Volvulus in git

1. VOLVULUS IN GIT

2. GASTRIC VOLVULUS SMALL BOWEL VOLVULUS (MIDGUT MALROTATION) LARGE BOWEL VOLVULUS (CECAL VOLVULUS, SIGMOID VOLVULUS) LARGE AND SMALL BOWEL VOLVULUS ( ILEOSIGMOID KNOT) DIFFERENT TYPES OF VOLVULUS

3. Gastric volvulus is a condition involving the stomach twisting upon itself Classified as one of two types organoaxial or mesenteroaxial A combination of both types may occur in an individual. GASTRIC VOLVULUS

4. Twist occurs along a line connecting the cardia and the pylorus--the luminal ( long ) axis of the stomach. Most common type. Usually associated with diaphragmatic defects. Vascular compromise more common. Organoaxial volvulus

5. Organoaxial volvulus the rotation of the stomach along its long axis

6. Twist occurs around a plane perpendicular to the luminal (long) axis of the stomach from lesser to greater curvature. Chronic symptoms are more common. Diaphragmatic defects are less common. Mesenteroaxial volvulus

7. Mesenteroaxial volvulus the stomach twisting along its short axis

8. Abnormality of suspensory ligaments of stomach. Congenital defects of their diaphragm (Hiatal hernia). Weak Muscles (MND). Tumors of stomach. CAUSES OF GASTRIC VOLVULUS

9. Those with defects of the diaphragm commonly suffer with the common type ( organoaxial volvulus), and it is the most serious form, needing urgent surgical intervention. The mesenteroaxial type does not often lead to compromise of blood supply to the stomach speedily, and may run a chronic course.

10. Unless acute, patients are frequently asymptomatic. When acute and obstructing Abdominal pain Attempts to vomit without results Inability to pass an NG tube Together, these three findings comprise the Borchardt triad which is diagnostic of acute volvulus . Clinical findings

11. In mesenteroaxial volvulus, distended stomach appears spherical on supine images. Two air-fluid levels visible on upright film: in fundus and in antrum . U pright image often demonstrates a beak where the esophagogastric junction is seen on normal images. Radiography

12. If a nasogastric tube is passed, the esophagogastric junction is seen inferior to its normal location. If barium moves past the esophagogastric junction, the upside-down configuration of the stomach and the degree of obstruction can be documented.

13. X-RAY shows gastric volvulus as a air-filled sac behind the heart shadow on a chest x-ray, described as a retro-cardiac air bubble, or fluid filled sac. X-ray of the abdomen may show part of the stomach that may still be in the abdomen, massively distended.

14. BARIUM MEAL show narrowing or absence of barium in the part of the stomach where the obstruction is.

15. The computed tomography (CT) scanning and magnetic resonance imaging (MRI) appearance of gastric volvulus can be variable. The extent of diaphragmatic herniation, the points of torsion, and the final position of the stomach determine the appearance Computed Tomography

16. peanut sign- in a case of chronic gastric volvulus. The ultrasonographic features consist of a constricted segment of stomach, with 2 dilated segments located above and below the constricted part, akin to a peanut. ULTRASONOGRAPHY

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18. Gastric ischemia Gastric emphysema Twisting of stomach may tear spleen from its normal attachments Perforation is rare Complications

19. Torsion of the entire gut around superior mesenteric artery (SMA) due to a short mesenteric attachment of small intestine in malrotation . Malrotation with a midgut volvulus

20. AGE Usually neonate or young infant Occasionally older child and adult ASSOCIATED WITH (IN 20%) Duodenal atresia Duodenal diaphragm Duodenal stenosis Annular pancreas

21. Degree of twisting is variable and determines symptomatology Severe volvulus (twist of 3 ½ turns) result in bowel necrosis Acute symptoms in newborn (medical emergency ) Bile-stained vomiting Intermittent , Postprandial, Projectile Abdominal distension Shock Pathophysiology

22. Dilated , air-filled duodenal bulb and paucity of gas distally "Double bubble sign" = air-fluid levels in stomach & duodenum Isolated collection of gas-containing bowel loops distal to obstructed duodenum = gas-filled volvulus = closed-loop obstruction From non resorption of intestinal gas secondary to obstruction of mesenteric veins Plain film Findings

23. "Corkscrew" duodenum in malrotation with a midgut volvulus   " Corkscrew" duodenum in malrotation with a midgut volvulus

24. CT findings Whirl-like pattern of small bowel loops and adjacent mesenteric fat converging to the point of torsion (during volvulus) SMV to the left of SMA (NO volvulus) Chylous mesenteric cyst (from interference with lymphatic drainage)

25. Clockwise whirlpool sign = color Doppler depiction of mesenteric vessels moving clockwise with caudal movement of transducer Distended proximal duodenum with arrowhead-type compression over spine Superior mesenteric vein to the left of SMA Thick-walled bowel loops below duodenum and to the right of spine associated with peritoneal fluid US findings

26. "Barber pole sign" = spiraling of SMA Tapering / abrupt termination of mesenteric vessels Marked vasoconstriction and prolonged contrast transit time Absent venous opacification / dilated tortuous superior mesenteric vein Angio fIndings

27. Intestinal ischemia and necrosis in distribution of SMA (bloody diarrhea, ileus, abdominal distension ) DD: Pyloric stenosis (same age group, no bilious vomiting) Complications

28. Twisting of loop of intestine around its mesenteric attachment site may occur at various sites in the GI tract Most commonly: sigmoid & cecum Rarely : stomach, small intestine, transverse colon Results in partial or complete obstruction May also compromise bowel circulation resulting in ischemia Large bowel volvulus

29. Sigmoid volvulus most common form of GI tract volvulus Accounts for up to 8% of all intestinal obstructions Most common in elderly persons (often neurologically impaired) Patients almost always have a history of chronic constipation Sigmoid volvulus

30. Redundant sigmoid colon that has a narrow mesenteric attachment to posterior abdominal wall allows close approximation of 2 limbs of sigmoid colon à twisting of sigmoid colon around mesenteric axis Other predisposing factors Chronic constipation High-roughage diet (may cause a long, redundant sigmoid colon) Roundworm infestation Megacolon (often due to Chagas ) Pathophysiology

31. 20-25 % mortality rate Peak age > 50 years Torsion usually counterclockwise ranging from 180 – 540 degrees Luminal obstruction generally @ 180 degrees Venous occlusion generally @ 360 degrees à gangrene & perforation

32. Diagnosis Abdominal plain films usually diagnostic Inverted U-shaped appearance of distended sigmoid loop Largest and most dilated loops of bowel are seen with volvulus Loss of haustra Coffee-bean sign à midline crease corresponding to mesenteric root in a greatly distended sigmoid Sigmoid volvulus – bowel loop points to RUQ

33. torsion of the caecum around its own mesentery which often results in obstruction It accounts for 11% of all intestinal volvulus can result in bowel perforation and faecal peritonitis CECAL VOLVULUS

34. Clinical presentation Caecal volvulus presents with clinical features of proximal large bowel obstruction. This is usually with colicky abdominal pain, vomiting and abdominal distension.

35. Bowel loop points to LUQ Dilated cecum comes to rest in left upper quadrant Bird’s-beak or bird-of-prey sign à seen on barium enema as it encounters the volvulated loop CT scan useful in assessing mural wall ischemia

36. large , dilated loop of large bowel with an inverted U-shape with walls between two volvulated loops pointing from LLQ toward RUQ ; same patient with decompressed sigmoid volvulus following insertion of rectal tube

37. Differential Diagnosis Large bowel obstruction due to other causes à sigmoid colon CA Giant sigmoid diverticulum Pseudoobstruction Complications Colonic ischemia Perforation Sepsis

38. Ba contrast enema contrast-filled rectum illustrates the " bird's beak " sign (white arrow), corresponding to the luminal narrowing at the site of sigmoid obstruction. This is the characteristic presentation of a sigmoid volvulus

39. 20 year old woman presented to the ED with 12 hours of abdominal pain, nausea. and vomiting low grade fever. No past surgical history PMH: Polycystic ovarian disease Case

40. Frontal scout Dilated cecum

41. CT Axial with IV and rectal contrast Cecum

42. CT Coronal reconstructions Contrast In Descending colon Cecum

43. Barium Enema Point of Obstruction Ascending colon

44. THANKS