Sigmoid volvulus/ Generalised abdominal pain

SIGMOID VOLVULUS- GENERALISED ABDOMINAL PAIN
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• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Sigmoid Volvulus- a didactic lecture.
• It is one of the life-threatening surgical problems you see in surgical wards.
• I have discussed the various causes for Generalised Abdominal Pain, epidemiology, etiology, pathology, clinical features, investigations, and treatment of Sigmoid volvulus.
• I have also included a mind map, diagnostic algorithm and a treatment algorithm for Sigmoid Volvulus.
• I hope the video will be very useful and you will enjoy it.
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• Thank you for watching the video.

1. SIGMOID VOLVULUS GENERALISED ABDOMINAL PAIN AN OVRVIEW Dr.B.Selvaraj MS;Mch;FICS ; “Surgical Educator” Malaysia

2. SIGMOID VOLVULUS Different causes for generalized abdominal pain Epidemiology Etiology- Risk Factors Pathology Clinical features- Symptoms & Signs Differential diagnosis Investigations Treatment Mindmap Diagnostic Algorithm Treatment Algorithm

3. SIGMOID VOLVULUS D/D for Generalised Abdominal Pain

4. SIGMOID VOLVULUS Epidemiology Volvulus occurs when a segment of colon undergoes twisting along its own mesentery ( mesenterio -axial) resulting in obstruction. Twisting of 180 degrees results in clinical obstruction, and further twisting to 360 degrees causes strangulation with venous gangrene, ischemia, and eventual perforation. It is a closed loop obstruction Common in elderly and those who are taking neuro-psychiatric drugs Sigmoid volvulus accounts for 5% of large bowel obstruction in developed countries. and 10% to 50% in developing countries This is because of intake of high-fibre diet in these countries Patients are often institutionalized and debilitated due to underlying neurologic or psychiatric disease and have a history of constipation

5. SIGMOID VOLVULUS ETIOLOGY-Risk Factors Higher incidence in developing countries (attributed to high fiber diets) Seen mostly in elderly, institutionalized male with chronic neuropsychiatric conditions Long pelvic mesocolon Narrow attachment of pelvic meso-colon Overloaded pelvic colon- constipation A loop of bowel fixed at its apex by adhesions.

6. SIGMOID VOLVULUS PATHOLOGY The loop of sigmoid colon usually undergoes twisting in an anticlockwise direction from one half to three turns. As the volvulized segment enlarges, it becomes trapped in the confines of the abdominal wall and is unable to spontaneously detorse .

7. SIGMOID VOLVULUS Clinical Features- Symptoms & Signs SYMPTOMS Abdominal pain (initially left-sided, later diffuse) Enormous abdominal distension (left iliac fossa and then whole of abdomen) Obstipation Hiccough, retching Vomiting- late feature SIGNS Tympanic abdomen Tyre-like consistency of abdomen is diagnostic Empty rectal vault (on digital rectal exam) Just distension of abdomen without tenderness Viable bowel Generalised tenderness with rebound tenderness Gangrenous bowel Rigid abdomen Bowel perforation

8. SIGMOID VOLVULUS Clinical Features- Symptoms & Signs

9. SIGMOID VOLVULUS DIFFERENTIAL DIAGNOSIS Colorectal carcinoma causing obstruction Toxic megacolon Colorectal strictures Hirschsprung's disease Caecal volvulus Paralytic ileus Ileosigmoid knotting Ogilvie's disease (colonic pseudo-obstruction)- Dysfunction of Sacral para-sympathetic nerves Acquired megacolon Giant colonic diverticulum

10. SIGMOID VOLVULUS INVESTIGATIONS Blood tests : FBC, Serum Electrolytes RFT: Blood urea&Creatinine AXR- Erect is diagnostic - Coffee-bean appearance - Bent-inner tube sign -Omega sign - Frimann -Dhal sign

11. SIGMOID VOLVULUS INVESTIGATIONS Barium Enema: - Bird’s beak appearance - Ace of spade sign Upper end of Barium column tapers into spirally-twisted distal sigmoid colon

12. SIGMOID VOLVULUS INVESTIGATIONS CT Abdomen: - whirl sign, which represents tension on the tightly twisted mesocolon by the afferent and efferent limbs of the dilated colon.

13. SIGMOID VOLVULUS TREATMENT Indication: Young patients without signs of Ischemia Rigid/Flexible Sigmoidoscopy- negotiate obstruction and decompress proximal bowel Risk of recurrence >50% To prevent recurrence -Percutaneous endoscopic sigmoidopexy (Non- resectional ) - Mesosigmoidoplasty -Sigmoid colectomy( Resectional ) Indication: Old patients with signs of Ischemia Exploratory laparotomy If bowel is viable - Sigmoidopexy / Sigmoidectomy If bowel non-viable - Paul- Mickulicz double barrel colostomy - Hartman’s procedure Never do primary anastomosis in an emergency scenario for fear of anastomotic leakage CONSERVATIVE OPERATIVE RESUSCITATION - I.V.Fluids -Antibiotics -Bladder Catheterisation

14. SIGMOID VOLVULUS TREATMENT Paul- Mickulicz Double barrel Colostomy Hartman’s temporary End-Colostomy

15. SIGMOID VOLVULUS MINDMAP

16. SIGMOID VOLVULUS DIAGNOSTIC ALGORITHM

17. SIGMOID VOLVULS TREATMENT ALGORITHM

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