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Management of sigmoid volvulus avoiding sigmoid resection.

Katsikogiannis N, Machairiotis N, Zarogoulidis P, Sarika E, Stylianaki A, Zisoglou M, Zervas V, Bareka M, Christofis C, Iordanidis A - Case Rep Gastroenterol (2012)

Bottom Line: When this segment twists on its pedicle, the result can be obstruction, ischemia and perforation.A healthy, 18-year-old Caucasian woman presented to the emergency department complaining of cramping abdominal pain, distention, constipation and obstipation for the last 72 h, accompanied by nausea, vomiting and abdominal tenderness.Although urgent resective surgery seems to be the appropriate treatment for those who present with acute abdominal pain, intestinal perforation or ischemic necrosis of the intestinal mucosa, the first therapeutic choice for clinically stable patients in good general condition is considered, by many institutions, to be endoscopic decompression.

View Article: PubMed Central - PubMed

Affiliation: Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis.

ABSTRACT
Acute sigmoid volvulus is typically caused by an excessively mobile and redundant segment of colon with a stretched mesenteric pedicle. When this segment twists on its pedicle, the result can be obstruction, ischemia and perforation. A healthy, 18-year-old Caucasian woman presented to the emergency department complaining of cramping abdominal pain, distention, constipation and obstipation for the last 72 h, accompanied by nausea, vomiting and abdominal tenderness. The patient had tympanitic percussion tones and no bowel sounds. She was diagnosed with acute sigmoid volvulus. Although urgent resective surgery seems to be the appropriate treatment for those who present with acute abdominal pain, intestinal perforation or ischemic necrosis of the intestinal mucosa, the first therapeutic choice for clinically stable patients in good general condition is considered, by many institutions, to be endoscopic decompression. Controversy exists on the decision of the time, the type of definitive treatment, the strategy and the most appropriate surgical technique, especially for teenagers for whom sigmoid resection can be avoided.

No MeSH data available.


Related in: MedlinePlus

Abdominal CT image showing sigmoid dilatation, indicating the whirl sign (arrow).
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Figure 2: Abdominal CT image showing sigmoid dilatation, indicating the whirl sign (arrow).

Mentions: A healthy, 18-year-old Caucasian woman presented to the emergency department with a 3-day history of abdominal pain, distention, fecal vomiting, obstipation and constipation. Physical examination revealed decreased bowel sounds, abdominal distention with tympanitic percussion and tenderness. The patient was afebrile and hemodynamically stable. Abdominal X-ray showed a markedly distended sigmoid loop with an inverted U shape, also known as ‘coffee bean sign’, consistent with SV (fig. 1). Computed tomography (CT) demonstrated a dilated colon with a transitional zone and swirling of the mesentery (fig. 2). A working diagnosis of SV was established. Laboratory data revealed a WBC count of 13,850/mm3 with left shift (86.9% neutrophils), Ht 37.8%, LDH 394 U/l, CPK 83 U/l, CRP 7.44 mg/dl and metabolic acidosis. The patient underwent flexible nasogastric tube insertion, i.v. fluids (lactated Ringer's), i.v. administration of antibiotics (Metronidazole, Amikacin, Cefoxitin), sodium, and food deprivation. Decompression through colonoscopy was not attempted because of the 3 days of pain history. This kind of history is considered to be an absolute contraindication for decompression through colonoscopy because of the risk of existing ischemic colon necrosis, which could lead to bowel perforation during the colonoscopical detorsion attempt. Considering all the facts mentioned above, the patient was taken to the operating room. The findings were a markedly dilated colon (fig. 3) (including the right colon), a very redundant mesentery of the left and sigmoid colon, and a counterclockwise SV. The volvulus was located at the rectosigmoid. The sigmoid helices were dilated with 9 cm diameter. The bowel appeared viable, there was no evidence of ischemia, and the decision was made to perform reduction of the volvulus, sigmoidopexy and, in addition, appendectomy. Biopsies were not taken because of the bad state of the bowel. The operative time was 128 min. Postoperatively, the patient recovered well (fig. 4) and regained bowel function on postoperative day 4; the drainage tubes were removed on postoperative day 4, and she was discharged home on postoperative day 6.


Management of sigmoid volvulus avoiding sigmoid resection.

Katsikogiannis N, Machairiotis N, Zarogoulidis P, Sarika E, Stylianaki A, Zisoglou M, Zervas V, Bareka M, Christofis C, Iordanidis A - Case Rep Gastroenterol (2012)

Abdominal CT image showing sigmoid dilatation, indicating the whirl sign (arrow).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC3376344&req=5

Figure 2: Abdominal CT image showing sigmoid dilatation, indicating the whirl sign (arrow).
Mentions: A healthy, 18-year-old Caucasian woman presented to the emergency department with a 3-day history of abdominal pain, distention, fecal vomiting, obstipation and constipation. Physical examination revealed decreased bowel sounds, abdominal distention with tympanitic percussion and tenderness. The patient was afebrile and hemodynamically stable. Abdominal X-ray showed a markedly distended sigmoid loop with an inverted U shape, also known as ‘coffee bean sign’, consistent with SV (fig. 1). Computed tomography (CT) demonstrated a dilated colon with a transitional zone and swirling of the mesentery (fig. 2). A working diagnosis of SV was established. Laboratory data revealed a WBC count of 13,850/mm3 with left shift (86.9% neutrophils), Ht 37.8%, LDH 394 U/l, CPK 83 U/l, CRP 7.44 mg/dl and metabolic acidosis. The patient underwent flexible nasogastric tube insertion, i.v. fluids (lactated Ringer's), i.v. administration of antibiotics (Metronidazole, Amikacin, Cefoxitin), sodium, and food deprivation. Decompression through colonoscopy was not attempted because of the 3 days of pain history. This kind of history is considered to be an absolute contraindication for decompression through colonoscopy because of the risk of existing ischemic colon necrosis, which could lead to bowel perforation during the colonoscopical detorsion attempt. Considering all the facts mentioned above, the patient was taken to the operating room. The findings were a markedly dilated colon (fig. 3) (including the right colon), a very redundant mesentery of the left and sigmoid colon, and a counterclockwise SV. The volvulus was located at the rectosigmoid. The sigmoid helices were dilated with 9 cm diameter. The bowel appeared viable, there was no evidence of ischemia, and the decision was made to perform reduction of the volvulus, sigmoidopexy and, in addition, appendectomy. Biopsies were not taken because of the bad state of the bowel. The operative time was 128 min. Postoperatively, the patient recovered well (fig. 4) and regained bowel function on postoperative day 4; the drainage tubes were removed on postoperative day 4, and she was discharged home on postoperative day 6.

Bottom Line: When this segment twists on its pedicle, the result can be obstruction, ischemia and perforation.A healthy, 18-year-old Caucasian woman presented to the emergency department complaining of cramping abdominal pain, distention, constipation and obstipation for the last 72 h, accompanied by nausea, vomiting and abdominal tenderness.Although urgent resective surgery seems to be the appropriate treatment for those who present with acute abdominal pain, intestinal perforation or ischemic necrosis of the intestinal mucosa, the first therapeutic choice for clinically stable patients in good general condition is considered, by many institutions, to be endoscopic decompression.

View Article: PubMed Central - PubMed

Affiliation: Surgery Department (NHS), University General Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis.

ABSTRACT
Acute sigmoid volvulus is typically caused by an excessively mobile and redundant segment of colon with a stretched mesenteric pedicle. When this segment twists on its pedicle, the result can be obstruction, ischemia and perforation. A healthy, 18-year-old Caucasian woman presented to the emergency department complaining of cramping abdominal pain, distention, constipation and obstipation for the last 72 h, accompanied by nausea, vomiting and abdominal tenderness. The patient had tympanitic percussion tones and no bowel sounds. She was diagnosed with acute sigmoid volvulus. Although urgent resective surgery seems to be the appropriate treatment for those who present with acute abdominal pain, intestinal perforation or ischemic necrosis of the intestinal mucosa, the first therapeutic choice for clinically stable patients in good general condition is considered, by many institutions, to be endoscopic decompression. Controversy exists on the decision of the time, the type of definitive treatment, the strategy and the most appropriate surgical technique, especially for teenagers for whom sigmoid resection can be avoided.

No MeSH data available.


Related in: MedlinePlus