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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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Ehlers-Danlos syndrome, hypermobility type (EDS-HT) is unexpectedly common and is associated with a high rate of gastrointestinal manifestations. We herein report the first documented case of mobile cecum associated with EDS-HT. A 21-year-old woman with repeated right lower abdominal pain was initially diagnosed with EDS-HT. Abdominal examinations performed in the supine position, such as CT and ultrasonography, showed no gross abnormalities. In contrast, oral barium gastrointestinal transit X-ray images obtained with changes in the patient’s body position revealed position-dependent cecal volvulus with mobile cecum. She was finally discharged with a dramatic resolution of her symptoms after laparoscopic cecopexy for mobile cecum.

Concepts: Medical imaging, Abdominal pain, Syndromes, Bowel obstruction, Marfan syndrome, Ehlers-Danlos syndrome, Hypermobility, Volvulus

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Small bowel obstruction secondary to adhesions is a recognized complication of Caesarian section. However, obstruction due to small bowel volvulus caused by adhesions at the Caesarian-section scar has not been reported. We report such a case identified on computed tomography. We review the literature on small bowel volvulus in pregnant patients and discuss the computed tomography findings.

Concepts: Childbirth, Obstetrics, Crohn's disease, Abdominal pain, Constipation, Bowel obstruction, Adhesion, Volvulus

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The aim of this report is to discuss with high-quality images, a case of a caecal volvulus herniating through the foramen of Winslow with signs of perforation.

Concepts: Perforation, Volvulus

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Pediatric colonic volvulus is both rare and underreported. Existing literature consists only of case reports and small series. We present an analysis of cases (n=11) over 15 years at a single institution, focusing on workup and diagnosis.

Concepts: Series, Mathematical analysis, Case, Volvulus

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Small bowel obstruction is a clinical condition commonly caused by postoperative adhesion, volvulus, intussusceptions, and hernia. Small bowel obstruction due to bezoars is clinically uncommon, accounting for approximately 2-4% of all obstructions. Computed tomography (CT) is a useful method in diagnosing the cause of small bowel obstruction. However, small bowel obstruction caused by bezoars may not be detected by an abdominal CT examination. Herein, we report a rare case of small bowel obstruction by Aloe vera bezoars, which were undetected by an abdominal CT. Phytobezoars should be included in the differential diagnosis of small bowel obstruction in patients with predisposing factors, such as excessive consumption of high-fiber food and diabetes.

Concepts: Medical terms, Crohn's disease, Abdominal pain, Constipation, Large intestine, Hernia, Bowel obstruction, Volvulus

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We report a case of a 10-month-old girl who presented with a 10-day history of emesis that became bilious on the last day. The initial evaluation suggested small bowel obstruction. An upper gastrointestinal study confirmed the normal location of the duodenojejunal junction with normal rotation and no evidence of midgut volvulus. Ultrasound (US) evaluation demonstrated two intraluminal lesions that do not follow the typical features of solid or cystic lesions. Two rubber balls were found at surgery to be responsible for the small bowel obstruction. Foreign body ingestion is common in children, but this case demonstrates a unusual foreign object to be ingested as well as the US appearance of this particular foreign body.

Concepts: Digestive system, Crohn's disease, Abdominal pain, Constipation, Gastroenterology, Bowel obstruction, Duodenum, Volvulus