Sigmoid volvulus is the most common form of volvulus of the gastrointestinal tract. Its prevalence among patients who present with acute intestinal obstruction varies geographically, ranging from fewer than 10% in the US to as high as 80% of cases from the Bolivian and Peruvian Andes. Sigmoid volvulus, if complicated carries high risk of mortality and/or morbidity, hence low threshold and early detection is required.[1,2,3]
The true incidence of sigmoid volvulus in Saudi Arabia, and its presentation as acute intestinal obstruction has not been studied, and has not been published in Saudi national journals. We share our experience of patients with sigmoid volvulus presenting with acute intestinal obstruction at King Fahad Medical City due to the fact its rarity to occur in young adulthood and few reported cases in the gulf areas.
A 22 year old patient presented to emergency room (ER) complaining of abdominal pain associated with distension and non projectile vomiting for three days. The pain was intermittent, localized mainly in the lower abdomen with no radiation. On examination, his abdomen was distended and tender in the lower quadrants. His vitals were stable.
A 25 year old patient arrived to ER with sudden abdominal pain. On examination, his vitals were stable, and abdomen was distended with the absence of guarding and rigidity. He had a familiar episode 2 years ago, and at that time he underwent colonoscopy and his symptoms were relieved.
Both patients were diagnosed of sigmoid volvulus based upon clinical presentation and radiological findings (Figure 1,2). They did not have signs of peritonitis, nor perforation. Both underwent colonoscopic decompression to reduce the sigmoid volvulus. Later, they were offered sigmoid colectomy to prevent recurrence but both refused.
Sigmoid volvulus is common in elderly persons, in individuals with neurologic conditions, and in patients in nursing homes or mental health facilities. The reasons why sigmoid volvulus is more common with advancing age are not well-understood. Lengthening of the sigmoid colon and its mesentery is not a feature of normal ageing. One possible explanation is colonic dysmotility, which could predispose to torsion of the sigmoid colon. In a report of 40 patients from England, the average age was 72 years.
In children, sigmoid volvulus can be the initial presenting feature of Hirschsprung’s disease. The majority of patients with sigmoid volvulus present with abdominal pain, nausea, abdominal distension, and constipation; vomiting is less common. However, some patients (particularly younger patients) may have a more insidious presentation with recurrent attacks of abdominal pain, with resolution presumably due to spontaneous distortion. The diagnosis is often suspected based upon the clinical presentation and physical examination. The pain associated with sigmoid volvulus is usually continuous and severe, with a superimposed colicky component occurring during peristalsis. The abdomen is usually distended and tympanitic.
A plain film of the abdomen can establish the diagnosis in approximately 60 percent of patients. The distended sigmoid colon appears as an ahaustral collection of gas that extends from the pelvis to the right upper quadrant as high as the diaphragm. Distended large bowel proximal to the sigmoid and air-fluid levels in the small bowel are often present. A barium enema using water-soluble contrast may be helpful in certain cases.
The diagnosis can also be made by CT scan. Typical findings include a whirl pattern, caused by the dilated sigmoid colon around its mesocolon and vessels, and a bird-beak appearance of the afferent and efferent colonic segments. Many endoscopists choose to leave a rectal tube in place with its proximal end beyond the area of twisting. However, a rectal tube may lessen colonic distension and reduce the chance of recurrent volvulus in the acute setting. Sigmoidoscopy is used to detorse the volvulus, which can be accomplished by advancing a flexible or rigid sigmoidoscope through the twisted segment. Reduction of the sigmoid volvulus using this technique has been successful in 85 to 95 percent of cases in some series.[6,8] The major problem is recurrence in up to 60 percent of patients.[7,9] The time to recurrence can vary from hours to weeks; as a result, definitive treatment soon after sigmoidoscopic reduction is advised. Although surgical resection without decompression has been used at some centers with acceptable outcomes, most favor preoperative decompression whenever feasible. The surgical approaches to prevent recurrent volvulus include mesosigmoidopexy and resection with primary anastomosis or a Hartmann’s procedure.[1,9,10]
In these two cases, both patients were young adults with no predisposing factors. The precise incidence of sigmoid volvulus in Saudi populations, and the risk factors for its development in relatively younger patients needs to be studied.
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