Simultaneous transverse colon and sigmoid volvulus

Abstract

Colonic volvulus is one of the most common causes of bowel obstruction. It could occur in different parts of the colon. The sigmoid is the most common part, but it rarely occurs in the transverse colon because of the colon’s anatomical features. So, simultaneous sigmoid and transverse colon volvulus is a rare phenomenon that could endanger patients’ lives due to its rarity, ischemia, necrosis of the colon wall, and the lack of a definite algorithm to approach this disease. So, it is essential to consider this disease as one of the most important differential diagnoses in patients with abdominal pain and distention. In this article, a 45-year-old male presented to the surgical ward with severe prolonged abdominal pain, diagnosed with simultaneous sigmoid and transverse colon volvulus during laparotomy.

Introduction

Colonic volvulus is caused by twisting the colon around itself for various reasons and could lead to strangulation and, following that, bowel obstruction, ischemia, and necrosis.^1,2 Colonic volvulus is the third most common reason for bowel obstruction worldwide, accounting for 3%–5% of all cases after tumor obstruction and complicated sigmoid diverticulitis. ³ It could happen in different parts of the colon. The most common part is the sigmoid (61%), cecum (34.5%), and transversal colon (3.6%). ² Simultaneous occurrence of volvulus in different parts of the colon is infrequent. However, synchronous sigmoid and cecal volvulus and ilio-sigmoid knots happen more in comparison with others. ⁴ Studies show that simultaneous transversal and sigmoid volvulus is a rare condition that could threaten patients’ lives because of its clinical features. The most important diagnostic ways are patient clinical features, paying attention to related blood tests analysis, using proper imaging methods such as X-ray, computed tomography (CT) scan, and even MRI if necessary, and finally, choosing the best surgical method depending on the patient’s condition.^2,3 So, diagnosing and treating this condition quickly and accurately is essential to save patients’ lives. In this article, a 45-year-old male presented with synchronous transverse and sigmoid colon volvulus.

Case presentation

A 45-year-old patient presented to the surgical emergency department with complaints of diarrhea, nausea, vomiting, abdominal pain, and prolonged periods of constipation, which began 1 year ago. The patient’s past medical history revealed nothing. The patient claimed his diarrhea was bloody and started 10 days ago. He claimed that he had had at least seven vomiting episodes since last month, which included unbloody undigested food. He also complained of no defecation and gas-passing in the previous 3 days. The patient’s abdominal pain started 2 months ago and increased gradually. The abdominal pain was initially generalized, but it spread to the left upper quadrant over time. The abdominal pain was improved by defecation and sitting but increased by laying down or feeding. He did not have a fever. He had stable vital signs at the time of admission. Patient’s Body Mass Index was 15.2. On the abdominal examination, He had severe and progressive abdominal distention, as can be seen in Figure 1 and abdominal tenderness with a predominance of the left upper quadrant, which spread to his back and left shoulder. Rebound or guarding was not detected during the abdominal examination. The rectal examination was normal and represented nothing. The patient was admitted to the surgical ward for more investigation.

Figure 1.

Patient’s abdominal distention.

The patient was asked to do an upright chest X-ray and an upright and abdominal X-ray for more investigation. Upright chest X-ray revealed nothing, as can be seen in Figure 2, but air-fluid level and dilated bowel loops were seen in upright and supine abdominal X-rays as can be seen in Figures 3 and 4. So, the patient asked to do abdominal CT scan for more investigation with suspicion of colon obstruction, and the result confirmed dilated bowel loops, as can be seen in Figure 5, and the probability of obstruction and volvulus. The blood test analyzed revealed hemoglobin of 11.6 g/dL, a high level of lactate dehydrogenase = 750 (usually should be under 280 in adults), erythrocyte sedimentation rate = 42 (usually should be under 15 in males), leukocytosis (white blood cell (WBC) = 13,700 g/dL with neutrophilia ratio of 87%), and metabolic acidosis (pH of 7.21, PCO2 of 41, and Hco3 of 18), probably caused by decreased tissue perforation.

Figure 2.

Upright chest X-ray.

Figure 3.

Upright abdominal X-ray: Red arrows show air-fluid level.

Figure 4.

Supine abdominal X-ray: Red arrows show dilated bowel loops.

Figure 5.

Abdominal CT scan: Red arrows show dilated loops.

Due to clinical presentation, imaging, blood test, and CT scan results, a laparotomy was conducted for the patient. After opening the patient’s abdomen, a severely distant colon was seen, and the colon’s wall was thinner along its entire length and was ischemic. Abdomen exploration revealed a torsion in the transverse colon and another in the sigmoid part, where the colon was twisted twice around itself. But due to severe ilium wall inflammation, edema, and increased thickness of the wall, and due to low blood pressure (BP = 90/67 mmHg), total colectomy (Figures 6 and 7) and end ileostomy were created instead of ileorectal anastomosis. The abdominal cavity was washed with 5 L of normal saline, and the abdomen was closed. The patient had a proper and comfortable recovery. After the operation, the patient was transferred to the ICU and the surgical ward 2 days later. Adequate treatment was stated for him. The patient was discharged from the hospital after toleration per orally and in good general condition. Loperamide and Diphenoxylate were started for the patient. After 45 days, due to decreasing inflammatory condition vital sign stability, and since the patient with an ileostomy loses a lot of fluids, which can lead to an imbalance in the patient’s electrolytes, the patient underwent a laparotomy again. The end ileostomy was closed then, and end-to-side ileorectal anastomosis was created. After PO tolerated and performed proper treatment, the patient was discharged after 3 days. There was no complication in the 3-month follow-up.

Figure 6.

Transverse colon volvulus: Green arrow shows the location of volvulus.

Figure 7.

Colon after total colectomy.

Discussion

Bowel obstruction could occur for various reasons, such as tumors, diverticulitis, or volvulus. When the bowel twists around itself along its mesenteric axis abnormally, it leads to closed-loop obstruction, described as volvulus. This condition could disrupt venous returning and arterial supply and causes ischemia. ⁵ Volvulus is one of the rare causes of bowel obstruction, which includes only 3%–5% of cases. ³ The most common part that volvulus occurs in the colon is the sigmoid colon (61%–75%), caecum (15%–34.5%), transverse colon (3%–-5%), and splenic flexure (2%).^4,6 Transverse colon volvulus is rare because of its anatomical position; a short mesocolon and colonic flexure keep it in its location. ⁶ So, the simultaneous occurrence of sigmoid and transverse colon is a rare phenomenon, and because of its life-threatening features, it should be considered as one of the differential diagnoses in patients with obstruction signs and symptoms.

Several risk factors could increase the probability of colonic volvulus occurrence, such as sex (males are more at risk than females), intestinal malrotation, enlarged colon, long mesentery, Hirschsprung disease, inflammatory bowel disease such as Crohn’s disease (by increasing the risk of intestinal dilation, torsion, and fixation), abdominal adhesion, pregnancy, and chronic constipation.^2,7,8

The first step for diagnosis of this disease is physical examination. In terms of clinical presentation, colonic volvulus could be divided into two groups, including first acute fulminant, which manifested by nausea, vomiting, marked leukocytosis, acute abdominal pain, and peritoneal irritation, and second subacute progressive, which is presented with less nausea and vomiting, mild abdominal pain, abdominal distention without significant peritonitis, and normal or slightly elevated leukocytosis in compare with the first group.^6,9 Studies have shown that no particular signs or symptoms could help surgical teams differentiate between a single and double volvulus.^1,2,4,6,9

Another diagnostic way that could be very useful and effective is imaging methods such as abdominal X-ray, upright and supine, and CT scan, which could help the surgical team to make a better decision. Although imaging methods could reveal many diagnostic features such as the coffee bean sign, north-ern sign, or inverted U-shaped sign by X-ray or even two concomitant whirl signs by CT scan, in simultaneous volvulus conditions, these features may not be seen.^2,10

Different treatment methods are divided into two general groups: nonsurgical and surgical. Choosing between those two groups or even choosing between different surgical techniques depends on the patient’s condition and the surgical team.

In our case, the surgical team chose open laparotomy due to the patient’s condition. Because of several ischemic and necrotic parts in the length of the colon wall, the surgical team decided to do a total colectomy and ileorectal anastomosis. But as mentioned above, due to the patient’s low blood pressure and inflammation and edema of the ileum, the surgical team decided to prepare an ileostomy first, and after one and half months, an ileorectal anastomosis was done, and the ileostomy was closed.

Conclusion

Although colonic volvulus is the third most common reason for bowel obstruction, the occurrence of simultaneous sigmoid and transverse colon volvulus is a rare condition that threatens patients’ lives. As there are no definite signs or symptoms or even clinical and imaging findings for simultaneous colonic volvulus, it is essential to consider this disease, do a careful physical examination, and pay attention to laboratory and imaging findings, especially in patients with abdominal pain or distention.