Jeremy Van, DO, Ioannis Economou, MD; Rush University Medical Center, Chicago, IL
Introduction: Colonic Volvulus is the 3rd leading cause of colonic obstruction worldwide behind carcinoma and diverticulitis. The sigmoid colon and cecum are the most common locations. This case describes a patient with prior sigmoid volvulus (SV) and sigmoidectomy (SDY) presenting with descending colon volvulus (DCV). There have only been a few reports of DCV and to our knowledge no case in someone with a prior SV s/p SDY.
Methods: A 75-yo male with past medical history (hx) of SV s/p SDY with colo-colonic anastomosis after failed detorsion, chronic constipation, and hypothyroidism presented with a 4-day hx of abdominal pain and obstipation. No hx of opiate use. K+ 3.9 and TSH 1.021. Abdominal x-ray showed dilated loops of large bowel with concern for distal obstruction. On CT Abdomen and Pelvis (CT A/P) with IV contrast, there was diffuse large bowel dilatation up to the sigmoid colon with no mass or wall thickening visualized. Colonoscopy showed a patent anastomosis, spiraling of the descending colon and viable mucosa. Successful detorsion was performed. Discussion: Volvulus is the torsion of a colonic segment over its mesenteric axis. DCV is a rare entity. The descending colon is a retroperitoneal structure usually without a mesentery. However, the primitive dorsal mesocolon may fail to fuse with the parietal peritoneum in the 4th-5th month of gestation, resulting in persistent descending mesocolon. Abdominal X-ray can show a grossly dilated ahaustral colonic loop without air in the rectum. CT A/P can show “coffee bean” sign with a large twisted loop of bowel, “whirl” sign with twisting of the mesentery and its vessels, “X marks the spot” sign with crossing loops of bowel at the site of transition, and “split wall” sign with mesenteric fat indenting. Typical CT imaging features may be absent in 1/4th of all patients. On colonoscopy, there is usually a spiral, sphincter-like area of mucosa and viability of mucosa can be assessed. Gentle pressure and insufflation are carried out for reduction. Recurrence rate after detorsion is around 85%. The incidence of recurrent volvulus after previous resection and anastomosis is around 6-36%. As this patient is at high risk for recurrence after detorsion, subtotal colectomy will be completed. Chen A, Yang FS, Shih SL, et al. CT Diagnosis of Volvulus of the Descending Colon with Persistent Mesocolon. 2003 April. 1003-1006. Booij KA, Tanis PJ, van Gulik TM, et al. Recurrent volvulus of the transverse colon after sigmoid resection. 2009 April. 471–472.
Markedly dilated gas-filled loops of large bowel concerning for distal obstruction
Axial view-> Markedly dilated transverse and descending colon
A: coronal view-> Significant distension of the descending colon without any obvious colonic wall mass or thickening with abrupt narrowing distally
B: Sagittal view-> Significant distension of the descending colon
Disclosures: Jeremy Van indicated no relevant financial relationships. Ioannis Economou indicated no relevant financial relationships.