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Sigmoid and Cecal Volvulus Differential Diagnoses

  • Author: Scott C Thornton, MD; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Nov 30, 2015
 
 

Diagnostic Considerations

The differential diagnosis of colonic volvulus includes a rare condition known as an ileosigmoid knot. An ileosigmoid knot occurs when the ileum and sigmoid colon become entangled, creating a knot that results in vascular compromise of the bowel. The patient presents with acute onset of abdominal pain and rapidly developing shock. Ileosigmoid knot is a life-threatening condition that requires urgent surgical treatment.

 
 
Contributor Information and Disclosures
Author

Scott C Thornton, MD Associate Clinical Professor of Surgery, Yale University School of Medicine; Director, Colorectal Teaching, Bridgeport Hospital; Private Practice, Park Avenue Surgical Associates

Scott C Thornton, MD is a member of the following medical societies: American Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Neelu Pal, MD General Surgeon

Neelu Pal, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Acknowledgements

Brian James Daley, MD, MBA, FACS, FCCP, CNSC Professor, Associate Program Director, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association

Disclosure: Nothing to disclose.

David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: RFA Medical None Director; MRC Biotec None Director

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Lianos G, Ignatiadou E, Lianou E, Anastasiadi Z, Fatouros M. Simultaneous volvulus of the transverse and sigmoid colon: case report. G Chir. 2012 Oct. 33(10):324-6. [Medline].

  2. Elsharif M, Basu I, Phillips D. A case of triple volvulus. Ann R Coll Surg Engl. 2012 Mar. 94(2):e62-4. [Medline].

  3. DRAPANAS T, STEWART JD. Acute sigmoid volvulus. Concepts in surgical treatment. Am J Surg. 1961 Jan. 101:70-7. [Medline].

  4. HENDRICK JW. TREATMENT OF VOLVULUS OF THE CECUM AND RIGHT COLON. A REPORT OF SIX ACUTE AND THIRTEEN RECURRENT CASES. Arch Surg. 1964 Mar. 88:364-73. [Medline].

  5. Vaez-Zadeh K, Dutz W, Nowrooz-Zadeh M. Volvulus of the small intestine in adults: a study of predisposing factors. Ann Surg. 1969 Feb. 169(2):265-71. [Medline]. [Full Text].

  6. Halabi WJ, Jafari MD, Kang CY, Nguyen VQ, Carmichael JC, Mills S, et al. Colonic volvulus in the United States: trends, outcomes, and predictors of mortality. Ann Surg. 2014 Feb. 259(2):293-301. [Medline].

  7. Grossmann EM, Longo WE, Stratton MD, Virgo KS, Johnson FE. Sigmoid volvulus in Department of Veterans Affairs Medical Centers. Dis Colon Rectum. 2000 Mar. 43(3):414-8. [Medline].

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Sigmoid volvulus. (A) Counterclockwise torsion at base of mesentery. (B) Adhesions at base of sigmoid mesocolon leading to formation of fixed omega loop that is susceptible to repeat torsion.
Cecal volvulus. (A) Clockwise torsion of mesentery of cecum, ascending colon, and terminal ileum. (B) Absence of dorsal mesenteric attachments of cecum and proximal ascending colon, leading to lack of fixation to retroperitoneum.
Cecal bascule. (A) Anterior folding of cecum. (B) Lack of dorsal mesenteric fixation of cecum to retroperitoneum.
Plain abdominal radiograph demonstrating massively dilated sigmoid colon loop and convergence of walls of colon into beaklike formation.
CT scan of abdomen demonstrating massive dilation of sigmoid colon and normal caliber of proximal bowel.
Barium enema of sigmoid volvulus revealing termination of contrast in bird's-beak formation at base of volvulus.
Cecal volvulus with associated small bowel obstruction.
Extent of resection required for sigmoid volvulus is limited to resection of omega loop of sigmoid volvulus and resection of sigmoid mesentery.
Divided descending colon and rectum are reanastomosed in hand-sewn manner or with GI stapling device.
Hartmann procedure for sigmoid volvulus.
Extent of resection for cecal volvulus is similar to that in right hemicolectomy for benign disease.
Terminal ileum is anastomosed to transverse colon in reconstruction after right hemicolectomy.
Algorithm for treatment of patients with sigmoid and cecal volvulus.
Variable degrees of attachment of ascending colon to abdominal wall by reflection of overlying parietal peritoneum. (A) Normal attachment. (B) Reflection of peritoneum to create paracolic gutter. (C) Mobile colon with reflection of peritoneum to create colonic mesentery.
Jackson veil over ascending colon contains numerous small blood vessels from renal and lumbar arteries.
Average measurements of sigmoid mesocolon.
Arterial blood supply to colon.
Cecal volvulus with ischemic changes of distended cecum and terminal ileum. Remainder of small bowel involved in volvulus appears distended but not ischemic. No obvious peritoneal contamination is observed.
 
 
 
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