A volvulus is when a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction that can compromise intestinal blood flow. For this reason, it tends to be a surgical emergency which requires prompt attention; failure to recognize the signs and symptoms of intestinal volvulus may lead to bowel ischemia and perforation. A volvulus can develop anywhere along the intestine, however for this blog we will discuss types of Colonic Volvulus.

 

The most common forms of volvulus in the gastrointestinal tract are sigmoid and cecal volvulus, both colonic volvulus. Sigmoid volvulus is responsible for 80% of intestinal obstructions.

Volvulus can occur anywhere in the large and small GI tract. This is caused by a bowel twist around an anchor position, which may be the mesentery. Think about how the loose skin hangs lower with weight loss. We see the mesentery fat thinning, which causes the bowel to twist around it. A very high degree of suspicion is needed to make the diagnosis.

High-fiber diets and chronic constipation are common risk factors because they cause increased gas and sigmoid colon elongation. Worldwide, the incidence of men is much higher than in women, which may be explained by the mesenteric shape, which tends to be longer and has a narrower base. In weight loss surgical patients specifically, such as Duodenal Switch, increased gas and diarrhea are shared in patients with carbohydrate and fiber-rich diets. In some cases, they are recommended to have a high fiber diet by other providers who may not be aware that this may only complicate the problem and exacerbate the symptoms. The solution would not include adding fiber but eliminating the underlying food items causing the increased gas and diarrhea.

The presentation of volvulus is much the same, regardless of its anatomic site; Cramping abdominal pain, distention and constipation are present. With progressive obstruction, nausea and vomiting will occur.

A definitive diagnosis is made with a CT scan, and the treatment is generally a bowel resection. However, in the case of a sigmoid volvulus, an urgent endoscopic detorsion may be attempted first, only if there are no signs of ischemia. The risk of recurrence following endoscopic detorsion alone is as high as 90% and carries a high risk of mortality up to 35%, therefore definitive elective sigmoid resection is recommended. 

Here is a short video of an operation.

We want to thank Miguel Rosado, MD, for his significant contributions provided in this Blog.

We are all aware of the arterial and venous systems. Arteries take the oxygenated blood from the heart to the organs and the veins take the blood back to the lungs to unload the carbon dioxide and reload oxygen to be taken back to the organs. In addition to the arterial and venous vascular systems, we also have the lymphatic channels that flow into the lymphatic system.

The Lymphatic channels and system may be new to some, however, it is the third vascular network that is much less defined. The Lymphatic system collects fluids that has left the artierial/venous vascular system along their travel outlined above and take it back to the venous system. The lymphatic vessels transport this fluid to the lymph nodes throughout the body where the nodes filter the fluid of bacteria and harmful substances. Eventually, the fluid makes it way back to the venous system via the Superior Vena Cava. Additionally, Lymphatics collect the lipids within the GI tract and transport them to the venous system for metabolism. Most of the time these serosal lymphatic vessels are very small and hard to notice on the bowel.

Example of Lymphatic channels

The following image is in a patient who had small bowel obstruction. The obstruction had resulted in vascular congestion at the base of the mesentery. The congestion had effected the low pressure system of the veins and the lymphatics disproportionately more that the arterial system. The white-milky tubular structures are the lymphatic channels filled with lipids.

There are three layers to the small intestinal lymphatic system, in the villi, submucosal and serosal layers and has the unique ability to transport absorbed intra-lumenal nutrients. There is a need for further research in the areas of health, obesity and disease in regards to the lymphatic system.