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Concept: Volvulus

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Midgut malrotation is an anomaly of intestinal rotation that occurs during fetal development and usually presents in the neonatal period. We present a rare case of malrotation in a 14-year-old patient who presented with cramping, generalized right abdominal pain, and vomiting for a duration of one day. A computed tomography abdominal scan and upper gastrointestinal contrast studies showed malrotation of the small bowel without volvulus. Laparoscopy revealed typical Ladd’s bands and a distended flabby third and fourth duodenal portion extrinsically obstructing the misplaced duodeno-jejunal junction. The Ladd procedure, including widening of the mesenteric base and appendectomy, was performed. Symptoms completely resolved in a half-year follow up period. Patients with midgut malrotation may present with vague abdominal pain, intestinal obstruction, or intestinal ischemia. The laparoscopic Ladd procedure is feasible and safe, and it appears to be as effective as the standard open Ladd procedure in the diagnosis and treatment of teenage or adult patients with intestinal malrotation.

Concepts: Abdominal pain, Small intestine, Bowel obstruction, Abdomen, Jejunum, Volvulus, Intestinal malrotation, Ladd's bands

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BACKGROUND: Sigmoid volvulus (SV) is the wrapping of the sigmoid colon around itself and its mesentery. The goal of this study was to investigate the diagnosis approach to 938 patients with SV treated at our institution and their clinical outcomes. METHODS: The clinical records of 938 patients with SV treated at our institution between June 1966 and January 2012 were retrospectively reviewed. RESULTS: The mean age was 58.6 years (range 10 weeks to 98 years), and 774 patients (82.5 %) were male. A total of 210 (25.1 %) of 837 patients, who provided information on anamnesis and clinical features, had recurrent episodes of volvulus; 215 patients (25.7 %) had comorbidities, and 108 patients (12.9 %) presented with toxic or hypovolemic shock. The mean duration of symptoms was 38.7 h (range 6 h to 7 days), and the most common clinical features were abdominal pain and tenderness (827 of 837 patients, 98.8 %), distention (805 patients, 96.2 %), and obstipation (771 patients, 92.1 %). The final diagnosis was made with endoscopy in 519 patients (55.3 %), endoscopy followed by surgery in 154 patients (16.4 %) and at surgery in 265 patients (28.3 %). The correct diagnosis rate was 71.6 % based on clinical findings compared with 66.7 % based on plain X-ray films, 81.4 % based on both clinical and plain X-ray findings, and 100.0 % based on CT or MRI findings. CONCLUSIONS: Sigmoid volvulus is common in adult men. The disease is generally associated with recurrent episodes, comorbidity, and shock. SV generally presents as a large-bowel obstruction. Although plain X-rays may help with diagnosis, CT and MRI are more reliable diagnostic tools, and flexible endoscopy is always diagnostic. However, surgery is used to diagnose SV in limited situations.

Concepts: Medicine, X-ray, Diagnosis, Medical imaging, Abdominal pain, Rectum, Volvulus, Mesentery

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Background/Purpose Malrotation with a common mesentery is the classical pathology allowing midgut volvulus to occur. There are only a few reports of small bowel volvulus without malrotation or other pathology triggering volvulation. We describe three cases of small bowel volvulus in very premature newborns with a perfectly normal intra-abdominal anatomy and focus on the question, what might have set off volvulation.Methods In 2005 to 2008, three patients developed small bowel voluvulus without any underlying pathology. Retrospective patient chart review was performed with special focus on clinical presentation, preoperative management, intraoperative findings, and potential causative explanations. Mean follow-up period was 46 months.Results All patients were born between 27 and 31 weeks (mean 28 weeks) with a birth weight between 800 and 1,000 g (mean 887 g). They presented with an almost identical pattern of symptoms including sudden abdominal distension, abdominal tenderness, erythema of the abdominal wall, high gastric residuals, and radiographic signs of ileus. All of them were treated with intensive abdominal massage or pelvic rotation to improve bowel movement before becoming symptomatic.Conclusions Properistaltic maneuvers including abdominal massage and pelvic rotation may cause what we term a “manufactured” volvulus in very premature newborns. Thus, this practice was stopped.

Concepts: Digestive system, Abdominal pain, Small intestine, Bowel obstruction, Peritoneum, Abdomen, Volvulus, Intestinal malrotation

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INTRODUCTION:: Colonic volvulus is a rare entity associated with high mortality rates. Most studies come from areas of high endemicity and are limited by small numbers. No studies have investigated trends, outcomes, and predictors of mortality at the national level. METHODS:: The Nationwide Inpatient Sample 2002-2010 was retrospectively reviewed for colonic volvulus cases admitted emergently. Patients' demographics, hospital factors, and outcomes of the different procedures were analyzed. The LASSO algorithm for logistic regression was used to build a predictive model for mortality in cases of sigmoid (SV) and cecal volvulus (CV) taking into account preoperative and operative variables. RESULTS:: An estimated 3,351,152 cases of bowel obstruction were admitted in the United States over the study period. Colonic volvulus was found to be the cause in 63,749 cases (1.90%). The incidence of CV increased by 5.53% per year whereas the incidence of SV remained stable. SV was more common in elderly males (aged 70 years), African Americans, and patients with diabetes and neuropsychiatric disorders. In contrast, CV was more common in younger females. Nonsurgical decompression alone was used in 17% of cases. Among cases managed surgically, resective procedures were performed in 89% of cases, whereas operative detorsion with or without fixation procedures remained uncommon. Mortality rates were 9.44% for SV, 6.64% for CV, 17% for synchronous CV and SV, and 18% for transverse colon volvulus. The LASSO algorithm identified bowel gangrene and peritonitis, coagulopathy, age, the use of stoma, and chronic kidney disease as strong predictors of mortality. CONCLUSIONS:: Colonic volvulus is a rare cause of bowel obstruction in the United States and is associated with high mortality rates. CV and SV affect different populations and the incidence of CV is on the rise. The presence of bowel gangrene and coagulopathy strongly predicts mortality, suggesting that prompt diagnosis and management are essential.

Concepts: Chronic kidney disease, Epidemiology, United States, U.S. state, Bowel obstruction, Native Americans in the United States, Volvulus, Population history of American indigenous peoples

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Wilms' tumor (WT) accounts for 90% of all pediatric renal malignant tumors. The most common postoperative complication based on the National Wilms' Tumor Study is small bowel obstruction. We report on a 2-year-old girl with postoperative bowel obstruction following a right nephrectomy for WT. The patient was reintervened 48 hours after surgery and a cecal volvulus was found. Here, we will describe possible causes of this postoperative complication and discuss management.

Concepts: Cancer, Oncology, Tumor, Abdominal pain, Large intestine, Bowel obstruction, Wilms' tumor, Volvulus

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CLINICAL PRESENTATION: A 53-year-old man was admitted with a 2-week history of bowel obstruction on a background of gradually worsening dyspeptic symptoms associated with vomiting and weight loss. He was under regular gastroenterology review for Barrett’s oesophagus and had a recent endoscopic diagnosis of megaduodenum (mainly D1 dilatation) confirmed by barium study (figure 1). He was also known to have bladder emptying problems and an enlarged bladder. His mother died at age 28 due to ‘megacolon’, and he has a monozygotic twin brother with Barrett’s oesophagus.gutjnl;gutjnl-2017-315465v1/F1F1F1Figure 1Barium meal and follow through confirmed dilation of the duodenum with normal small bowel transit.Abdominal X-ray showed marked large bowel dilatation (figure 2) and urgent CT scan of the abdomen and pelvis confirmed sigmoid volvulus (figure 3).gutjnl;gutjnl-2017-315465v1/F2F2F2Figure 2Urgent abdominal X-ray with prominent large bowel dilatation.gutjnl;gutjnl-2017-315465v1/F3F3F3Figure 3Representative axial image from urgent CT scan  of the abdomen and pelvis indicating sigmoid volvulus.Despite two attempts at endoscopic decompression, he eventually underwent Hartmann’s sigmoidectomy. His postoperative recovery was delayed by prolonged ileus requiring nasogastric drainage and parenteral nutritional support. He was discharged on the 19th day postoperatively.

Concepts: Crohn's disease, Abdominal pain, Large intestine, Gastroenterology, Small intestine, Bowel obstruction, Abdomen, Volvulus

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Adhesive closed-loop small bowel obstruction can lead to volvulus and ischemia with risk of necrosis. The vital prognosis and bowel viability are highly dependent on rapid management. The physical examination is often insufficient to establish the diagnosis and computed tomography is ordered. The whirl sign provides the best imaging evidence of volvulus and can be sufficient to establish the indication for surgery.

Concepts: Crohn's disease, Abdominal pain, Medical diagnosis, Constipation, Hernia, Bowel obstruction, Physical examination, Volvulus

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Sigmoid volvulus is a condition with a tendency to recur if treated conservatively. Little is known about the type or when to perform definitive surgery. The aim of this study was to review treatment, and asses the outcome, of sigmoid volvulus in adult patients treated at a Swedish university hospital.

Concepts: Cohort study, Cohort, Hospital, Physician, Volvulus

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Cecal volvulus is a rare clinical entity with an average incidence of 2.8-7.1 per million people per year, accounting for 1-2% of all large bowel obstructions. Cecal bascule is the rarest type of cecal volvulus, accounting for 5-20% of all cases. Although several case reports have been published, there is no consensus regarding its diagnosis and treatment. The aim of this study was to review the literature on cecal bascule in order to summarize the etiopathogenesis, clinical features, diagnosis, and treatment options.

Concepts: Digestive system, Colon, Large intestine, Bowel obstruction, Case, Rare, Volvulus, Cecum

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Intestinal malrotation places pediatric patients at the risk of midgut volvulus, a complication that can lead to ischemic bowel, short gut syndrome, and even death. Even though the treatments for symptomatic patients of this complication are clear, it is still a challenge to identify asymptomatic patients who are at a higher risk of midgut volvulus and decide on a suitable course of treatment. Development of an accurate computerized model of this intestinal abnormality could help in gaining a better understanding of its integral behavior. To aid in developing such a model, in the current study, we have characterized the biaxial mechanical properties of the porcine small bowel mesentery. First, the tissue stress-strain response was determined using a biaxial tensile testing equipment. The stress-strain data were then fitted into a Fung-type phenomenological constitutive model to quantify the tissue material parameters. The stress-strain responses were highly nonlinear, showing more compliance at the lower strains following by a rapid transition into a stiffer response at higher strains. The tissue was anisotropic and showed more stiffness in the radial direction. The data fitted the Fung-type constitutive model with an average R-squared value of 0.93. An averaging scheme was used to produce a set of material parameters which can represent the generic mechanical behavior of the tissue in the models.

Concepts: Abdominal pain, Large intestine, Intestine, Small intestine, Bowel obstruction, Jejunum, Volvulus, Intestinal malrotation