Recurrent volvulus of the transverse colon after sigmoid resection

Abstract

Dear Editor: Volvulus of the large bowel is a relatively rare cause of colonic obstruction in Western countries, with an incidence of up to 6%. Volvulus of the colon is mostly located in the sigmoid (43-80%) and caecum (15-43%). Rarely, a volvulus of the transverse colon or splenic flexure occurs due to fixation of this part of the colon by the phrenicocolic, gastrocolic and splenocolic ligaments.Risk factors for developing large bowel volvulus are congenital anatomical variations such as increased colonic length and abnormal fixation, Chagas disease resulting in megacolon, chronic constipation, distal obstruction such as carcinoma of the sigmoid, previous abdominal surgery and pregnancy. There is a male predominance and a geographical variation, with a higher incidence in African, Asian and Eastern countries.A 39-year-old, mentally disabled man was presented to the emergency department with progressive abdominal distension and pain since day 1. He complained of nausea, vomiting and fever of up to 38.5°C. Time of last bowel movement was unclear. He had a medical history of chronic constipation, epilepsy and hydrocephalus with placement of two ventriculoperitoneal (VP) shunts at a young age. These drains needed revision because of dysfunction a few times thereafter. The patient lives in a sheltered home.During physical examination, a moderately ill man was seen, with an evident enlargement of the skull (circumference 73 cm). His consciousness was clear and there were no signs of meningitis. The abdomen was distended with highpitched bowel sounds and diffuse pain but without signs of peritonitis. Blood analysis showed a C-reactive protein (CRP) of 73 mg/L and a white blood cell count of 11×10 9 per litre. An abdominal X-ray showed a large bowel obstruction and coprostasis. Conservative management during 24 h, consisting of nasogastric tube drainage and enemas, did not result in relief of complaints. A laparotomy was performed, where a significantly distended sigmoid colon was seen (diameter 15 cm) because of rotation around its own mesentery. This had resulted in distension of the proximal part of the colon and small bowel. Adhesiolysis was performed, followed by resection of the sigmoid and reconstruction by end-to-end anastomosis. On day 4 postoperatively, the patient was discharged without any complications.Four years later, at the age of 43 years, the patient was presented again to the emergency department with progressive abdominal pain, nausea and vomiting over a period of several days. His last bowel movement had been a few days ago, despite the use of enemas. At clinical examination, the patient was moderately ill with a temperature of 39°C. There were no signs of meningitis. The abdomen was very much distended, with high-pitched bowel sounds and diffusely localized pain during palpation. Because of the stressed abdominal wall, signs of peritoneal reaction could not be adequately tested. Laboratory testing revealed a CRP of 216 mg/L and a white blood cell count of 20×10 9 per litre. On abdominal X-ray, max...

Spontaneous transverse colon volvulus

“…Among them, transverse colon is involved in 2 to 4% [2, 3] versus 43 to 80% and 15 to 43% respectively for the sigmoid colon and the coecum [3]. A male predominance is noticed [3]. Its pathogenesis is not completely understood yet.…”

“…Physiological causes include high-roughage diet and large bowel distension secondary to chronic constipation. This constipation is associated with psychiatric or neurologic diseases [3]. Mechanical causes include previous volvulus of the transverse or the sigmoid colon, distal colonic obstruction, adhesions, malposition of the colon following previous surgery, mobility of the right colon, inflammatory strictures, and carcinoma [1, 4].…”

“…In fact, detorsion alone or associated with colopexy has a higher rate of recurrence than resection [1, 4]. The incidence of recurrent volvulus after previous resection and primary anastomosis varies between 22% and 36% [3]. Therefore, some authors recommend considering a subtotal colectomy in the presence of a megacolon, instead of partial resection of the involved bowel segment [3].…”

Volvulus of the transverse colon

“…1 It usually occurs in the sigmoid colon and transverse colon volvulus (TCV) is probably the rarest form of colonic volvulus, accounting for less than 11% of all cases of colonic volvulus, but with the highest mortality.…”

“…The most common signs associated with it are abdominal pain, constipation and vomiting; none of which are specific for the condition. 1 Abdominal radiography permits diagnosis in 70% of cases by 3 typical signs: caecum dilatation, a single air-fluid level in the right lower quadrant, and absence of gas in the colon. 2 The CT scan typically shows a massively dilated caecum with associated small bowel dilation.…”