volvulus

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sigmoid volvulus & other types

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VOLVULUS:

VOLVULUS DR.M.RAVICHANDRA,M.S ASST.PROF OF SURGERY RIMS,SRIKAKULAM

DEFINITION:

DEFINITION A VOLVULUS IS TWISTING OR AXIAL ROTATION OF A PORTION OF BOWEL ABOUT IT’S MESENTRY

VOLVULUS:

VOLVULUS OBSTRUCTION CAUSED BY TWISTING OF THE INTESTINES MORE THAN 180 DEGREES ABOUT THE AXIS OF THE MESENTERY 1-5% OF LARGE BOWEL OBSTRUCTIONS SIGMOID ~ 65% CECUM ~25% TRANSVERSE COLON ~4% SPLENIC FLEXURE

TYPES:

TYPES PRIMARY&SECONDARY PRIMARY CONGENITAL MALROTATION OF GUT ABNORMAL MESENTERIC ATTACHMENTS CONGENITAL BANDS SECONDARY ACQUIRED ADHESION (OR) STOMA

SIGMOID VOLVULUS:

SIGMOID VOLVULUS WORLDWIDE - UP TO 50% OF OBSTRUCTION INDIA, AFRICA, E. EUROPE MORE COMMONLY SEEN IN ELDERLY PATIENTS IN WESTERN SOCIETIES RISK FACTORS CHRONIC CONSTIPATION PSYCHIATRIC PROBLEMS NON-WESTERN SOCIETIES HIGH RESIDUE DIET

PREDISPOSING FACTORS:

PREDISPOSING FACTORS BAND OF ADHESIONS(PERIDIVERTICULITIS) OVER LOADED PELVIC COLON LONG PELVIC MESOCOLON NARROW PELVIC MESOCOLON

THE ACUTE ABDOMEN IN RHYME.ZACHARY COPE,1881-1974 :

THE ACUTE ABDOMEN IN RHYME.ZACHARY COPE,1881-1974 SOMETIMES A BOWEL-COIL GETS OUT OF PLACE BY TWISTING ROUND A NARROW BASE WITH GRADUAL STRANGULATING OF THE BLOOD SUPPLY AND DANGER THAT THE AFFECTED COIL WILL DIE THIS IS AVOLVULUS WHICH YOU SHOULD LEARN IS FROM THE LATIN-VOLVERE-TO-TURN

PowerPoint Presentation:

*Image by [email protected] via Flickr

PowerPoint Presentation:

*Image by [email protected] via Flickr

PRESENTATION:

PRESENTATION HX: ABDOMINAL PAIN, DISTENSION,ABSTIPATION,VOMITING OCCURS LATE,HICCOUGH&RETCHING NO FLATUS OR BOWEL MOVEMENTS EXAM: TYMPANITIC ABDOMEN, DISTENSION, MILD TENDERNESS, PALPABLE MASS

SIGMOID VOLVULUS:

SIGMOID VOLVULUS “ BENT INNER TUBE ” APPEARANCE DILATED SIGMOID LOOP WITH LIMBS POINTING TOWARDS THE RLQ

ZACHARY COPE:

ZACHARY COPE THOUGH SOMETIMES IN A PERSON WHO IS FAT THE DIAGNOSIS IS NOT CLEAR AS THAT TIS THEN YOU GET HELP FROM PLAIN XRAY WHICH GAS WITHIN THE GUT SHOWED WELL DISPLAY SO THAT THE COIL YOU SEE IN THE RADIOGRAM REACHING FROM PELVIS TO THE DIAPHRAGM

SIGMOID VOLVULUS:

SIGMOID VOLVULUS “ COFFEE BEAN ” APPEARANCE WITH THE TWO TWISTED LOOPS WITH A CENTRAL DOUBLE WALL COMPONENT

PowerPoint Presentation:

*Image by [email protected] via Flickr

PowerPoint Presentation:

*Image by [email protected] via Flickr

BARIUM ENEMA:

BARIUM ENEMA CONTRAINDICATED IN PATIENTS WITH FREE AIR ON AXR, CLINICAL SIGNS OF PERITONITIS, OR SUSPICION FOR NECROSED BOWEL BIRD’S BEAK CAN DECOMPRESS

MANAGEMENT OF CHOICE:

MANAGEMENT OF CHOICE ENDOSCOPIC DECOMPRESSION RIGID OR FLEXIBLE PROCTOSIGMOIDOSCOPE INSERTED INTO RECTUM GUSH OF AIR/FECES --> SUCCESSFUL DECOMPRESSION RECTAL TUBE SUCCESSFUL IN 85-90% OF CASES RECURRENCE RATE >60% DECREASED RISK FOR BOWEL NECROSIS IF TREATED EARLY COLON ISCHEMIA, PERFORATION ELECTIVE RESECTION

OPERATIVE MANAGEMENT FOR SIGMOID VOLVULUS:

OPERATIVE MANAGEMENT FOR SIGMOID VOLVULUS ELECTIVE RESECTION SAME ADMISSION EMERGENT LAPAROTOMY OPERATION DEPENDS ON VIABILITY OF THE BOWEL RESECTION AND ANASTOMOSIS HARTMANN RESECTION EXTERIORIZATION RESECTION (PAUL MICKULISZ PROCEDURE) DETORSION DETORSION WITH COLOPEXY PERCUTANEOUS COLOSTOMY PERCUTANEOUS SIGMOIDPEXY

PowerPoint Presentation:

DELAYED RESECTION WITH PRIMARY ANASTOMOSIS MORTALITY RATE 8% OPERATIVE MORTALITY RELATED TO VIABILITY OF BOWEL VIABLE 12% VS NONVIABLE 53% MORTALITY

AN ANECDOTE:

AN ANECDOTE A FRAGILE LADY IN HER MID 80S SUFFERED ONE EPISODE AFTER ANOTHER BUT EACH TIME SHE WAS THOUGHT UNFIT FOR AN ELECTIVE OPERATION ON A BENIGN CONDITION. AFTER HER 12 TH VOLVULUS SHE HAD PROVED HER CASE AND WAS SUBJECTED TO SIGMOIDECTOMY FROM WHICH SHE RECOVERED UNEVENTFULLY AND WAS DISCHARGED AFTER 5 DAYS

CECAL VOLVULUS:

CECAL VOLVULUS LESS COMMON THAN SIGMOID VOLVULUS PARIETAL PERITONEUM FAILS TO CONNECT WITH THE CECUM AND RIGHT COLON PRESENT IN ABOUT 10% OF POPULATION INCREASED MOBILITY OF BOWEL, RESULTING IN IT FOLDING ON ITS AXIS OR UPWARD TORSION OCCURS PROXIMAL TO CECUM RISK FACTORS: DISTAL OBSTRUCTION, PREGNANCY, ADHESIONS, CONGENITAL BANDS, PROLONGED CONSTIPATION, METEORISM (AIR IN INTESTINES) THAT OCCURS WITH NON-PRESSURIZED AIR TRAVEL

PowerPoint Presentation:

HX: ABDOMINAL PAIN, COLICKY DISTENTION AXIAL TORSION TYPE TWIST 180-360 DEGREES ON LONGITUDINAL AXIS OF ASCENDING COLON (DISTAL ILEUM AND ASCENDING COLON) ASSOCIATED WITH BOWEL COMPROMISE, ISCHEMIA, AND PERFORATION CECAL BASCULE CECUM FOLDS ANTERIORLY ON ASCENDING COLON MAY RESULT IN INTERMITTENT OBSTRUCTIVE SYMPTOMS

X-RAYS:

X-RAYS “ COMMA” SHAPED CONVEXITY TOWARD RIGHT AND DOWNWARD BE - RISK OF PERFORATION WITH GETTING AIR/CONTRAST TO RIGHT COLON

PowerPoint Presentation:

*Image by [email protected] via Flickr

PowerPoint Presentation:

*Image by [email protected] via Flickr C.T OF CAECAL VOLVULUS

MANAGEMENT:

MANAGEMENT DECOMPRESSION WITH COLONOSCOPE LESS SUCCESSFUL THAN WITH SIGMOID VOLVULUS EMERGENT OPERATION IF SIGNS OF VASCULAR COMPROMISE

OPERATIVE MANAGEMENT FOR CECAL VOLVULUS :

OPERATIVE MANAGEMENT FOR CECAL VOLVULUS DETORSION ± APPENDECTOMY CECOPEXY/LAPAROSCOPIC CECOPEXY SUTURE R COLON TO LATERAL PARACOLIC GUTTER OR USE LATERAL PERITONEAL FLAP CECOSTOMY RESECTION RIGHT COLECTOMY WITH PRIMARY ANASTOMOSIS

RESULTS :

RESULTS DETORSION ± APPENDECTOMY HIGH RATE OF RECURRENCE (NOT COMMONLY DONE ANYMORE) CECOPEXY DO NOT NEED TO HAVE PREPPED BOWEL RECURRENCE 25% CECOSTOMY ± CECOPEXY COMBINED PROCEDURE MORE EFFECTIVE IN PREVENTING RECURRENCE RESECTION PRIMARY ANASTOMOSIS UNLESS PERITONEAL CONTAMINATION IS PRESENT

TRANSVERSE COLON VOLVULUS:

TRANSVERSE COLON VOLVULUS LESS COMMON AREA FOR VOLVULUS(4%) ASSOCIATED WITH MOBILE RIGHT COLON, DISTAL OBSTRUCTION, CHRONIC CONSTIPATION, CONGENITAL MALROTATION OF THE MIDGUT USUALLY NOT DIAGNOSED PREOPERATIVELY NO CHARACTERISTIC RADIOLOGICAL FINDINGS EXCEPT COLONIC DILATATION RESECTION OF TRANSVERSE COLON HIGH RATE OF RECURRENCE IF TREATED WITH DETORSION ALONE

VOLVULUS NEONATARUM:

VOLVULUS NEONATARUM PREDISPOSED BY ARRESTED ROTATION OF GUT WITH A RESULTANT NARROW MESENTERY OF SMALL BOWEL & CAECUM SYMPTOMS – VOMITINGS,ABDOMINAL DISTENTION, & DEHYDRATION AXR REVEALS SIGNS OF DUODENAL OBSTRUCTION LAPAROTOMY REVEALS DISTENDED STOMACH & COILS OF INTESTINE TORSION IS IN CLOCKWISE DIRECTION OPERATION REDUCTION BY UNTWISTING & DIVISION OF ANY SECONDARY OBSTRUCTIVE LESIONS LIKE TRANSDUODENAL BAND OF LADD

VOLVULUS OF SMALL INTESTINE:

VOLVULUS OF SMALL INTESTINE OCCURS IN LOWER ILEUM PRIMARY & SECONDARY PRIMARY SPONTANEOUS IN AFRICANS FOLLOWING CONSUMPTION OF LARGE VOLUME OF VEGETABLE MATTER SECONDARY WEST ADHESIONS PASSING TO PARIETIES/FEMALE PELVIC ORGANS TREATMENT - REDUCTION OF TWIST & TREAT UNDER LYING CAUSE

VOLVULUS OF STOMACH:

VOLVULUS OF STOMACH ROTATION OF STOMACH AROUND THE AXIS AND 2 FIXED POINTS THE CARDIA & THE PYLORUS 2 TYPES HORIZONTAL(ORGANO AXIAL) M.C VERTICAL(MESENTERIO AXIAL) USUALLY ASSOCIATED WITH A DIAPHRAMATIC DFEFECT AROUND ESOPHAGUS AND THERE IS PARAESOPHAGEAL HERNIATION

VOLVULUS OF STOMACH CONTD…:

VOLVULUS OF STOMACH CONTD … TRANSVERSE COLON MOVES UPWARDS TO LIE UNDER THE LEFT HEMIDIAPHRAGM DURING THIS PROCESS IT TAKES STOMACH ALONG WITH IT STOMACH& COLON BOTH ENTER THE CHEST THROUGH THE EVENTRATION OF DIAPHRAGM CHRONIC- DIFFICULTY IN EATING ACUTE MAY PRESENT WITH ISCHAEMIA

VOLVULUS OF STOMACH CONTD…:

VOLVULUS OF STOMACH CONTD … TREATMENT BOTH OPEN&LAP REDUCTION OF SAC & CONTENTS CLOSURE OF DEFECT IN DIAPHRAGM WITH MESH SEPARATE STOMACH FROM TRANS. COLON PERFORM ANTERIOR GASTROPEXY

PowerPoint Presentation:

*Image by [email protected] via Flickr

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