Cleveland Clinic Foundation Cleveland, OH, United States
Award: Presidential Poster Award
Aditi Mittal, MD, Charles B. Chen, MD, Anthony DeRoss, MD, Deborah Goldman, MD, FACG, Marsha Kay, MD, FACG Cleveland Clinic Foundation, Cleveland, OH
Introduction: Acute colonic dilation in pediatric patients with ulcerative colitis (UC) raises the concern for toxic megacolon, but other rare conditions such as sigmoid volvulus may present in a similar manner. We present an unusual case of a pediatric patient with UC without prior surgery who developed an obstructing sigmoid volvulus managed with endoscopic detorsion and decompression.
Case Description/Methods: A 16-year-old female with left-sided UC on infliximab therapy presented with abdominal pain, hematochezia, and diarrhea. She had new C. difficile colonization without active infection, which was treated with minimal response. Magnetic resonance enterography showed recto-sigmoid inflammation with dilated proximal colon concerning for a distal stricture or toxic megacolon. Surgery was consulted. She was passing flatus without signs of acute abdomen. She was made NPO and was managed with serial exams, intravenous steroids and antibiotics. After 72 hours, her serial imaging showed worsening distension of left colon up to 10 cm and she stopped passing flatus or stool. She underwent a limited diagnostic colonoscopy which demonstrated near complete obstruction of the sigmoid colon suggestive of a volvulus with scattered exudates distal to the obstruction. A neonatal upper endoscope was subsequently used to traverse the sigmoid narrowing and detorse the volvulus with spontaneous passage of flatus during the procedure; endoscopic decompression of the colon was performed. The colonic mucosa was very pale from rectum to splenic flexure with normal appearing mucosa proximal to the transverse colon. The patient tolerated regular diet after the procedure, passed stools and was discharged the next day. One month later colonoscopy showed mild active left-sided colitis suggesting that ongoing inflammation was the likely cause of her volvulus rather than a mechanical cause; the rest of the colon was visually normal.
Discussion: Colonic volvulus is rarely reported as a complication of UC. The sigmoid colon is the most common site of volvulus. Risk factors include advanced age, chronic constipation, myopathies and prior surgery. The role of underlying colonic inflammation due to UC and possible C. difficile as an etiology of the volvulus should be considered in a pediatric patient without other known risk factors. Endoscopic detorsion is the preferred technique for sigmoid volvulus reduction with rectal tube placement; surgery is often required as volvulus may recur. Our patient did well without a surgical intervention.
Aditi Mittal indicated no relevant financial relationships.
Charles Chen indicated no relevant financial relationships.
Anthony DeRoss indicated no relevant financial relationships.
Deborah Goldman indicated no relevant financial relationships.
Marsha Kay indicated no relevant financial relationships.
Aditi Mittal, MD, Charles B. Chen, MD, Anthony DeRoss, MD, Deborah Goldman, MD, FACG, Marsha Kay, MD, FACG. P1692 - Obstructing Sigmoid Volvulus: An Unusual Complication in a Pediatric Patient with Ulcerative Colitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.