Volvulus

Definitions & Key takeaways

Volvulus is an obstruction caused by a loop of an intestine that rolls or twists around itself and its surrounding tissue. There are three types of volvulus: sigmoid, cecal, and midgut, with sigmoid being the most common. Risk factors include chronic constipation, Hirschsprung disease, and abdominal adhesions. Symptoms range from mild bloating to severe pain and bowel infarction. Diagnosis is usually made through abdominal x-rays or barium enema. Treatment options include sigmoidoscopy, colonoscopy, or surgery depending on the type and severity of the volvulus. Surgery typically involves untwisting the intestine and attaching it to the abdominal wall.

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Introduction0:00–0:40

The term volvulus actually comes from the Latin word volvere, which means “to roll”. So a volvulus is an obstruction caused by a loop of the intestine that rolls or twists around itself and its surrounding mesentery, which is the tissue that attaches the intestine to the back wall of the abdomen.
The three most common types of volvulus are a sigmoid volvulus, which happens in the the last part of the large intestine, leading to the rectum; a cecal volvulus, which happens in the beginning of the large intestine, and a midgut volvulus, which happens in the small intestine.

Sigmoid volvulus0:40–1:32

Now, a sigmoid volvulus is the most common type of volvulus, and it can happen in a variety of settings. One classic one being pregnancy, because the growing fetus can cause displacement and twisting of the colon.
It can also develop, though, in middle-aged and elderly individuals. This can sometimes happen as a result of chronic constipation, where a big load of stool can act like a pivot point around which the rest of the colon can twist.
Hirschsprung disease, a disease of the large intestine that causes severe constipation or intestinal obstruction, therefore raises the risk for developing sigmoid volvulus.
In addition, there are also abdominal adhesions, where internal scar tissue creates a physical attachment between two parts of the abdomen, which again serves as a pivot point around which the colon can twist.

Cecal volvulus1:32–1:59

A cecal volvulus is usually found in young adults, and usually happens in individuals who didn’t develop their abdominal mesentery normally during fetal development.
Since some mesentery contacts may be missing in these individuals, the colon can flop around freely and any large object—like a baby in pregnancy or a load of stool in someone constipated—can act as a pivot point in the cecum and cause the colon to twist.

Midgut volvulus1:59–2:51

Midgut volvulus is most commonly found in babies and small children and is the result of abnormal intestinal development in fetuses.
In normal fetal development, the digestive tract starts as a straight tube from the stomach to the rectum. For a little while, a part of the intestine protrudes from the abdomen into the umbilical cord.
Once the fetus reaches around 10 weeks, though, the intestine pulls back out of the umbilical cord, and returns to the abdominal cavity and makes two turns, so that it is no longer a straight tube.
Malrotation happens when the cecum and appendix, which are normally found in the lower right side of the abdomen, stay in the upper right side.
Babies with malrotation can later develop twisting of the small intestine, which is a midgut volvulus. In any type of volvulus, a portion of the intestines becomes twisted and it pinches the lumen shut and results in bowel obstruction, which prevents the normal passage of digested food and water.

Symptoms and complications2:51–3:35

Sometimes, the mesentery can become so tightly twisted that blood flow to that part of the intestine is cut off, which leads to infarction, or death of the intestinal wall.
This can cause a variety of symptoms ranging from mild bloating and constipation to severe pain and bloody stools. In fact, bowel infarction can also cause the intestinal wall to break down and allow the bacteria in the gut to move into the body, which causes sepsis and the potential for cardiovascular collapse.

Diagnosis3:35–3:59

Abdominal x-rays are usually used to diagnose volvulus. These x-rays show the shape of the volvulus, which can look like a bent inner tube or a coffee bean.
A barium enema can also be used to show a bird’s beak shape, enlarged at one end and tapered at the other end, which is the point where the bowel is twisted.

Treatment3:59–5:07

A sigmoid volvulus is usually treated with sigmoidoscopy, an examination of the sigmoid colon using a set of flexible tubes inserted through the anus.
If the tissues look normal and pink, the tubes untwist and decompress the colon to relieve pressure. A similar procedure that goes a bit further in, called a colonoscopy, examines the entire colon and can occasionally be used to resolve a cecal volvulus.
But a midgut volvulus can’t be treated with colonoscopy, since it’s even further back in the small intestine. Normally surgery is recommended within two days of receiving treatment, or, in some cases, surgery should be performed immediately, like if the bowel is severely twisted or if the blood supply is cut off.
The normal surgical procedure involves untwisting the intestine, if it hasn’t been corrected yet, and attaching the intestine up against the abdominal wall to prevent it from twisting in the future.
In severe cases, such as infarction, pieces of the intestine have to be removed, a process called bowel resection, before the intestine is reattached.

Review5:07–5:49

Aright, as a quick recap: a volvulus is a twist in the intestine and surrounding mesentery, and it’s most commonly found in the sigmoid of middle-aged and older adults, the cecum of young adults, and the midgut, or small intestine, of babies.
Volvulus results in bowel obstruction and can sometimes cause infarction, or death, of the bowel tissues. Volvulus is diagnosed using x-rays and is usually treated with surgery to remove part of the bowel and attach the bowel up against the intestinal wall.
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