectal tube insertion he was taken for an emergency laparotomy. Following sigmoid colectomy and primary anastomosis there was no morbidity. He made an uneventful recovery. In East Africa, the mortality rate was found to be 7.7% with one-stage sigmoid colectomy. The main cause of death is septic shock due to a delay in patients presenting in hospital with sigmoid volvulus. Conclusions: An early diagnosis and expedient management of a patient with bowel obstruction due to sigmoid volvulus are necessary to minimize morbidity and mortality.
... Volvulus of the sigmoid colon is the twisting of the sigmoid loop on its mesocolic axis resulting in a low mechanical intestinal obstruction (AIO) by strangulation [1]. Abdominal and pelvic computed tomography (CT) without and then with injection of contrast medium allows the diagnosis to be made with certainty, but above all the diagnosis of severity [2]. ...
... Our results corroborate the data in the literature [1,7,14,15] . The search for signs of gravity (fever, collapse, abdominal contracture, traces of blood on rectal examination) is essential [1,2,4,15]. The average consultation time was 3.8 days with extremes of 1 day and 15 days. ...
... Septic shock was the most common cause of death: 5 cases or 83.32%. Our results corroborate those of most of the data from African series [2,11,16]. Traoré D et al 2014 in Mali had found 77 cases of complications out of 417 patients recorded, i.e. a percentage of 16.07%. They recorded 17 cases of death, i.e. 4.08% [11]. ...
Introduction: The aim of this study was to evaluate the results of one-stage colectomy versus two-stage colectomy at Conakry University Hospital. Methods: This was a retrospective study conducted at the University Hospital of Conakry from January 1, 2015 to December 31, 2019. All patients hospitalized and operated on in the Ignace Deen General Surgery and Donka Visceral Surgery departments for pelvic colon volvulus (PCV) who underwent colectomy during the study period were included. Results: We collected 87 cases of pelvic colon volvulus (PCV). The average age was 45.71 years with extremes of 5 years and 80 years with a male predominance of 82.83% and a sex ratio of 5.18. The morbidity was marked by 2 cases of anastomotic fistulas, 7 cases of parietal suppuration and 1 case of peristomal hemorrhage. 4 cases of death were noted in two-stage colectomy and 2 cases in one-stage colectomy. Conclusion: The occurrence of morbidity and mortality was not related to the type of colectomy. As our study does not allow us to affirm the superiority of one technique over the other, we recommend considering a future dynamic study that would take into account a larger sample.
... Afterward, in 2010, Levsky et al. [3] reported a series of 21 cases of sigmoid volvulus in which 43% were of organo-axial type-or incomplete twisting, as they named. Then subsequently, few small series of sigmoid volvulus were reported describing two types of twisting, the mesenterico-axial and the organo-axial [4][5][6]. In these series [3][4][5][6], the incidence of organo-axial sigmoid volvulus varied between 43 and 74%. ...
... Then subsequently, few small series of sigmoid volvulus were reported describing two types of twisting, the mesenterico-axial and the organo-axial [4][5][6]. In these series [3][4][5][6], the incidence of organo-axial sigmoid volvulus varied between 43 and 74%. ...
... En cas de signes de gravité ou d'échec du traitement endoscopique le traitement est chirurgical selon des modalités très variables [2,7,11,14]. Les signes ou critères de gravité, dont la recherche est primordiale, sont cliniques (fièvre, collapsus, [22,23,24,25]. Celle-ci permet également de préciser le nombre de tours de spire [25]. ...
... Les signes ou critères de gravité, dont la recherche est primordiale, sont cliniques (fièvre, collapsus, [22,23,24,25]. Celle-ci permet également de préciser le nombre de tours de spire [25]. En effet, dans notre série, les 2 cas d'hyperkaliémie, les 4 cas sur 5 d'hyperleucocytose et le seul cas de défense abdominale étaient associés à une nécrose de l'anse. ...
Objective: To report the results of the use of rectal tube in emergency as first line treatment in sigmoid volvulus in a context where endoscopic treatment is not available and describe those of the secondary care. Patients and Methods : This retrospective study carried out from January 2008 to December 2014 included 116 patients admitted at Hospital Principal of Dakar for volvulus of the sigmoid and treated immediately by rectal tube. A complete recruitment of patients fulfilling the inclusion criteria had been made during the period of the investigation. A collection sheet was crafted to collect data at the patient records. The procedure was to introduce through the anus in a patient in “taille” position, without anesthesia, a rectal tube previously lubricated. If successful, the tube, was removed at the second day. Then the patients were discharged and underwent a barium enema before the planned one stage sigmoidectomy. The absence of progression of the tube was considered as failure and motivated surgical treatment. The data entry and analysis were made using the Excel 2007 software. Results : This was of 110 men and 6 women with a median age of 47.5 years. Untwisting was obtained in 88 cases against 28 failures. After untwisting, 9 sigmoidectomy with primary anastomosis were performed during the same admission. In 62 cases, the sigmoidectomy was done later within an average of 130.5 days. The post operative follow up was uneventful. However 16 patients were lost during the follow up. After failure, we performed by laparotomy 9 one stage sigmoidectomy, 11 sigmoidectomy with end colostomy and 10 non resective surgery. We noted 4 wound infections, 1 anastomotic leakage and 1 death. Conclusion : The rectal tube is a good alternative to treat the sigmoid volvulus and allow delay sigmoidectomy on flat colon. Key words : acute intestinal obstruction, volvulus of sigmoïde, rectal tube, sigmoidectomy
... Organo-axial volvulus is common in gastric and cecal volvulus [1,2]. In the sigmoid colon, which is anatomically similar to the small intestine, the CT findings of partial twisting, which we consider identical to organoaxial volvulus, were reported just recently [3] and it has turned out that organo-axial volvulus of the sigmoid colon occurs more frequently than used to be expected [3][4][5]. On the other hand, the small bowel volvulus has been reported mainly associated with malrotation in children [6], though we think midgut volvulus corresponds to large mesentero-axial volvulus. With the development of multi detector-row CT (MDCT), however, some cases of small bowel volvulus without anatomical abnormalities and its imaging findings have also been reported [7,8], but, to our best knowledge, there is no previous article which reported detailed imaging or intraoperative findings of organo-axial volvulus of the small intestine, except for a few articles on organo-axial volvulus secondary to adhesion [9,10]. ...
... As seen in the present case, the mesenteric vasculatures, especially mesenteric veins, can be involved, so strangulation may occur in organo-axial volvulus of the small intestine. On the other hand, if there is no clinical and radiological finding of strangulation, we think organo-axial volvulus of the small intestine can be released by reducing intraluminal pressure conservatively, because it has only one transition point and abruptly increased pressure in the proximal intestine is thought to be important to maintain tight volvulus, as shown in Fig. 4. In the sigmoid colon, however, organo-axial volvulus was reported to recur more often than mesentero-axial volvulus [5], though further studies are needed to determine whether this result can also be applied to organoaxial volvulus of the small intestine. ...
Gastrointestinal volvulus is mainly classified into two subtypes, mesentero-axial volvulus and organo-axial volvulus. The detailed imaging findings of organo-axial volvulus of the small intestine have never been reported as far as we know. In this article, we report a case of organo-axial volvulus of the small intestine, focusing on the computed tomography (CT) findings. An 80-year-old man was radiologically diagnosed as having organo-axial volvulus of the terminal ileum and it was confirmed by open surgery without adhesion or any other anatomical abnormalities. CT showed two specific findings, split-bowel sign and rotating-C sign, which we think reflect pathophysiologic features of organo-axial volvulus. We think the pathogenic mechanism of organo-axial volvulus can be explained by the convergence of the reversed-rotational twist following the formation of a twisted but non-obstructive circular loop, even if there is no adhesion. Radiologists should be aware that organo-axial volvulus can occur even in the small intestine, and in the case of small bowel obstruction with single transition point, the two pathophysiologic signs mentioned above must be looked for to diagnose the possibility of organo-axial volvulus.
... It can also illustrate associated complications, such as bowel ischemia and perforation. In addition, it could characterize the type of volvulus, the degree of rotation and exclude other etiologies of bowel obstruction, informations which are important in the choice of the adequate treatment [8,10,20,21] . In Africa, abdominal CT is rarely used owing to its nonavailability and high cost [4,11,12,14,16] . ...
Background: Sigmoid volvulus (SV) is the commonest cause of large bowel obstruction in sub Saharan Africa. However few studies have been done in our country. Our goal was to describe the presentation, management outcome of adult SV and to evaluate our therapeutic methods in a context of non availability of endoscopic decompression. Methods: It was a retrospective, descriptive review of all adult patients, admitted in the visceral surgery department of Hospital Principal of Dakar for SV, from January 2014 to August 2018. We studied demographics variables, clinical and paraclinical features, treatment and outcome. The data were entered and analyzed using Excel 2017 software and Epi-info version 7.2.2.6. Results: We collected 103 cases of SV for 86 patients, representing 45.9% of intestinal obstruction. The mean age was 54.9 years. There were 82 males and 4 females. The mean duration of symptoms was 3.8 days. The triad acute abdominal pain, inability to pass gas and feces, abdominal meteorism was noted in 52.4%. Plain abdominal X-ray (n=55; 53.3%) showed the classical 'coffee bean' sign in 69%. CT scan (n=77; 74.7%) confirmed the diagnosis in 100%. It revealed signs of intestinal gangrene in 8 cases confirmed at laparotomy in 6 cases. In 4 cases imaging was not performed. Detorsion was spontaneous in 2 cases. Faucher rectal tube decompression was performed in 81 cases with a success rate of 86.4% representing 53 patients. Elective sigmoidectomy was realized in 33 patients (31 after successful rectal tube decompression, 2 after spontaneous decompression). After elective sigmoidectomy mortality and morbidity were nil. In those with successful rectal tube decompression, 7 did not have elective sigmoidectomy for comorbidities, 12 refused the elective sigmoidectomy. Emergency surgery was performed in 34 patients: 20 patients for suspicious of complicated SV, 14 patients after failure of rectal tube decompression. It was 9 (26.4%) one stage sigmoidectomy, 24 (70.5%) 2 stage sigmoidectomy, 1 surgical detorsion without pexy. Mortality and mortality after emergency surgery were respectively 8.3% and 14.7%. After 2 stage sigmoidectomy, 86.3% benefited from a restoration of digestive continuity. During the follow-up, no recurrence occurred in patients who were operated. Conclusion: SV is a middle-age man pathology in sub Saharan Africa. In uncomplicated SV rectal tube decompression followed by elective sigmoidectomy is a good option.
... It can also illustrate associated complications, such as bowel ischemia and perforation. In addition, it could characterize the type of volvulus, the degree of rotation and exclude other etiologies of bowel obstruction, informations which are important in the choice of the adequate treatment [8,10,20,21] . In Africa, abdominal CT is rarely used owing to its nonavailability and high cost [4,11,12,14,16] . ...
... Abdomino-pelvic CT scan (CT) with or without contrast injection is an important examination. It allows not only positive, etiological diagnoses but also that of severities [8]. ...
... Actuellement, le scanner a supplanté cet examen en ayant l"avantage, non seulement de faire le diagnostic positif de VCS ou de rechercher les signes d"ischémie, mais aussi d"analyser le type de volvulus et son degré de rotation conditionnant ainsi la décision thérapeutique. En effet, de nombreux auteurs ont rapporté l"intérêt de la TDM et en font l"examen de référence devant un syndrome occlusif [13]. L"association VCS-grossesse fait que le diagnostic de volvulus est presque toujours méconnu et ne se fait qu"au stade de complications. ...
Resumé : Le volvulus du colon sigmoïde (VCS) réalise une occlusion intestinale et constitue une urgence médico-chirurgicale. L‟objectif de ce travail était de rapporter les résultats de la prise en charge du volvulus du colon sigmoïde au CHR de Maradi à travers une étude rétrospective, descriptive, de Janvier 2013 à Avril 2016. Trente patients ont été opérés pour VCS soit 2,06% des urgences chirurgicales digestives (n= 1451) et 14,70% (n=204) des occlusions intestinales. Il s‟agissait de 28 hommes (93,33%) et 2 femmes (6,67%) soit un sex ration de 14. Les 2 cas chez les femmes étaient associés à une grossesse.
L‟âge moyen était de 51±11,75 ans. L‟état général était bon dans 53,33% et mauvais dans 46,67% des cas. L‟anse volvulée était nécrosée dans 56,66% (n=17) des cas. Les gestes réalisés étaient une colectomie idéale dans 53,33% des cas (n=16) et une sigmoïdectomie suivie d‟une colostomie selon Hartmann dans 46,67% des cas (n=14). Les suites opératoires étaient simples dans 73,33% des cas (n=22). La mortalité post-opératoire était de 13,33% (n=4). La durée moyenne de séjour hospitalier était de 8,3±1,5 jours. Le VCS n‟est pas rare et sa prise en charge dépend de l‟état général du patient et de l‟anse volvulée.
Mots-clés : volvulus, sigmoïde, Hartmann, colectomie, Maradi.
... Au niveau du côlon, le volvulus est généralement spontané par rotation d'une anse sigmoïdienne longue. Sur les deux types de volvulus du sigmoïde décrits, un seul réalise une anse fermé [9] (Fig. 8) : ...
Une occlusion est dite à anse fermée lorsqu’un segment digestif est occlus en deux points contigus. Le diagnostic repose sur la présence de zones de transition multiples contiguës. Le segment incarcéré présente une configuration en « U » ou en « C », ou une disposition radiaire vers le site d’obstruction. Il est extrêmement important d’établir le type d’obstruction, car chez les patients avec une obstruction mécanique simple, une approche conservatrice est acceptable. À l’opposé, une occlusion à anse fermée doit bénéficier d’emblée d’une chirurgie en raison d’une morbi-mortalité élevée en cas de retard de prise en charge.
Résumé
Introduction : Le nœud iléo-sigmoïdien est une cause rare d’occlusion intestinale dont le diagnostic est per opératoire suite aux difficultés du diagnostic pré opératoire.
Observation clinique : Il s’agissait d’un patient âgé de 32 ans sans antécédents particuliers admis aux urgences pour une prise en charge d’un syndrome occlusif. Le diagnostic per opératoire du nœud iléosigmoidien a été retenu suite aux ressources diagnostiques limitées.
Conclusion : Devant l’atypie clinico-radiologique, le diagnostic est, dans la majorité des cas, porté en per opératoire. La bonne compréhension du mécanisme et le diagnostic per opératoire permettent de diminuer la morbimortalité par une prise en charge précoce et adéquate.
Mots clés : Nœud , ileosigmoidien ; Occlusion intestinale , Hôpital de Zone de BOKO
Introduction:
Sigmoid volvulus is a potentially devastating and life-threatening condition associated with sigmoid colon redundancy. Many of the classical radiological signs are considered to represent the two adjacent loops of bowel in a mesentero-axial volvulus. However, limited case reports and series have reported on an organo-axial subtype of sigmoid volvulus. This clinical entity is not widely understood. In this study, we assess the radiological and clinical features of mesentero-axial and organo-axial sigmoid volvulus.
Methods:
After institutional board approval (CH62/6/2016-228), all computed tomography (CT) studies from 2011 to 2017 reported as sigmoid volvulus at a single institution were reviewed. The cases were reviewed by three radiologists retrospectively and the course of the bowel followed with a focus on assessing its rotational axis. In each case, the sigmoid volvulus was independently subclassified as mesentero-axial or organo-axial volvulus based on the axis of rotation of the volvulus. In addition, X-ray signs including disproportionate sigmoid dilatation, distended inverted 'U' in sigmoid, coffee bean sign, opposed wall sign, direction of apex of sigmoid loop, liver overlap sign, northern exposure sign and proximal colonic dilatation and CT features including whirl sign, 'X' marks the spot sign, split wall sign and number of transition points were reported for each case. The clinical management and outcomes including morbidity, mortality, endoscopic decompression and need for surgery were also evaluated. The subtype of volvulus was correlated with the above X-ray signs, CT features and clinical management and outcomes. Statistical analysis was conducted using Stata/MP, version 15 (StataCorp LP, College Station, TX, USA).
Results:
A total of 38 scans were reviewed. There were 19 patients identified. Of these, six (32%) were reported as mesentero-axial and 13 (68%) as organo-axial volvulus. No X-ray signs were able to distinguish the two types of volvulus. The number of transition points on CT was predictive of volvulus subtype (OR 25, 95% CI: 1.30-1295.30, P = 0.01). Within the limitations of a small cohort, there was no statistically significant difference in unsuccessful endoscopic decompression, need for colectomy, repeated admissions or mortality between the groups.
Conclusion:
This study has demonstrated that organo-axial sigmoid volvulus may be as common as mesentero-axial volvulus. Distinguishing organo-axial from mesentero-axial volvulus can be achieved on CT, but not on abdominal X-ray. The number of transition points (two for mesentero-axial and one for organo-axial) may be used as a diagnostic feature for differentiating the two forms of volvulus.
The CT semiology of acute abdomen is extremely rich and is based on the analysis of the organs of the abdominal cavity. Defined criteria, such as the morphological aspect of organs, spontaneous attenuation of the tissues, enhancement of parenchyma after intravenous contrast material injection, and location of the organs within the abdominal cavity, are the basis of this analysis. It is also very important to look for some key CT findings which correspond to acute modifications of the normal feature and are often specific. Thus, a meticulous analysis of the CT scans and good knowledge of these key CT findings may allow accurate CT diagnosis in acute abdomen.
Closed loop obstruction occurs when a segment of bowel is incarcerated at two contiguous points. The diagnosis is based on multiple transitional zones. The incarcerated loops appear in U or C form or present a radial layout around the location of the obstruction. It's very important to specify the type of obstruction because, in patients with simple bowel obstruction, a conservative approach is often advised. On the other hand, a closed loop obstruction immediately requires a surgical approach because of its high morbidity and the risk of death in case of a late diagnosis.
Acute sigmoid volvulus is a well recognised cause of acute large bowel obstruction.
We reviewed our unit's experience with non-operative and operative management of this condition. A total of 27 patients were treated for acute sigmoid volvulus between 1996 and 2006. In total, there were 62 separate hospital admissions.
Eleven patients were managed with colonoscopic decompression alone. The overall mortality rate for non-operative management was 36.4% (4 of 11 patients). Fifteen patients had operative management (five semi-elective following decompression, 10 emergency). There was no mortality in the semi-elective cohort and one in the emergency surgery group. The overall mortality for surgery was 6% (1 of 15). Five of the seven patients managed with colonoscopic decompression alone who survived were subsequently re-admitted with sigmoid volvulus (a 71.4% recurrence rate). The six deaths in our overall series each occurred in patients with established gangrene of the bowel. With early surgical intervention before the onset of gangrene, however, good outcomes may be achieved, even in patients apparently unsuitable for elective surgery. Eight of the 15 operatively managed patients were considered to be ASA (American Society of Anesthesiologists) grade 4. There was no postoperative mortality in this group.
Given the high rate of recurrence of sigmoid volvulus after initial successful non-operative management and the attendant risks of mortality from gangrenous bowel developing with a subsequent volvulus, it is our contention that all patients should be considered for definitive surgery after initial colonoscopic decompression, irrespective of the ASA score.
Between 1960 and 1980, 137 patients with colonic volvulus (52% cecal, 3% transverse colon, 2% splenic flexure, and 43% sigmoid) were seen at the Mayo Clinic. Among the 59 patients with sigmoid volvulus, four (7%) had colonic infarction. Total mortality with sigmoid volvulus was seven per cent. There were 71 patients with cecal volvulus. Colonoscopic decompression was accomplished in two of these patients; in 15 (21%), gangrenous colon developed and mortality was 33%. Total mortality for cecal volvulus patients was 17%. Mortality for all forms of volvulus in patients with viable colons was 11%. Mortality for all patients with volvulus was 14%.
To evaluate different types of treatment for sigmoid volvulus and clarify the role of endoscopic intervention versus surgery.
A retrospective review of the clinical presentation and imaging characteristics of 33 sigmoid volvulus patients was presented, as well as their diagnosis and treatment, in combination with a literature review.
In 26 patients endoscopic detorsion was achieved after the first attempt and one patient died because of uncontrollable sepsis despite prompt operative treatment. Seven patients had unsuccessful endoscopic derotation and were operated on. On two patients with gangrenous sigmoid, Hartmann's procedure was performed. In five patients with viable colon, a sigmoid resection and primary anastomosis was carried out. Three patients had a lavage "on table" prior to anastomosis, while in the remaining 2 patients a diverting stoma was performed according to the procedure of the first author. Ten patients were operated on during their first hospital stay (3 to 8 d after the deflation). All patients had viable colon; 7 patients had a sigmoid resection and primary anastomosis, 2 patients had sigmoidopexy and one patient underwent a near-total colectomy. Two patients (sigmoidectomy-sigmoidopexy) had recurrences of volvulus 43 and 28 mo after the initial surgery. Among 15 patients who were discharged from the hospital after non-operative deflation, 3 patients were lost to follow-up. Of the remaining 12 patients, 5 had a recurrence of volvulus at a time in between 23 d and 14 mo. All the five patients had been operated on and in four a gangrenous sigmoid was found. Three patients died during the 30 d postoperative course. The remaining seven patients were admitted to our department for elective surgery. In these patients, 2 subtotal colectomies, 3 sigmoid resections and 2 sigmoidopexies were carried out. One patient with subtotal colectomy died. Taken together of the results, it is evident that after 17 elective operations we had only one death (5.9%), whereas after 15 emergency operations 6 patients died, which means a mortality rate of 40%.
Although sigmoid volvulus causing intestinal obstruction is frequently successfully encountered by endoscopic decompression, however, the principal therapy of this condition is surgery. Only occasionally in patients with advanced age, lack of bowel symptoms and multiple co-morbidities might surgical repair not be considered.
Little is known about sigmoid volvulus in the Middle East despite textbooks referring to the region as part of the "volvulus belt." Our objectives were to assess the prevalence, clinical presentations, radiological findings, operative treatments, and postoperative outcomes of patients managed for sigmoid volvulus in Jordan as a model for the region. The medical records of patients with large bowel obstruction who were managed at King Abdullah University Hospital and its affiliated institutes, northern Jordan, over a 6-year period between January 2001 and January 2007 were retrospectively reviewed to identify patients with a confirmed diagnosis of sigmoid volvulus. Sigmoid volvulus was responsible for 9.2% of all cases of large bowel obstruction seen during the study period. There were 32 patients with sigmoid volvulus, 24 (75%) of whom were men. The median age of the patients was 59 years (range 21-83 years). Abdominal pain and distention were the main presentations. Colonoscopic detorsion was applied in 25 patients, which was achieved in 17 (68%) of them after the first attempt. Six patients had a gangrenous sigmoid colon, four of which required resection and a Hartmann procedure. Sigmoid resection with primary anastomosis was performed in 28 patients, including 2 with a gangrenous colon. Postoperative complications were observed in five patients, including one patient with viable colon who develop an anastomotic leak. Two patients died, making the mortality rate 6%. Sigmoid volvulus is uncommon in Jordan. Resection of the sigmoid colon with primary anastomosis appears to be the preferred procedure.
The variable incidence of sigmoid volvulus, which depends on the presence of an elongated sigmoid colon, suggests the possibility of variations in the length of the sigmoid colon. This study was undertaken among the three major population groups to prove this hypothesis.
Radiological films of patients of the three population groups (African, Indian and White) undergoing barium enema were reviewed. The stature was measured by the distance from T12 to L4. The collective length of the rectum and sigmoid colon as well as the entire colon was measured on the barium enema film using an opisometer. Measurement was from the upper border of the symphysis pubis to the upper border of the left iliac crest. The level of the apex of the sigmoid colon loop and its redundancy were also assessed.
There were 109 patients (61 females) undergoing barium enema (39 Africans, 49 Indians, and 21 Whites). For the entire group the T12-L4 distance was 16.6 +/- 2.2 cm and the entire colon length was 133 cm (range 88-262 cm) and was significantly longer among African patients (P = 0.003). The combined length of the rectum and sigmoid colon was 48.8 +/- 15.7 cm (Africans 60.9 +/- 14.4 cm, Indians 41.3 +/- 12.2 cm and Whites 44 +/- 11.6 cm). The sigmoid colon was significantly more redundant in Africans (90%), compared to Indians (25%) and Whites (24%) (P = 0.003 for Indians and P = 0.048 for whites). The apex of the sigmoid colon reached L1-L3 in 54% among Africans, 6% among Indians and in 10% among Whites (10%).
African patients had the longest combined length of the rectum and sigmoid colon translating into a long sigmoid colon. They also had the highest number of redundant sigmoid colon. This may explain the high incidence of sigmoid volvulus in African patients.
AIM: To evaluate different types of treatment for sigmoid volvulus and clarify the role of endoscopic intervention versus surgery.
METHODS: A retrospective review of the clinical presentation and imaging characteristics of 33 sigmoid volvulus patients was presented, as well as their diagnosis and treatment, in combination with a literature review.
RESULTS: In 26 patients endoscopic detorsion was achieved after the first attempt and one patient died because of uncontrollable sepsis despite prompt operative treatment. Seven patients had unsuccessful endoscopic derotation and were operated on. On two patients with gangrenous sigmoid, Hartmann’s procedure was performed. In five patients with viable colon, a sigmoid resection and primary anastomosis was carried out. Three patients had a lavage “on table” prior to anastomosis, while in the remaining 2 patients a diverting stoma was performed according to the procedure of the first author. Ten patients were operated on during their first hospital stay (3 to 8 d after the deflation). All patients had viable colon; 7 patients had a sigmoid resection and primary anastomosis, 2 patients had sigmoidopexy and one patient underwent a near-total colectomy. Two patients (sigmoidectomy-sigmoidopexy) had recurrences of volvulus 43 and 28 mo after the initial surgery. Among 15 patients who were discharged from the hospital after non-operative deflation, 3 patients were lost to follow-up. Of the remaining 12 patients, 5 had a recurrence of volvulus at a time in between 23 d and 14 mo. All the five patients had been operated on and in four a gangrenous sigmoid was found. Three patients died during the 30 d postoperative course. The remaining seven patients were admitted to our department for elective surgery. In these patients, 2 subtotal colectomies, 3 sigmoid resections and 2 sigmoidopexies were carried out. One patient with subtotal colectomy died. Taken together of the results, it is evident that after 17 elective operations we had only one death (5.9%), whereas after 15 emergency operations 6 patients died, which means a mortality rate of 40%.
CONCLUSION: Although sigmoid volvulus causing intestinal obstruction is frequently successfully encountered by endoscopic decompression, however, the principal therapy of this condition is surgery. Only occasionally in patients with advanced age, lack of bowel symptoms and multiple co-morbidities might surgical repair not be considered.
In the acute obstructive syndrome, beyond the evaluation of the morphologic findings of the intestine (e.g. dilation, air-fluid level, whirl sign, transition point), it is important to consider the pathophysiology of the bowel wall in order to better estimate the status of viability, the degree of the obstruction and the presence of the intestinal ischemic complications or infarction: the intestine is a dynamic system and the same pathological condition can appear in different forms, depending on the stage of disease. MDCT examination could be of help in differentiating various type and degree of disease of the intestinal ischemia correlated to obstruction.
A 59 year old man presented with subacute abdominal distension and diarrhea. Plain radiographs and barium enema demonstrated organo-axial volvulus of the sigmoid colon. The radiologic, surgical, and pathologic findings are presented. The radiologic differences between organo-axial volvulus and the common mesentero-axial volvulus of the sigmoid colon are discussed.
Colonic volvulus accounts for 1-7% of cases of large bowel obstruction in the United States and Western Europe. It is, however, a much commoner condition in parts of Africa, South Asia and South America. Volvulus is thought to be an idiopathic condition, probably with an anatomical basis, particularly in cecal volvulus. Some cases are, however, secondary to a known condition such as Chagas' disease. The sigmoid colon is involved in 65-80% of cases and the right colon in 15-30%. Transverse colon and splenic flexure volvulus are rare. Emergency surgery has in the past been associated with a high mortality. Nonoperative, tube decompression of sigmoid volvulus has been the single most important advance in the management of the condition--this has allowed surgery to be deferred to an elective schedule and performed on a fitter patient with a prepared bowel. Emergency surgery is still required for a minority of patients--those in whom tube decompression is unsuccessful; in those with signs of gangrenous bowel and patients with volvulus proximal to the sigmoid. When the bowel is not viable, resection is mandatory. In patients with a viable colon, there are several options. Sigmoid resection and colostomy for sigmoid volvulus and detorsion, cecopexy and tube cecostomy as a combined procedure for cecal volvulus are the usually recommended procedures.
The authors report of 34 cases of sigmoid colon volvulus occurring in young subjects (15%) and in elderly subjects (60% over the age of 75 years). The diagnosis is frequently suggested by the clinical features and the history (30% of patients have a history of a previous identical episode) and is confirmed by a plain abdominal x-ray and/or an opaque enema. Endoscopy is performed in every case, except in the presence of peritoneal signs, in an attempt to perform detorsion and colonic intubation under direct vision in order to avoid emergency surgery; this procedure is effective in 87% of cases. Emergency surgery has a high mortality rate (43.5%). Elective or deferred emergency surgery after preparation is much safer (6.6% mortality). In patients with multiple diseases, non-surgical conservative management after detorsion too frequently results in repeated complications, leading to decompensation of the concurrent illnesses and a mortality rate of 34%. Endoscopic detorsion followed by surgical resection after a short 3 to 4 day preparation seems to be the best guarantee of therapeutic success.
Sigmoid volvulus is not a common disease in the United States. Thus, a good understanding of this disease can be obtained only by compiling the experiences of many physicians. The purpose of this paper has been to review the reported clinical experience with sigmoid volvulus throughout the world with sigmoid volvulus. This has revealed two clinical patterns of presentation. In Asia, Eastern Europe, and much of Africa and Brazil, sigmoid volvulus is a common cause of intestinal obstruction, frequently occurring in middle-aged men living in rural areas. In English-speaking countries, it is a rare cause of intestinal obstruction. In these countries the patient with sigmoid volvulus is typically old, male, black and institutionalized. The pathogenesis of sigmoid volvulus has been attributed to many etiologies. A single mechanism combining two features probably provides the basis for these theories. A narrow mesocolon at its parietal attachment produces an excellent pivot point for a redundant sigmoid colon, predisposing the individual to sigmoid volvulus. Whether in Africans eating coarse fiber diets, in Brazilians with Chagas' disease, or institutionalized Americans, the combination of a narrow mesosigmoid parietal attachment and redundant colon is nearly always found in patients in whom sigmoid volvulus develops.
Between 1970 and 1980, 12 patients were admitted 16 times to San Bernardino County Medical Center for sigmoid volvulus. The seven men and five women averaged 68.5 years old. Sixty-seven per cent recounted histories of neuropsychiatric disorders. Fifty per cent had been institutionalized. Forty-two per cent had endured previous episodes of sigmoid volvulus. Fourteen of 24 nonoperative attempts at reduction were successful but were followed by nine recurrences. Ten of 12 patients eventually underwent surgery. Eight procedures were electively scheduled following spontaneous or nonoperative reductions. Two emergency procedures for gangrenous colons were required. Both of these patients died. Mortality following elective surgery was 25 per cent. Twenty-nine major complications followed the ten procedures. All ten patients underwent sigmoid resections. Follow-up disclosed only two living patients. Only five had survived one year following initial hospitalization and only two for two years. The high mortality of this and other American series was attributed to the frail nature of the elderly, debilitated, institutionalized patients with neuropsychiatric and multiple medical disorders, who develop sigmoid volvulus in the United States. [Key words: Volvulus, sigmoid, Sigmoid, surgical treatment].
Cecal volvulus is a rare, but potentially fatal, cause of intestinal obstruction. As computed tomographic (CT) scanning is often the initial diagnostic test in patients with acute abdominal pain, we reiterate the importance of the "whirl sign" in diagnosing intestinal volvulus. We report the first description of the CT diagnosis of cecal volvulus.
Dilatation of the rectum and/or colon, in the absence of demonstrable organic disease, is an uncommon and poorly characterised condition.
To characterise the clinical and diagnostic features, and response to treatment, of patients with idiopathic megarectum (IMR) and idiopathic megacolon (IMC).
A retrospective review was undertaken of all patients operated on for these conditions over a 23 year period. In addition all patients treated over a three year period were prospectively studied by means of a questionnaire, contrast studies of the upper and lower intestine, spine x rays to exclude spinal dysraphism, anorectal physiological studies, and assessment of clinical outcome. Patients with Hirschsprung's disease and other known causes of gut dilatation were excluded.
(i) Retrospective study: Of 63 operated patients, 22 had IMR, 23 had IMR and IMC, and 18 had IMC only. Five patients with IMC had previous sigmoid volvulus, and three had associated non-gastrointestinal congenital abnormalities. Faecal incontinence was always associated with rectal impaction and 14 patients (82%) with IMR alone had had manual disimpaction. (ii) Prospective study: Twenty two patients had IMR, with a median rectal diameter of 10 cm (normal < 6.5 cm). Six patients had IMC and one patient had IMR and IMC. Patients with IMR were significantly (p = 0.0007) younger than patients with IMC. All patients with IMR became symptomatic in childhood, compared with half the patients with IMC who developed symptoms as adults. Patients with IMR all presented with soiling and impaction, compared with patients with IMC whose symptoms were variable and included constipation or increased bowel frequency, pain, and variable need for laxatives. No upper gut dilatation was seen in either group of patients. Spinal dysraphism was seen in two of 18 patients with IMR and two of four with IMC, suggesting extrinsic denervation as a possible cause in a minority. Twelve of 22 patients with IMR had a maximum anal resting pressure below normal, indicating sphincter damage or inhibition. Both IMR and IMC patients had altered rectal sensitivity to distension, suggesting that despite lack of dilatation the rectum in IMC has altered viscoelasticity, tone, or sensory function. Fifteen of 22 patients with IMR were successfully managed with laxatives or enemas, but seven required surgery. Two of seven patients with IMC required surgery, including one for sigmoid volvulus.
Patients with IMR differ clinically, diagnostically, and in their outcome from patients with IMC. These conditions demand specific investigation, and intensive treatment, to achieve optimum care.
To determine whether computed tomography (CT) can satisfactorily diagnose and evaluate patients with suspected colonic obstruction.
Seventy-five patients with suspected colonic obstruction were evaluated prospectively by CT and compared with the gold standards of surgery and/or endoscopy in 65 patients, clinical course in nine, and contrast enema (CE) in one. A limited comparison between CT and CE (26) patients was also made in those patients who had both studies.
CT successfully diagnosed colonic obstruction in 45 of 47 patients (96% sensitivity). Pseudo-obstruction was correctly diagnosed in 26 of 28 patients (93% specificity). CT correctly localized the point of obstruction in 44 of 47 patients (94%). CE successfully diagnosed obstruction in only 20 of 25 patients (80% sensitivity).
In this study, CT proved to be a satisfactory modality in evaluating patients with suspected colonic obstruction. CT may in certain circumstances be preferable to the traditional CE in evaluating these patients.
This study was a retrospective review of a series of patients with sigmoid volvulus to identify risk factors for recurrence and recommend appropriate treatment.
Thirty-five patients with sigmoid volvulus were treated over 8 years.
Six patients had emergency surgery for peritonitis. Twenty-eight of the other 29 patients had successful endoscopic decompression; 15 of these patients had elective surgery during the same admission. Twelve of the 14 patients who refused operation after endoscopic decompression developed recurrent volvulus, a median of 2.8 months later. Eight subsequently agreed to surgery and underwent elective operation following repeat decompression. Of 29 patients who had surgery, 27 had sigmoid colectomy (two were initial Hartmann procedures) and two had subtotal colectomy. Six patients who had sigmoid colectomy developed recurrent volvulus. Concomitant megacolon and megarectum at the time of initial surgery were significant predictors of recurrence.
Subtotal colectomy, carried out as the primary procedure if there is concomitant megacolon or megarectum, might reduce the risk of recurrent sigmoid volvulus.
Previous studies of sigmoid volvulus have focused on the migration and dilatation of the sigmoid with respect to both fixed and mobile landmarks in the abdomen. None has specifically referred to the relationship of this colonic segment to the more proximal large intestine. We analyzed findings on abdominal radiographs, all of which had been obtained with the patient supine, of sigmoid volvulus, with particular attention to the juxtaposition of the sigmoid colon with the transverse colon.
The abdominal radiographs of 30 patients with clinically confirmed sigmoid volvulus were obtained from the teaching files of four hospitals and were retrospectively reviewed. These radiographs were compared with abdominal radiographs of 28 individuals, each of whom had a dilated colon but not sigmoid volvulus. All radiographs had been obtained with the patient in the supine position.
The transverse colon was identified in 26 of the 30 patients with sigmoid volvulus. In each of these 26 patients, the sigmoid colon was cephalad to the transverse colon. Of the patients in the control group, the transverse colon was identified in 24 of the 28 patients. In none of these control group patients did the sigmoid colon extend rostral to the transverse colon. Thus, this sign had a sensitivity of 86% and a specificity of 100%.
A dilated sigmoid colon that ascends cephalad to the transverse colon is a newly described and accurate finding of sigmoid volvulus on abdominal radiographs obtained with the patient supine.
Sigmoid volvulus is the third leading cause of large-bowel obstruction. The optimal management strategy remains controversial. This study was undertaken to evaluate the care of patients with sigmoid volvulus recently treated at Department of Veterans Affairs hospitals.
All patients with the International Classification of Diseases, Ninth Revision, Clinical Modification, Third Edition code for colonic volvulus during the period 1991 to 1995 were identified in the computerized national Department of Veterans Affairs database. Data on patient demographics, clinical course, and outcomes were analyzed.
Two hundred twenty-eight patients had volvulus of the sigmoid colon and sufficient clinical data for evaluation. The mean age was 70; all were males. Endoscopic decompression was attempted in 189 of 228 (83 percent) patients and was successful in 154 of 189 (81 percent). Management included celiotomy in 178 of 228 (78 percent) patients. There were no intraoperative deaths. Twenty-five of 178 (14 percent) patients died within 30 days of surgery. The mortality rate was 24 percent for emergency operations (19/79), and 6 percent for elective procedures (6/99). Mortality was correlated with emergent surgery (P < 0.01) and necrotic colon (P < 0.05). Among those 50 patients managed by decompression alone, six (12 percent) died during the index admission. Ten of the remaining 44 (23 percent) patients eventually developed recurrent volvulus requiring further treatment, and 2 of 10 (20 percent) patients died.
In this cohort sigmoid volvulus often presents as a surgical emergency. Initial endoscopic decompression resolves the acute obstruction in the majority of cases. Surgical intervention carries a substantial risk of mortality, particularly in the setting of emergent surgery or in the presence of necrotic colon.
The epidemiology and clinical pattern of sigmoid volvulus are well defined. Although clinical manifestations of acute volvulus are often clear-cut, diagnostic doubt is not uncommon and, if gangrene supervenes, mortality rises appreciably. While gangrene requires resectional surgery, the management of the viable colon related to a volvulus episode has a variety of options. These, particularly non-resectional alternatives, require more critical reappraisal in the light of advances in minimally invasive techniques.
Sigmoid colon is the most frequent site for a volvulus. The condition has been a formidable one, fraught with innumerable complications responsible for many deaths. In this report, we reviewed our experience with sigmoid colon volvulus.
We present our experience of 61 cases of sigmoid volvulus admitted to our department. Twenty-four patients were subjected to non-operative decompression and the others underwent emergency operation.
Intestinal volvulus has quite a high morbidity and mortality. Mortality rate of elective resection following sigmoidoscopy was 7.6%. Mortality rate for emergency surgical detortion, primary resection and Hartman procedure were respectively 13%, 16.6% and 37.5%. Important factors such as the patient's features and frequent late diagnosis can influence the complicated outcome of the disease. Plain X-ray of the abdomen is helpful.
Management with the conservative method of treatment in the form of detortion by sigmoidoscopy and rectal tube application is initially effective in most cases of volvulus of the sigmoid colon. On the other hand, elective or emergency sigmoid resection is the most effective treatment for the disease.
We report a case of sigmoid volvulus. CT findings are presented. The value of CT compared to abdominal plain radiographs and contrast enema is described.
The whirl sign is highly suggestive of intestinal volvulus and should raise suspicion for complicated closed-bowel obstruction.
The value of imaging in patients with suspicion of bowel obstruction is dependent on the ability to answer questions relevant to the clinical management of patients. Is there mechanical obstruction? Is it a small bowel obstruction (SBO) or a large bowel obstruction (LBO)? What is the transition point? What is the cause of the obstruction? What is the severity of the obstruction? The results of studies published more than 10 years ago using axial and single-slice helical CT gave rise to findings based on axial slices that enables CT to answer these different questions. With the recent advent of multislice CT, large numbers of thin sections can be generated with short image intervals, which is well suited to postprocessing. Postprocessing techniques include standard reformatting methods such as sagittal, coronal and oblique reformatting, curved reformatting, maximum and minimum-intensity projection, variable thickness viewing, and volume and surface rendering. This pictorial review illustrates the added value of postprocessing for answering different questions concerning patients with suspicion of bowel obstruction.
Acute abdominal pain is one of the most common causes for referrals to the emergency department. The sudden onset of severe abdominal pain characterising the "acute abdomen" requires rapid and accurate identification of a potentially life-threatening abdominal pathology to provide a timely referral to the appropriate physician. While the physical examination and laboratory investigations are often non-specific, computed tomography (CT) has evolved as the first-line imaging modality in patients with an acute abdomen. Because the new multi-detector CT (MDCT) scanner generations provide increased speed, greater volume coverage and thinner slices, the acceptance of CT for abdominal imaging has increased rapidly. The goal of this article is to discuss the role of MDCT in the diagnostic work-up of acute abdominal pain.
Large bowel obstruction may present as an emergency as high-grade colonic obstruction and can result in perforation. Perforated large bowel obstruction causes faecal peritonitis, which can result in high morbidity and mortality. Multidetector row computed tomography (MDCT) has the potential of providing an accurate diagnosis of large bowel obstruction. The rapid acquisition of images within one breath-hold reduces misregistration artefacts than can occur in critically ill or uncooperative patients. The following is a review of the various causes of large bowel obstruction with emphasis on important pathogenic factors, CT appearances and the use of multiplanar reformatted images in the diagnostic workup.
Large-bowel volvulus is a rare cause of bowel obstruction in the industrialized world. We analyzed the presentation and outcome of 49 patients at the Princess Alexandra Hospital, Brisbane, Australia, who received a diagnosis of colonic volvulus from 1991 to 2001.
A retrospective chart study was carried out.
Twenty-nine patients had sigmoid volvulus (59%), 19 patients had cecal volvulus (39%) and 1 patient had a transverse colon volvulus (2%). The diagnosis of sigmoid volvulus was made accurately on plain abdominal radiography or contrast enema in 90% of cases (n = 26), compared with only 42% of cases (n = 8) of cecal volvulus. Twenty-two patients with sigmoid volvulus were treated initially with endoscopic decompression. The success rate was 64% (n = 14). There was a high early recurrence rate of sigmoid volvulus for those treated by endoscopic decompression alone (43%) during a mean period of 32 days. Of the 14 patients with cecal volvulus who were treated with right hemicolectomy, 12 had primary anastomosis and 2 had end ileostomy with mucous fistula formation. There was no anastomotic leak following right hemicolectomy with primary anastomosis, even though 6 of these patients had an ischemic cecum.
Endoscopic decompression of the sigmoid volvulus was safe and effective as an initial treatment but has a high early recurrence rate. Any patient who is fit enough to undergo operation should have a definitive procedure during the same admission to avoid recurrence. Cecal volvulus is associated with a higher incidence of gangrene and is treated effectively by right hemicolectomy with or without anastomosis. The need for swift operative intervention is emphasized.
Objective:
MDCT is performed as first imaging examination for patients with acute abdomen in most Emergency Departments. Clinical suspicion of ischemic colitis and infarction is related to specific findings, however, differential diagnosis as well as the staging for a confirmed ischemic affection may be critical. The individual signs from ischemia to infarction of large bowel is a captivating topic. In this study, we report our experience of the MDCT assessment of acute colonic disease from vascular mesenteric disorders.
Materials and methods:
We retrospectively reviewed the MDCT findings of 71 patients admitted to our attention for acute abdomen, with final proven diagnosis of colonic ischemia and/or infarction made by surgery and/or endoscopy. CT-scanning of the abdomen and pelvis was performed after i.v. contrast medium administration, using a multidetector row CT equipment. We correlated the presence of parietal disease, the evidence of mesenteric arterial or venous vessels occlusion, the parietal features as well as others findings, such as free fluid and/or air in peritoneal recess or in retroperitoneum, with the surgical and/or endoscopic findings.
Results:
Analysis of our data showed a segmental (84%) or complete (16%) involvement of the colon; 57 cases were related to ischemia, 14 to infarction. Inferior mesenteric vessels defect of opacification was noted in 10 cases. Various degree of wall thickening and parietal enhancement, peritoneal fluid, mural or portal-mesenteric pneumatosis were compared to evidence of mesenteric arterial or vein occlusion and to final proven diagnosis. A classification in a multi-stage grading for both decreased of arterial supply or impaired venous drainage disorders was done.
Conclusions:
A grading scale from ischemia to infarction affecting the large bowel from arterial or venous mesenteric vessels origin has been not previously reported in a series at our knowledge. MDCT findings may support the clinical evaluation of patients affected by acute colon from vascular disorders. In particular, it seems to provide effective and valuable information's in differentiating etiology and stage of disease.
The diseases affecting the large intestine represent a diagnostic problem in adult patients with acute abdomen, especially when clinical symptoms are not specific. The role of the diagnostic imaging is to help clinicians and surgeons in differential diagnosis for an efficient early and prompt therapy to perform. This review article summarizes the imaging spectrum of findings of colonic acute disease, from mechanical obstruction to inflammatory diseases and perforation, offering keys to problem solving in doubtful cases as well as discussing regarding the more indicated imaging method to use in emergency, particularly MDCT.
This study was designed to review the outcomes of emergent treatment of sigmoid colon volvulus.
The records of 827 patients were reviewed retrospectively.
The mean age was 57.9 years (range, 10 weeks to 98 years), and 688 patients (83.2 percent) were male. Nonoperative reduction was applied in 575 patients (barium enema in 13, rigid sigmoidoscopy in 351, and flexible sigmoidoscopy in 211, with rectal tube placement in all patients). The results were as follows: success of 78.1 percent, mortality of 0.9 percent, complication of 3 percent, and early recurrence of 3.3 percent. Surgical treatment was performed on 393 patients (detorsion in 46, mesosigmoidopexy in 56, exteriorization in 4, resection with Hartmann's procedure in 146, resection with Mikulicz procedure in 14, resection with primary anastomosis in 51, tube cecostomy and colonic cleansing with resection in 75, and laparotomy in 1). The results were as follows: mortality of 15.8 percent, complication of 37.2 percent, early recurrence of 0.8 percent, and late recurrence of 6.7 percent.
Nonoperative reduction is the initial treatment of sigmoid colon volvulus, and flexible sigmoidoscopy with rectal tube placement can be used successfully. Patients in whom bowel gangrene or peritonitis is present or nonoperative treatment is unsuccessful need emergency surgery. In surgical treatment, resection and primary anastomosis is the first choice, and it can be performed with acceptable mortality and morbidity rates if the patient is stable and a tension-free anastomosis is possible. Nondefinitive procedures have high recurrence rates; thus, definitive surgical techniques must be preferred.
TDM de l'abdomen aigu de l'adulte
- E Delabrousse
Delabrousse E. TDM de l'abdomen aigu
de l'adulte. Paris: Elsevier; 2004.
Colonic volvulus. Etiology and management
- I T Jones
- V W Fazio
Jones IT, Fazio VW. Colonic volvulus.
Etiology and management. Dig Dis 1989;
7:203-9.
Volvulus du sigmoïde: intérêt et apport de l’étude scanographique
- E Delabrousse
- O Saguet
- N Destrumelle
- X Lucas
- S Brunelle
- B Kastler
TDM de l’abdomen aigu de l’adulte
- E Delabrousse