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Sigmoid and Cecal Volvulus Workup

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

Approach Considerations

Laboratory tests include a complete blood count (CBC) with differential and a comprehensive metabolic profile. An elevated white blood cell (WBC) count and left shift indicate bowel ischemia, peritoneal infection, or systemic sepsis. Bowel obstruction may cause significant changes in electrolyte levels.

Other diagnostic studies include plain abdominal radiography, computed tomography (CT), barium enema, and sigmoidoscopy or colonoscopy.

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Plain Abdominal Radiography

Massive dilation of the sigmoid colon loop arising from the pelvis and extending to the diaphragm is a typical finding of sigmoid volvulus. The walls of the loop are evident as three bright lines converging in the pelvis to create a beaklike appearance (see the image below).

Plain abdominal radiograph demonstrating massivelyPlain abdominal radiograph demonstrating massively dilated sigmoid colon loop and convergence of walls of colon into beaklike formation.

Cecal volvulus produces large- and small-bowel obstruction. Radiographic findings reveal a markedly distended loop of bowel extending from the right lower quadrant upward to the left upper quadrant. The small bowel is distended, whereas the distal colon is decompressed (see the image below).

Cecal volvulus with associated small bowel obstrucCecal volvulus with associated small bowel obstruction.

Detailed overviews of the radiologic findings of colonic volvulus are available elsewhere (see Sigmoid Volvulus and Cecal Volvulus).

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CT of Abdomen and Pelvis

CT is not often needed, because the plain radiographic findings typically suffice for diagnosis of sigmoid volvulus. However, the radiographic findings for cecal volvulus may be less diagnostic. In such cases, CT can delineate the exact site of the torsion and reveal evidence of ischemia.

Upward displacement of the appendix with large-bowel obstruction is a definitive sign of cecal volvulus. Additionally, decompressed transverse and descending colon are apparent.

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Barium Enema

A contrast enema should be performed in patients who show no evidence of peritonitis and in whom plain abdominal radiographs are not diagnostic. The contrast study typically demonstrates a beaklike termination at the point of the sigmoid volvulus (see the image below). Similarly, a foldlike termination may be observed at the point of obstruction in the ascending colon in patients with cecal volvulus.

Barium enema of sigmoid volvulus revealing terminaBarium enema of sigmoid volvulus revealing termination of contrast in bird's-beak formation at base of volvulus.
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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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