Ver el código de «Volvulus»

==Backgound==
*Twisting of loop of bowel causing bowel obstruction and (if severe) ischemia, gangrene, perforation 
*Generally affects adults aged 60-70
*Can cause severe thirdspacing, electrolyte abnormality, and abdominal distention 
*Common sites include cecum and sigmoid 
**Cecal volvulus - mobile segment of cecum causing volvulus and cecal folding
**Sigmoid volvulus - redundant sigmoid attached to narrow mesentery twists on itself causing obstruction and further diation 

===Risk Factors<ref>Weerakkody Y et al. Caecal volvulus. http://radiopaedia.org/articles/caecal-volvulus.</ref><ref>Morgan MA et al. Sigmoid volvulus. http://radiopaedia.org/articles/sigmoid-volvulus</ref>===
*Sigmoid volvulus
**More common in elderly as opposed to cecal volvulus
**High fiber diet 
**Chronic constipation
**Chagas disease
**Patients of long term care facilities/psychiatric institutions
*Cecal volvulus
**Most between 30-60 years of age
**Prior abdominal surgery
**Pelvic mass, 3rd trimester pregnancy
**Cecal mobility cause by congenital abnormality with cecal mesentery failing to fuse with posterior abdominal wall
*Gastric volvulus
**Most common between 40-50 years of age
**Paraesophageal hernias

==Clinical Features==
*Sigmoid/Cecal volvulus 
**Triad: Abdominal pain, distention, constipation 
**Vomiting only occurs late as obstruction is rather distal. If so, may be faeculant in nature and indicates long-standing obstruction. 
**Vary from subtle to dramatic presentations 
**Physical Exam: 
***Distended, tympanitic abdomen (mostly upper abdomen and unilateral) 
***Severe abdominal tenderness, peritonitis, fever, shock highly suggestive for gangrenous bowel
*Gastric volvulus (Borchardt's triad)
**Abdominal and/or chest pain
**Retching, vomiting
**Inability to pass NGT

==Differential Diagnosis==
*Large bowel obstruction 
*Colorectal cancer 
*[[Diverticulitis]] 
*Strictures 
*Fecal impaction

{{Abdominal Pain DDX Diffuse}}
{{Constipation DDX}}

==Evaluation==
*Lactic acid
*CBC, CMP, UA
*Sigmoid Volvulus 
**Abdominal Series X-rays 
***May not be diagnostic 
***Grossly distended loop of colon (no haustral markings) either on R/L side.
***Coffee-bean sign
***"Bent inner tube" sign 
***Free air on upright chest/lateral decubitus if perforation
**Contrast enema 
***Bird's beak sign-contrast fills colon up to point of torsion
**Sigmoidoscopy (both diagnostic and therapeutic)
**CT
*Cecal Volvulus 
**Abdominal Series X-rays 
***Not definitive in many cases 
***Dilated cecum with air fluid level 
***Distended small bowel 
***Distal colon with paucity of gas 
***"Coffee bean sign"-Large oval gas shadow with line down middle in middle of abdomen 
***Free air on upright chest/lateral decubitus if perforation
**Contrast enema 
***Helpful to differentiate between sigmoid/cecal volvulus
**Ultrasound 
***Not particularly helpful
**CT 
***Mesocolon "whirl sign"- twisted mesentery
**Many only definitively diagnosed at surgery
*Gastric volvulus
**Upright CXR and abdominal XR
***Intrathoracic, upside-down stomach
***Double air fluid level in stomach
***Collapsed small bowel
**CT
***Gastric herniation around points of torsion
***Ischemia seen a lack of contrast enhancement of gastric wall

==Management==
*Emergent surgery consult
*Fluid resuscitation
*Analgesia
*Antibiotics if perforation or gangrene suspected 
*Sigmoid volvulus may be managed with endoscopic decompression/detorsion (if no signs of gangrenous bowel/perforation)
**Recurrence possible, which would mandate surgical repair
*Cecal volvulus always requires surgical repair with resection (preferred) or cecopexy
*Gastric volvulus
**Endoscopic reduction
**Endoscopy relatively contraindicated in signs of ischemia such as significantly elevated lactate

==Disposition==
*Admit 

==See Also==
*[[Volvulus (Peds)]]

==References==
<references/>

[[Category:GI]]