In adults, SBV is most often secondary to postsurgical adhesions, fibrous bands involving the mesentery, or congenital malrotation of the small bowel [ 4 ]. SBV may lead to ischemic necrosis of the bowel, underscoring the necessity of prompt diagnosis and surgical intervention [ 2 , 4 , 5 , 7 ]. We present a case of a year-old woman whose clinical evaluation did not lead to surgical intervention, resulting in death due to complications of small bowel infarction.
A year-old African-American woman came to the emergency department because of acute lower abdominal pain of four-hours duration. She described the pain as sharp and severe. She was nauseated and had vomited yellow, nonbloody fluid at home. Her past medical history was significant for hypertension and past surgical history included hysterectomy for leiomyomas , unilateral oophorectomy, and appendectomy. Physical exam showed a soft, nondistended, nontender abdomen with no masses or guarding.
Vital signs were temperature The patient was given one liter of normal saline, hydromorphone, promethazine, and ondansetron. She was discharged 4 hours after arrival and told to follow up with her primary care physician and to return to the ED if symptoms worsened. The patient was brought to another emergency department seven hours later with continuing abdominal pain that had begun 15 hours earlier.
Physical exam showed positive rebound tenderness and guarding in the epigastrium. Bowel sounds were present, and the abdomen was not distended. A right upper quadrant ultrasound was performed and interpreted as negative for gallbladder, common bile duct, or pancreatic pathology.
The patient was treated with a liter of normal saline, morphine, and ondansetron. She was discharged four hours after arrival and told to call her doctor for a follow-up appointment. That evening at home, the patient spoke by phone with a relative who felt she was confused and not responding appropriately. The mesentery and necrotic segment were twisted and tethered under a thick band of elastic connective tissue in the posterior upper abdomen Figure 1 b.
Duodenum and jejunum proximal to this segment were dilated. Mesenteric arteries supplying the segment contained no thrombi. The necrotic segment showed diffuse thinning of the muscularis propria and transmural dark purple discoloration Figure 1 c. There were no masses, ulcers, scarring, or perforations. Small intestine distal to the volvulus was normal in color and contained serosanguineous fluid.
Microscopically, the jejunum showed transmural vascular congestion and extensive hemorrhage Figure 2 a. The mucosa was mostly absent, showing only scattered remnants of villi with hypocellular lamina propria and no intact epithelium. Smooth muscle fibers in the muscularis propria were split and fragmented, with strands of myocyte cytoplasm floating in extravasated blood Figure 2 b.
Focally, only a thin layer of muscularis propria remained beneath the serosa Figure 2 c. Volvulus is a special form of mechanical intestinal obstruction. It results from abnormal twisting of a loop of bowel around the axis of its own mesentery [ 5 ].
Volvulus can be primary, without any predisposing anatomic abnormalities and risk factors, or secondary to congenital or acquired lesions [ 2 ]. The mechanism of primary SBV has been correlated with the ingestion of a large amount of fiber-rich foods in a short time. The subsequent forceful small bowel peristalsis is believed to cause primary SBV [ 10 ]. Secondary causes are numerous and include postsurgical adhesions, malrotation, and, as in our case, congenital fibrous bands.
Adhesions are the most common cause in adults; congenital fibrous bands are rare and typically cause symptomatic obstruction in children [ 11 ]. If volvulus is found, the doctor may use the sigmoidoscope to untwist the colon. However, if the colon is twisted tightly or if the blood flow has been cut off, immediate surgery will be needed. Surgery involves restoring the blood supply, if possible, to the affected part of the sigmoid colon.
Sometimes the affected part of the colon must be removed and the healthy ends reattached, a procedure called an intestinal resection. Resection prevents volvulus from recurring; untwisting the volvulus with the sigmoidoscope may not prevent recurrence. Cecal volvulus is twisting of the cecum and ascending colon. Normally, the cecum and ascending colon are fixed to the abdominal wall.
If improperly attached, they can move and become twisted. More commonly seen in people ages 30 to 60, cecal volvulus may be caused by abdominal adhesions, severe coughing, or pregnancy. People with cecal volvulus often have intermittent chronic symptoms—those that come and go over a longer period of time—including. If this happens, the surgeon may have to connect the two ends of the intestines to openings in the abdominal wall known as stomas. If a person requires a stoma, stool will pass through these openings into a colostomy bag.
This may be permanent or temporary. If this happens, a surgeon may remove the appendix, because if it were not in its proper place, a doctor might not be able to diagnose appendicitis in the future.
Removing the appendix prevents this problem. The outlook for volvulus varies and depends largely on the speed of treatment. Early diagnosis and treatment of volvulus can help prevent serious complications. However, in instances where a volvulus has lead to tissue death in the bowel, the prognosis may be poor.
Chronic appendicitis is an infection of the appendix. Though rare, it can become extremely painful and, in some cases, become life-threatening. We look at some possible natural alternatives to laxatives for people looking to have a bowel movement. We also look at when to see a doctor. Septicemia, or sepsis, occurs when an infection reaches the blood. It is a life-threatening emergency, as septic shock can occur without prompt….
When the twisting happens here, it is called sigmoid volvulus. Less frequently, the twisting occurs in the cecum, which is the pouch that connects the small and large intestines and ascending colon.
This is called cecal volvulus. Colon volvulus usually occurs suddenly. The area above the twist continues to work and fills with food, fluid and gas. However, below the twist, blood-starved tissue can die or tear, creating a life-threatening medical emergency. Volvulus is most commonly caused by a birth defect called malrotation, when the bowel becomes misaligned during fetal development.
Colon volvulus is a surgical emergency that requires immediate repair to return normal blood flow. By clicking "Subscribe" you agree to our Terms of Use. We'll be in touch every so often with health tips, patient stories, important resources and other information you need to keep you and your family healthy.
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