Volvulus is a twisting of the intestine around itself and can occur in childhood. The incidence and prevalence of volvulus is not known due to the fact that many cases of chronic volvulus go undiagnosed. Acute gastric volvulus is fatal in 42% to 56% of cases.
Approximately 20% of cases occur in infants less than 1 year of age and peak incidence is reported to be 40-50 years of age. Volvulus results in a blockage that can restrict blood flow and result in tissue damage. Colonic volvulus is usually classified as sigmoid volvulus or cecal volvulus, each representing about half of the cases of colonic volvulus with 5% being of the transverse colon or splenic flexure.
Volvulus is classified as type 1 (idiopathic) or type 2 (congenital or acquired). Two thirds of cases of volvulus are type 1, and due to laxity of gastric ligaments. Type 1 volvulus is more common in adults but has also been reported in children. Type 2 is found in one third of patients and is usually associated with acquired or congenital abnormalities resulting in abnormal mobility of the stomach.
Congenital abnormalities that may be associated with volvulus include diaphragmatic defects, gastric ligaments, abnormal attachments or adhesions, asplenism, small and large bowel malformations, pyloric stenosis, colonic distension, and rectal atresia.
Certainly, there are volvulus cases that could not have been avoided. But, regrettably, many of these cases could have been avoided if the doctor had simply done what a good doctor would have done. can be avoided. If you or someone you love has been hurt and you suspect negligence was the cause of the injuries or death, call 800-553-8082 or get a free online consultation.
Symptoms of Volvulus
Children with volvulus may experience bloody or deep red stools, constipation, abdominal distension, abdominal pain or tenderness, vomiting green material, nausea and/or shock. Symptoms develop quickly and most are severe requiring immediate medical attention in the emergency room.
Diagnosis usually requires a barium enema, blood tests and evaluation of electrolytes (sodium, potassium and chloride), CT scan, stool guaiac, and examination of the upper gastrointestinal tract. In cecal volvulus, barium enemas result in barium filling the colon distal to cecum. In sigmoid volvulus in adults, barium may form a configuration similar to an "ace of spades" and in children, may twist to a point. Abdominal X-rays and CT scans may show evidence of intestinal obstruction, however in midgut volvulus, abdominal X-rays may appear normal. In midgut volvulus, upper gastrointestinal tract examination may be necessary. Blood work may reveal a white blood cell count greater than 15,000/uL in cases of strangulation, and greater than 20,000/uL in bowel infarction.
Risk Factors for Volvulus
Children with a birth defect known as intestinal malrotation are at risk of developing volvulus, however, volvulus can also occur in children without intestinal malrotation. Volvulus usually occurs within the first year in children with intestinal malrotation. Volvulus does not seem to be associated with race or ethnicity. Sigmoid volvulus is more commonly associated with prolonged constipation, chronic mental illness and old age, whereas cecal volvulus is more common in younger, healthier individuals. Further, cecal volvulus has a higher prevalence in women than men, possibly due to the mobility of the small intestine as is seen during pregnancy.
Sigmoid volvulus is more common in people with a high fiber diets, chronic constipation, and laxitive abuse. You see sigmoid volvulus in patients in nursing home or those who are otherwise bedridden. Prior abdominal surgery also puts you at greater risk of volvulus.
Not surprisingly, a big risk factor for volvulus that some doctors inexplicably miss: prior history of volvulus, particularly patients who were treated for volvulus sigmoidoscopic reduction.
Treatment and Outcomes
Surgery is required to repair the volvulus by cutting into the abdomen and untwisting the bowels to restore blood supply. In cases where blood flow has been restricted and resulted in necrotic bowel tissue, the affected segment of bowel may be removed and the ends sewn together or used to connect the intestines to the outside to allow bowel contents to be removed (colostomy or ileostomy).
Quick diagnosis and treatment of volvulus usually has a positive outcome. If the bowel is necrotic (dead), the prognosis is poor and may be life-threatening depending on the amount of bowel that is dead. Complications may include secondary peritonitis (inflammation of the abdominal lining) and, after removal of a large portion of the bowel, short bowel syndrome.
Clinical diagnosis of malrotation is not usually considered after childhood due to the low incidence. However, patients with malrotation often present with obstruction and ischemia or chronic abdominal pain associated with volvulus. Diagnosis usually requires a high degree of suspicion and as a result can go undiagnosed. Due to the non-specific symptoms in children such as vomiting, abdominal pain and nausea, as well as difficulties in pediatric examination, surgical emergencies such as malrotation with volvulus are often delayed or missed, and is one of the most elusive diagnoses for emergency physicians.
Diagnosis is difficult and a common and often fatal error is the misdiagnosis of the type of volvulus, sigmoid vs. cecal. In cases where small bowel obstruction is possible, cecal volvulus should not be ruled out. In a retrospective study of patients later confirmed to have cecal volvulus, researchers reviewed X-rays from patients and found that the signs of cecal volvulus had been present in 90% of cases but suspected by physicians at the time in only 53% of these cases. The literature is in agreement that an abdominal X-ray is often the best method to detect and diagnose cecal volvulus. In many cases the additional information provided by a barium enema facilitates proper diagnosis, though it is important to note that misdiagnosis can still occur.
Colonoscopic decompression is often successful for sigmoid volvulus and is successful only in 3-5% of patients with cecal volvulus. A patient responding to colonoscopic decompression does not mean the patient has sigmoid volvulus and can lead to a delay in correct diagnosis and be potentially fatal.
Missed Volvulus and Other Medical Malpractice Claims in Maryland
If you or someone you love has suffered as the result of a medical misdiagnosis or failure to diagnose volvulus, call a Maryland attorney at 800-553-8082 or get a free on-line no obligation consultation.