Mercy Hospital St. Louis St. Louis, MO, United States
Wilfor J. Diaz Fernandez, MD, Marc Bernstein, MD Mercy Hospital St. Louis, St. Louis, MO
Introduction: Colonic volvulus (CV) is a common cause of large bowel obstruction. If left untreated, it compromises the blood supply of the involved segment, leading to ischemia, perforation, and death. We present the case of descending CV in a patient with prior sigmoid volvulus who underwent sigmoidectomy. There are only a few reports of descending CV, but to our knowledge, there has been no case in a patient with a prior sigmoid volvulus status post sigmoidectomy 8 years after.
Case Description/Methods: A 72-year-old male with a history of sigmoid volvulus status post sigmoidectomy presented to the emergency department with one day of abdominal pain similar to his past volvulus episode 8 years ago. Physical examination showed abdominal distension, diffuse tenderness, and high-pitched bowel sounds. CT of the abdomen and pelvis revealed colonic distension in the left upper quadrant with a whirling appearance proximal to the prior site of surgical anastomosis, suggesting CV. The patient underwent flexible sigmoidoscopy with visualization of a twist in the descending colon with no signs of ischemia. Rectal tube placement above the volvulus level accomplished deflation. The next morning, the patient passed stools and a follow-up abdominal X-ray showed resolution of the volvulus. Two days later, the patient underwent laparoscopic anterior colon resection with resection of prior colorectal anastomosis.
Discussion: Volvulus is the torsion of a bowel segment over its mesenteric axis. It rarely develops in the descending colon, mainly due to its retroperitoneal location and lack of mesentery. The incidence of volvulus after previous sigmoidectomy and primary anastomosis varies between 22-36%, averaging 11 months after surgery. This is the first case of recurrent volvulus after 8 years from sigmoidectomy.
Resection is the treatment of choice to prevent its recurrence. However, colonoscopy allows a delay in the timing of surgery from emergent to elective and confirms the colon's viability. Success of detorsion is almost 90% with recurrence in up to 85% of cases. Our patient was at high risk for recurrence after detorsion and a subtotal colectomy was performed.
Colonic volvulus requires a prompt diagnosis from surgery and gastroenterology. Early decompression via colonoscopy is indicated if no evidence of ischemia, gangrene, or perforation is present. This case represents how despite surgical resection, recurrence is still a problem for these patients even after years from surgery.
Figure: Figure A: Whirl sign on CT, with a dilated descending colon. Figure B-C: Benign-appearing, intrinsic twisted stenosis in the descending colon. Markedly dilated descending colon after a gentle advance of the colonoscope. The rectal tube was navigated proximal to the volvulus area. Figure D: Abdominal x-ray showing resolution of massive colonic distension after detorsion and rectal tube placement.
Wilfor Diaz Fernandez indicated no relevant financial relationships.
Marc Bernstein indicated no relevant financial relationships.
Wilfor J. Diaz Fernandez, MD, Marc Bernstein, MD. P1261 - Successful Endoscopic Decompression of a Descending Colonic Volvulus in a Patient With Prior Sigmoidectomy Due to Sigmoid Volvulus, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.