Intestinal volvulus in adults and children: aftercare, nutrition

By Cristiano Antonino On Sep 26, 2022

In medicine, ‘volvulus’ refers to a rare and serious condition of surgical interest characterised by the torsion of a tubular viscera or a segment thereof

The torsion occurs on itself and with respect to the portion of the mesentery that supports this tract.

The torsion can quickly lead to intestinal occlusion, intestinal ischaemia, intestinal infarction and death of the patient if normal vascularisation is not quickly restored: such complications therefore require very rapid medical intervention.

Organs affected in volvulus

Volvulus can affect virtually any organ of the body, however it mainly affects the digestive system, in particular the sigma (the part of the intestine located between the descending colon and the rectum) because it is more prone to torsion as it is mobile and sometimes particularly long (dolichosigma) and also the cecum, the intestinal loops, the splenic flexure of the colon and even more rarely the stomach.

Types of volvulus

Depending on the area of onset, various types of volvulus are distinguished:

cecal volvulus: the torsion concerns the first tract of the large intestine, called the ‘cecum’. It is frequent;
sigmoid volvulus: the torsion is located on the section of the large intestine known as the sigma and is the most frequent torsion along with that of the cecum;
ileo-sigmoid volvulus: a tract of the ileum forms a knot around the sigma colon;
gastric volvulus: occurs when the stomach twists in on itself;
splenic fissure volvulus: the twisting involves the curvature of the colon between the transverse and descending colon (rare).

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The majority of infants suffering from volvulus have other congenital defects, such as:

congenital diaphragmatic hernia;
gastroschisis;
omphalocele;
malformations of the anus and/or rectum;
cardiac malformations;
hepatic malformations (of the liver);
splenic malformations (of the spleen).

Volvulus originates from a torsion of the colon on its mesentery

For the torsion to occur, it is generally necessary for the affected segment to be unusually long and/or mobile, or for it to be non-fixed or partially fixed to the posterior wall of the abdomen.

Volvulus results in intestinal obstruction: if the occlusion is not treated, the volvulus progresses proximally and distally due to gas formation in the affected segment.

As a result, the mesenteric vessels that vascularise the segment are also occluded, causing intestinal ischaemia, with necrosis (intestinal infarction) with perforation of the wall, haemorrhage, shock and possible death of the patient.

Diffusion

Volvulus is common in the elderly and has a higher prevalence in inactive women with reduced mental capacity and living in nursing homes.

A predisposing factor is the combination of an unusually large and long colon with inadequate bowel cleansing.

The main cause of volvulus in infants and children is ‘intestinal malrotation’, a congenital defect that develops during foetal life.

Other possible causes, which can also lead to volvulus in adults, are:

Hirschsprung’s disease;
meconium ileus;
Meckel’s diverticulum;
abdominal intestinal adhesions;
previous abdominal surgery;
severe and prolonged constipation;
Parkinson’s disease;
diabetes.

Risk factors for volvulus include:

congenital defects of the intestine (intestinal malrotation);
dolichocolon;
Hirschsprung’s disease;
pregnancy;
abdominal adhesions with intestinal seat from abdominal surgery;
prolonged constipation;
advanced age;
diet too high in dietary fibre.

Symptoms

In caecal volvulus the symptoms are nausea, vomiting and flatulence, while in sigma volvulus the symptoms are mainly abdominal pain and constipation.

Young children obviously cannot easily communicate painful pain in the abdomen.

So how can one tell if a baby or toddler has a volvulus? Babies can ‘make themselves understood’ with two particular behaviours:

inconsolable crying fits;
crouching their legs towards the chest, a position that relieves the pain.

The diagnosis is made with anamnesis, objective examination and radiological investigations.

The clinical picture is characterised by intense pain and signs of peritonitis, taking on the features of an acute abdomen situation requiring urgent laparotomic intervention.

Radiography, ultrasound and abdominal CT scan can confirm the diagnosis.

The barium sulphate enema (or opaque enema) allows volvulus episodes to be detected and analysed in detail.

In the presence of a volvulus case, doctors resort to conservative treatment if the torsion is mild and the symptoms slight.

Surgical treatment is required when the torsion is severe and the risk of intestinal infarction is high.

conservative treatment: consists of decompression of the sigmoid colon through sigmoidoscopy or colonoscopy. If ineffective, surgery is required;
surgical treatment: must be carried out as early as possible to prevent intestinal infarction. If the viscera is viable, a simple derotation is performed with stitches to fix it and prevent recurrence; if the viscera is necrotic, it is removed with immediate anastomotic reconstruction. In the case of caecal torsion, the ‘Ladd procedure’ is applied.

The prognosis depends on the severity of the volvulus, its location, the timeliness of treatment and the patient’s general condition

Generally, the earlier the treatment, the greater the likelihood that the volvulus will resolve successfully.

Patients who arrive at the hospital with a volvulus that has already resulted in an intestinal infarction have a bleak prognosis, with mortality rates between 70% and 90%.

Postoperative course and nutrition

The postoperative course basically depends on the patient’s condition, the type of therapy applied and the portion of the intestine affected and possibly gone into necrosis.

In the case of removal of large parts of the intestine, the hospital stay may be prolonged.

Patients generally return to normal activities within 3-4 weeks, during which time they should avoid exertion and follow the diet recommended by their doctor.

The diet should contain adequate amounts of fruit and vegetables, limiting fatty foods, alcohol and binge eating.

It is important to consume the right amount of dietary fibre: neither too little nor too much.

Tips

You can reduce the risk of intestinal ischaemia and stroke by making a few simple changes to your lifestyle, which help prevent atherosclerosis and other risk factors.

A diet rich in fruit, vegetables and wholegrains and reducing the amount of added sugar, carbohydrates, cholesterol and fat is essential.

It is also recommended to:

do not smoke;
lose weight if obese or overweight;
exercise regularly;
keep your blood pressure under control;
avoid abdominal trauma;
avoid intense exertion;
avoid binge eating;
avoid drugs;
avoid alcohol;
avoid psychophysical stress and anger outbursts.

Volvulus of the sigma

As already mentioned volvulus most commonly occurs in the sigma.

The usual complaints are obstinate constipation, cramps and marked abdominal distension.

The X-ray of the abdomen shows an enlarged and distended colon.

The distention may be limited to the loop of the sigma, but sometimes extends above the liver.

The opaque schism shows the typical bird’s-beak appearance at the torsion.

Usually, a long rectal probe can be passed through a sigmoidoscope (or a choloscope) over the obstruction; this can produce an explosive decompression.

If decompression is incomplete or gangrene is observed, a laparotomy must be performed immediately.

Coloscopy is useful to ascertain the presence of gangrene.

If decompression is successful, resection of the affected colic segment is performed in election during the same admission, unless there are reasons to postpone the operation.

If surgery is not performed, the probability of recurrence is very high.

Volvulus of the cecum

The cecum is another frequent site of volvulus formation.

It causes abdominal cramping, nausea, vomiting, distension and stubborn constipation.

An X-ray of the abdomen shows a large gas bubble in the centre of the abdomen or in the left upper quadrant.

An opaque schism shows the typical bird’s beak appearance in the ascending colon and the absence of reflux in the ileum.

Gangrene occurs rapidly and, therefore, immediate surgical intervention is required.

If there are no signs of gangrene, after reducing the torsion, the cecum can be anchored to the wall using a cecostomy tube.

The alternative for low-risk patients is immediate resection with restoration of intestinal continuity.

When gangrene and perforation with faecal contamination occur in a high-risk patient, resection and creation of an ileostomy or colostomy are necessary.

Bowel continuity will then be re-established at a later date.

If faecal contamination is modest or the cecum remains intact, removal of the cecum can be performed by anastomosing the ileum to the ascending colon or performing a right haemicolectomy.

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