 GASTRIC VOLVULUS

 SMALL BOWEL VOLVULUS (MIDGUT MALROTATION)

 LARGE BOWEL VOLVULUS (CECAL VOLVULUS,

SIGMOID VOLVULUS)
 LARGE AND SMALL BOWEL VOLVULUS (
ILEOSIGMOID KNOT)
 Gastric volvulus is a condition involving the
stomach twisting upon itself

Classified as one of two types

organoaxial or mesenteroaxial
 A combination of both types may occur in an
individual.
 Twist occurs along a line connecting the
cardia and the pylorus--the luminal (long)
axis of the stomach.
 Most common type.
 Usually associated with diaphragmatic
defects.
 Vascular compromise more common.
 Organoaxial volvulus the rotation of the stomach
along its long axis
 Twist occurs around a plane perpendicular to
the luminal (long) axis of the stomach from
lesser to greater curvature.
 Chronic symptoms are more common.
 Diaphragmatic defects are less common.
 Mesenteroaxial volvulus the stomach twisting along its
short axis
◦ Abnormality of
suspensory ligaments of
stomach.
◦ Congenital defects of their
diaphragm (Hiatal hernia).
◦ Weak Muscles (MND).
◦ Tumors of stomach.
 Those with defects of the diaphragm
commonly suffer with the common type
(organoaxial volvulus), and it is the most
serious form, needing urgent surgical
intervention.
 The mesenteroaxial type does not often lead
to compromise of blood supply to the
stomach speedily, and may run a chronic
course.
◦ Unless acute, patients are frequently
asymptomatic.
◦ When acute and obstructing
 Abdominal pain
 Attempts to vomit without results
 Inability to pass an NG tube
 Together, these three findings comprise
the Borchardt triad which is diagnostic of
acute volvulus .
 In mesenteroaxial volvulus, distended
stomach appears spherical on supine images.
 Two air-fluid levels visible on upright film: in
fundus and in antrum.
 Upright image often demonstrates a beak
where the esophagogastric junction is seen
on normal images.
 peanut sign- in a case of chronic gastric
volvulus.
 The ultrasonographic features consist of a
constricted segment of stomach, with 2
dilated segments located above and below
the constricted part, akin to a peanut.
 .
 Gastric ischemia
◦ Gastric emphysema
◦ Twisting of stomach may tear spleen from its
normal attachments
◦ Perforation is rare
 Torsion of the entire gut around superior
mesenteric artery (SMA) due to a short
mesenteric attachment of small intestine in
malrotation.
 AGE
o Usually neonate or young infant
o Occasionally older child and adult

 ASSOCIATED WITH (IN 20%)

o Duodenal atresia
o Duodenal diaphragm
o Duodenal stenosis
o Annular pancreas
o Degree of twisting is variable and determines
symptomatology
o Severe volvulus (twist of 3 ½ turns)
result in bowel necrosis
 Acute symptoms in newborn (medical emergency)
o Bile-stained vomiting
Intermittent, Postprandial, Projectile
o Abdominal distension
o Shock
Dilated, air-filled duodenal bulb and paucity of
gas distally
"Double bubble sign" = air-fluid levels in
stomach & duodenum

oIsolated collection of gas-containing bowel

loops distal to obstructed duodenum = gas-
filled volvulus = closed-loop obstruction
From non resorption of intestinal gas
secondary to obstruction of mesenteric veins
"Corkscrew" duodenum in malrotation with a midgut volvulus

"Corkscrew" duodenum in malrotation

with a midgut volvulus
CT findings
 Whirl-like pattern of small bowel loops and
adjacent mesenteric fat converging to the point
of torsion (during volvulus)

 SMV to the left of SMA (NO volvulus)

 Chylous mesenteric cyst (from interference with

lymphatic drainage)
 Clockwise whirlpool sign = color Doppler
depiction of mesenteric vessels moving clockwise
with caudal movement of transducer

 Distended proximal duodenum with arrowhead-

type compression over spine

 Superior mesenteric vein to the left of SMA

 Thick-walled bowel loops below duodenum and to

the right of spine associated with peritoneal fluid
 "Barber pole sign" = spiraling of SMA

 Tapering / abrupt termination of mesenteric

vessels

 Marked vasoconstriction and prolonged contrast

transit time

 Absent venous opacification / dilated tortuous

superior mesenteric vein
 Intestinal ischemia and necrosis in
distribution of SMA (bloody diarrhea, ileus,
abdominal distension)

DD:

 Pyloric stenosis (same age group, no bilious

vomiting)
 Twisting of loop of intestine around its
mesenteric attachment site may occur at
various sites in the GI tract
 Most commonly: sigmoid & cecum
 Rarely: stomach, small intestine, transverse
colon
 Results in partial or complete obstruction
 May also compromise bowel circulation
resulting in ischemia
 Sigmoid volvulus most common form of GI
tract volvulus
 Accounts for up to 8% of all intestinal
obstructions
 Most common in elderly persons (often
neurologically impaired)
 Patients almost always have a history of
chronic constipation
 Redundant sigmoid colon that has a narrow
mesenteric attachment to posterior abdominal
wall allows close approximation of 2 limbs of
sigmoid colon à twisting of sigmoid colon
around mesenteric axis
 Other predisposing factors
 Chronic constipation
 High-roughage diet (may cause a long,
redundant sigmoid colon)
 Roundworm infestation
 Megacolon (often due to Chagas)
 20-25% mortality rate
 Peak age > 50 years
 Torsion usually counterclockwise ranging
from 180 – 540 degrees
 Luminal obstruction generally @ 180 degrees
 Venous occlusion generally @ 360 degrees à
gangrene & perforation
 Diagnosis
Abdominal plain films usually diagnostic
Inverted U-shaped appearance of distended
sigmoid loop
 Largest and most dilated loops of bowel are
seen with volvulus
 Loss of haustra
 Coffee-bean sign à midline crease
corresponding to mesenteric root in a greatly
distended sigmoid
 Sigmoid volvulus – bowel loop points to RUQ
 torsion of the caecum around its own
mesentery which often results in obstruction
 It accounts for 11% of all intestinal volvulus
 can result in bowel perforation and faecal
peritonitis
Clinical presentation
 Caecal volvulus presents with clinical features
of proximal large bowel obstruction. This is
usually with colicky abdominal pain, vomiting
and abdominal distension.
• Bowel loop points to LUQ
• Dilated cecum comes to rest in left upper
quadrant

• Bird’s-beak or bird-of-prey sign à seen on

barium enema as it encounters the volvulated
loop

• CT scan useful in assessing mural wall ischemia

large, dilated loop of large bowel with an inverted U-shape
with walls between two volvulated loops pointing from LLQ toward RUQ;
same patient with decompressed sigmoid volvulus following insertion of rectal tube
Differential Diagnosis
 Large bowel obstruction due to other causes
à sigmoid colon CA
 Giant sigmoid diverticulum
 Pseudoobstruction

Complications
 Colonic ischemia
 Perforation
 Sepsis
Ba contrast enema
contrast-filled rectum
illustrates the "bird's beak"
sign (white arrow),
corresponding to the
luminal narrowing at the
site of sigmoid obstruction.
This is the characteristic
presentation of a sigmoid
volvulus
 20 year old woman presented to the ED with
12 hours of abdominal pain, nausea. and
vomiting low grade fever.
 No past surgical history
 PMH: Polycystic ovarian disease
Dilated cecum
Cecum
 Contrast
Cecum
In Descending colon
 Barium Enema

Ascending colon

Point of Obstruction