Volvulus

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Basics

Description

  • Axial twist of a portion of the GI tract around its mesentery causing partial or complete obstruction of the bowel
  • Often associated with other GI abnormalities
  • In pediatric setting, infants typically involved:
    • Abnormal embryonic development
  • Can be precipitated by pathologic distention of the colon
  • Blood supply may be compromised by venous congestion and eventual arterial inflow obstruction, leading to gangrene of the bowel and potential infarction

Etiology

  • Third most common cause of colonic obstruction (10–15%) following tumor and diverticular disease
  • Epidemiology:
    • 0–1 yr old: 30%
    • 1–18 yr old: 20%
    • Over 18 yr old: 50%
  • Often associated with other GI abnormalities
  • Cecum (52%):
    • More common in young adults, <50 yr old
    • Due to improper congenital fusion of the mesentery with the posterior parietal peritoneum, causing the cecum to be freely mobile in varying degrees
    • Associated with increased gas production (malabsorption and pseudo-obstruction)
    • Can be seen in pregnancy and after colonoscopy
  • Sigmoid (43%):
    • More common in:
      • Elderly
      • Institutionalized
      • Chronic bowel motility disorders (Parkinson)
      • Psychiatric diseases (schizophrenia)
    • Due to redundant sigmoid colon with narrow mesenteric attachment
    • Associated with chronic constipation and concomitant laxative use
  • Transverse colon and splenic flexure (5%)
  • Gastric volvulus (rare) associated with diaphragmatic defects

Pediatric Considerations
  • Midgut volvulus:
    • Due to congenital malrotation in which the midgut fails to rotate properly in utero as it enters the abdomen
    • Entire midgut from the descending duodenum to the transverse colon rotates around its mesenteric stalk, including the superior mesenteric artery
    • Common in neonates (80% <1 mo old, often in first week; 6–20% >1 yr old)
    • Males > females, 2:1
    • Sudden onset of bilious emesis (97%) with abdominal pain
    • May have previous episodes of feeding problems/bilious emesis
    • In children >1 yr old, associated with failure to thrive, alleged intolerance to feedings, chronic intermittent vomiting, bloody diarrhea
    • Constipation
    • Mild distention, since obstruction higher in GI tract
    • May not appear toxic based on degree of ischemia

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Basics

Description

  • Axial twist of a portion of the GI tract around its mesentery causing partial or complete obstruction of the bowel
  • Often associated with other GI abnormalities
  • In pediatric setting, infants typically involved:
    • Abnormal embryonic development
  • Can be precipitated by pathologic distention of the colon
  • Blood supply may be compromised by venous congestion and eventual arterial inflow obstruction, leading to gangrene of the bowel and potential infarction

Etiology

  • Third most common cause of colonic obstruction (10–15%) following tumor and diverticular disease
  • Epidemiology:
    • 0–1 yr old: 30%
    • 1–18 yr old: 20%
    • Over 18 yr old: 50%
  • Often associated with other GI abnormalities
  • Cecum (52%):
    • More common in young adults, <50 yr old
    • Due to improper congenital fusion of the mesentery with the posterior parietal peritoneum, causing the cecum to be freely mobile in varying degrees
    • Associated with increased gas production (malabsorption and pseudo-obstruction)
    • Can be seen in pregnancy and after colonoscopy
  • Sigmoid (43%):
    • More common in:
      • Elderly
      • Institutionalized
      • Chronic bowel motility disorders (Parkinson)
      • Psychiatric diseases (schizophrenia)
    • Due to redundant sigmoid colon with narrow mesenteric attachment
    • Associated with chronic constipation and concomitant laxative use
  • Transverse colon and splenic flexure (5%)
  • Gastric volvulus (rare) associated with diaphragmatic defects

Pediatric Considerations
  • Midgut volvulus:
    • Due to congenital malrotation in which the midgut fails to rotate properly in utero as it enters the abdomen
    • Entire midgut from the descending duodenum to the transverse colon rotates around its mesenteric stalk, including the superior mesenteric artery
    • Common in neonates (80% <1 mo old, often in first week; 6–20% >1 yr old)
    • Males > females, 2:1
    • Sudden onset of bilious emesis (97%) with abdominal pain
    • May have previous episodes of feeding problems/bilious emesis
    • In children >1 yr old, associated with failure to thrive, alleged intolerance to feedings, chronic intermittent vomiting, bloody diarrhea
    • Constipation
    • Mild distention, since obstruction higher in GI tract
    • May not appear toxic based on degree of ischemia

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