Large Bowel Obstruction results from acute

blockage affecting the colon and the rectum.

The causes of large bowel obstruction include;
Sigmoid Volvulus
Carcinoma of the Colon
Diverticular Disease
Intussusception
If large bowel obstruction is not managed it
leads to Faecal Peritonitis as a complication
Clinical Features of Large Bowel Obstruction
Abdominal Pain – Due to distension and colic (severe pain
in the abdomen caused by wind/air or obstruction of intestines)
Abdominal Distension – Due to retention of faeces and
flatus
Constipation - Absolute constipation is the complete
obstruction without passage of faeces or flatus
 Clinical Features of Large Bowel
Obstruction Continued
Peritonism – if perforation has occurred.
Vomiting – As a late complication
NOW VOLVULUS
What is Volvulus? Volvulus is a condition where a part
of the intestine loops around itself and the surrounding
mesentery, which can result in bowel obstruction.
This obstruction caused by twisting of the stomach or
intestine.
 Types Of Volvulus
Sigmoid Volvulus
Cecal Volvulus
Midgut Volvulus

The most common type of volvulus

An abnormal twist of the sigmoid colon forming a loop
resulting in large bowel obstruction
 Anatomy
The sigmoid colon is narrowest part of the large
intestine and is extremely mobile.
Although the sigmoid colon is usually located in the
left lower quadrant , redundancy and mobility can
result in a portion of the sigmoid colon projecting in
to right lower quadrant. This mobility explains why
volvulus is most common in the sigmoid colon .
The narrow caliber of the sigmoid colon makes
this segment of the large intestine the most
vulnerable to obstruction
The sigmoid colon is supplied by multiple
sigmoid arteries which are branches of the
inferior mesenteric artery.
The inferior mesenteric vein drains blood from
the sigmoid colon drains into splenic vein.
The lymphatic vessels drain into the epicolic and
paracolic lymph nodes, then to intermediate colic
nodes and finally to the inferior mesenteric lymph
nodes.
The sympathetic nerve supply is from the
superior hypogastric plexus while
parasympathetic innervation is from the pelvic
splanchnic nerves.
 Pathology
The anatomical characteristics described earlier facilitate
twisting of the sigmoid colon around its narrow base on an
unusually long mesentery.
The degree of twisting can vary from 90 degree to 360
degree and can occur in an anticlockwise direction or
clockwise direction.
Complete rotation will result in a closed loop obstruction
leading to trapping of intestinal contents within the loop and
compromise vascular inflow and outflow.
If the obstruction persists it results in massive extravasation
both into the bowel and peritoneal cavity.
In later stages the massively distended bowel together
with extravasated fluid can cause abdominal
compartment syndrome or the bowel may undergo
necrosis followed by perforation with leakage of
contents into the abdominal cavity resulting in florid
peritonitis.
The distension can also lead to severe compromise in
respiratory function.
 Aetiology
Chronic constipation
Sedentary lifestyle
Nursing home residency
Bedridden or debilitating status
Redundant sigmoid loop
Neurologic disease
Chagas disease, congenital megacolon ,high altitude,
hirschsprung’s disease and pregnancy.
 Interesting
The cause of sigmoid volvulus is unclear. The primary predisposing
factors include congenital redundancy of the sigmoid colon, combined
with a narrow mesenteric base, chronic constipation, a high residue diet,
and acquired megacolon. The high incidence of sigmoid volvulus can
been attributed to the high fiber vegetable diet. Excessive use of
laxatives, especially of the anthraquinone group, may lead to damage of
the mysentric plexus of the bowel wall, resulting in loss of coordination
of contracture. Anticholinergics, tranquilizers, ganglion blockers, and
antiparkinsonian drugs commonly used in elderly patients have been
implicated in producing acquired megacolon.
Adhesions from previous abdominal surgery occasionally have been
implicated in the genesis of sigmoid volvulus. Luminal obstruction and
vascular compromise occurs when the torsion exceeds 180 degrees, in
 DIAGNOSIS
Plain radiograph is diagnostic in up to 90% cases. Many signs like
coffee bean sign, bent inner tubes, omega, Horse shoe, inverted U sign,
central black band sign, Northern express sign has been described in
plain X-Ray.
Barium enema may show bird beak appearance.
CT and MRI may be 100% diagnostic and they reveal twisted pedical
as a whirled soft tissue mass.
Doppler ultrasound, and colonoscopy may be helpful in prediction
colonic ischaemia.
 Presentation
Symptoms of volvulus are those of acute bowel
obstruction. Patients presentation can be acute or
indolent:
Abdominal distension and pain.
Nausea , and vomiting ,
constipation
Post –obstruction diarrhea.
Symptoms of peritonitis and sepsis in advanced stage
Two conditions that can mimic the radiographic
appearance of sigmoid volvulus are pseudo-obstruction
and caecal volvulus.
Presence of air in the rectum, in the absence of rectal
examination, will point towards the diagnosis of a
pseudoobstruction.
A single air fluid level as opposed to multiple levels is
more in favor of a caecal volvulus.
In the vast majority of patients, clinical examination
with X-ray finding alone is sufficient to make a
diagnosis of sigmoid volvulus
 Management
The management of volvulus starts with an evaluation of the
general condition of the patient.
Patients should initially be resuscitated with fluids and
electrolytes ,and broad spectrum antibiotics , followed by
emergency surgery.
A nasogastric tube for decompression and urinary catheter
to monitorurine output should be placed in all patients.
A central line may be of value in assisting fluid therapy in
elderly patients with co-morbidities. Patients with gangrene
will often need blood transfusion.
 Non-operative Intervention
Sigmoidoscopic or colonoscopic detorsion
Rigid or flexible sigmoidoscopy or colonoscopy is
preferred as the first modality of intervention.
In those cases where there is a short history and no
obvious signs of gangrene or perforation, on
clinical or radiological examination, endoscopic
decompression can be attempted.
The presence of necrotic material , ulceration or dark
blood = operate.
Colonoscopy will facilitate better visualization of
mucosa thereby helping to identify areas suspicious of
necrosis.
It will also help to assess the presence of any
concomitant pathology in the segment proximal to the
area of the twist.
 Complications of
sigmoidoscopy/colonoscopy
Perforation
Reperfusion syndrome …from untwisting of a gangrenous
segment.
If circumstances permit, an attempt at detorsion is highly
desirable since the outcome following elective surgical
intervention is superior to that in emergency settings.
Since the chances of recurrence following detorsion alone is very
high, all patients should undergo a definitive procedure in the
index admission unless they have severe co-morbidities
precluding surgical intervention.
Tube Decompression after detorsion
Apex of volvulus is identified as a spiralling of the
mucosa with accomapnying edema.
If reduction is successful an 18 F rectal tube is left
and the patient is prepared for elective surgery.
There is no hard and fast rule as to the length of
time a flatus tube should be left before proceeding
to surgery and it is reasonable to wait until the
patient is fully optimized for the surgery.
 Barium enema
Death from perforation and peritonitis are not
unusual complications of barium enema.
The use of this modality should be restricted and
should not be resorted to if facilities for
sigmoidoscopy or colonoscopy are available, or if
doubts as to the viability of the gut persist.
Water soluble contrast can be used if available.
# risk of spillage and contamination.
 Role of colostomy
Relatively simple technical procedure and is often
performed in elective and emergency surgery.
post operative complications vary
In many Third World countries the availability of
colostomy bags is restricted, and may be unaffordable for
the majority.
A colostomy is also a social taboo in certain societies.
 Considering the above factors and that many patients
cannot come for regular follow up
 Paul Mickulicz procedure
The gangrenous part is resected and both ends are
brought out as separate stomas. There are reports of
vascular compromise and gangrene of the stoma due to
traction on the exteriorized segment.
When the distal area of resection is close to the rectum, as
is often the case, it may warrant extensive mobilization of
the rectum which can add to time and morbidity from this
procedure.
This procedure is no longer recommended.
 Elective Surgery
RPA (Resection and primary anastomosis)
Elective resection following sigmoidoscopic resection and
resuscitation of the patient has a better outcome compared to
emergency surgery.
omega loop and that extensive dissection is unnecessary.
Considering that this is a benign pathology the inferior mesenteric
artery should be divided at the most accessible point.
For the reasons mentioned above, RPA is the gold standard for the
management of sigmoid volvulus in the elective situation.
Mesosigmoidoplasty

Detorsion with sigmoidopexy

The detorsion of colon ,the serosa is sutured to the
peritoneal wall with interrupted stitches or by gortex
banding.
The procedure can be time consuming and the results are
often equvalent to detorsion, with high rate of recurrence.
The procedure is not recommended.
 Special Considerations
Recurrence following resection is mentioned in the literature
though the number of cases is very small.
Concomitant megacolon or megarectum are recognized as
causes for the same.
When such conditions are suspected after initial reduction of
the volvulus, fluoroscopy may be used to assess the length of
non motile segment.
Segmental colectomy or subtotal colectomy may be undertaken
in such situations to include the entire non motile segment.
 Conclusions
Volvulus of the sigmoid colon is a major cause of intestinal
obstruction in both developing and developed countries and is
more common in the male sex.
The initial management consists of non-operative decompression
using sigmoidoscope, preferably flexible, followed by elective
surgery in the index admission in all candidates fit for surgery.
Patients in whom gangrene or perforation is suspected should
initially undergo rapid fluid resuscitation with appropriate
monitoring.
Broad spectrum antibiotics should be instituted as early as
possible.
Resection with primary anastomosis is the
gold standard and the experience of the
surgeon is crucial to its success in the patient
undergoing emergency surgery.
Hartmann‟s procedure, while certainly useful,
should be reserved for special situations –
hemodynamically unstable patient,
absence of a clear line of demarcation for the
distal part,
severe peritoneal contamination,
inability to perform a tension free anastomosis,
lack of adequate experience in the part of
operating surgeon
 References
https://www.iffgd.org/other-disorders/volvulus.html
Sigmoid Volvulus: A Nonresective Alternative for Viable Sigmoid
Colon. A K Khanna
Sigmoid volvulus By Dr. CHAITANYA KRISHNA
https://
www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptom
s-causes/syc-20351460
https://emedicine.medscape.com/article/2048554-treatment
https://www.medicalnewstoday.com/articles/321479.php
Thamk You
Kind Regards