Which of the following statement about volvulus is False:
Correct Answer: Lower GI scopy is contraindicated in sigmoid volvulus
Description: Ans is 'c'' i.e. Lower GI scopy is contraindicated in sigmoid volvulus Volvulus describes a condition in which there is rotation of a segment of the intestine on an axis formed by its mesentery resulting in paial or complete obstruction of the lumen and may be followed by circulatory impairment of the bowel. Most common site is colon, among which following are involved in descending order - Sigmoid volvulus (- 75%) - Cecal volvulus (< 25%) - Transverse colon - Splenic flexure - Sigmoid volvulus Most common site of volvulus Volvulus can occur in any segment of large bowel that is attached to a long and floppy mesentery that is fixed to the retroperitoneum by a narrow base of origin. The mesenteric anatomy is such that volvulus is most commonly seen in sigmoid colon. Associated predisposing factors are : - age : average age of presentation is 60-70 yrs. - chronic constipation - institutionalized or neurologically impaired or psychiatric patients (their medication may decrease intestinal motility, or they may fail to pass stool regularly, leading to fecal loaded large bowel predisposing to volvulus) - diet high in fibre and vegetables (as in third world countries) Signs and symptoms are those of acute or subacute intestinal obstruction. X-ray picture is dramatic - there is a markedly dilated sigmoid colon with the appearance of a bent inner tube or coffee bean appearance. Inferior convergence of the dilated loop points towards left side of pelvis. - contrast enema demonstrates the point of obstruction with the pathognomic 'birds beak' or 'bird of prey' or 'ace of spades' sign. Management of sigmoid volvulus Unless there are obvious signs of gangrene or peritonitis, the initial management is resuscitation followed by endoscopic decompression and detorsion. Decompression/detorsion can be achieved by placement of rectal tube through a proctoscope or the use of a colonoscope. If detorsion / decompression cannot be achieved with either the rectal tube or colonoscope, laprotomy with resections of the sigmoid colon is done. Even if detorsion of the sigmoid volvulus is successful, risk of recurrence is high (approx. 50%). Hence an effective sigmoid colectomy is indicated after the pt. has stabilized. Any evidence of bowel gangrene or perforation contraindicates non-operative decompression and an immediate surgical exploration is done. Cecal volvulus The condition commonly referred to as cecal volvulus is actually a cecocolic volvulus and consists of an axial rotation of the terminal ileum, cecum and ascending colon. Cecal bascule - is a condition in which the cecum folds in a cephalad direction anteriorly over a fixed ascending colon. This causes intermittent bouts of abdominal pain because the mobile cecum causes intermittent episodes of Isolated cecal obstruction. It is relieved spontaneously as the cecum falls back into its normal position. Cecocolic volvulus is possible because of lack of fixation of the cecum to the retroperitoneum. Associate predisposing factors are: - previous surgery - pregnancy - malrotation - obstructing lesion of the left colon Cecocolic volvulus affects a younger age group (late 50s) than sigmoid volvulus (60s & 70s). X-ray picture - dilated cecum usually occupying the left upper quadrant. - haustral markings can be seen in the distended cecocolic segment and is a distinguishing feature from sigmoid colon in which generally there are no haustra. Management According to Schwaz Surgery - Cecal volvulus, unlike sigmoid volvulus can almost never be detorsed / decompressed endoscopically. As vascular compromise occurs early in the course of cecal volvulus, surgical exploration is necessary when the diagnosis is made. Right hemicolectomy is the procedure of choice. Sabiston surgery writes that - 'Although there have been repos of detorsion of cecocolic volvulus with a colonoscope most cases require operation to correct the volvulus and prevent ischemia." An aicle published in the journal 'Diseases of Colon and Rectum' - The management of Cecal Volvulus writes"Non-operative decompression of cecal volvulus is rarely achievable"
Category:
Surgery
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