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Intestinal Volvulus
Small intestinal volvulus is a very rare entity in the western world. The corollary is true. It is very common in many other countries. In fact, it is reported to be the commonest cause of intestinal obstruction in parts of the world like Ethiopia. It is also called mid gut volvulus.
This occurs when the intestine twist around it self, causing a close loop blockage of the lumen of the small or mid gut.
Small intestinal or mid gut volvulus is often associated with a malrotation of the mid gut. It is however a very different entity from mal rotation.
Intestinal volvulus is a dire surgical emergency. If the twisting involves the large artery supplying the mid gut (superior mesenteric artery), that portion could rapidly become gangrenous (death of the tissue). Loss of mid gut is not compatible with life.
Cases of intestinal volvulus in man have been more commonly reported in Iran, India, Afghanistan, and Zimbabwe. It is postulated to be due to the consumption of very large amount of high residue diet.
Spider-web-like materials called adhesions following surgical operations in the abdomen could lead to these entangling the small intestines, and provide a fulcrum for twisting.
Stomach by-pass surgery for obesity (bariatic surgery) involving the Roux-en-Y surgical anastomosis could be complicated by small intestinal volvulus.
Rarely, ventriculo-peritoneal shunts for hydrocephalus could be complicated by the development of intestinal volvulus.
Other conditions associated with small intestinal volvulus include:
• Parkinson’s disease
• Diabetes
• Tumours e.g. fat mass on the wall of the small intestinal (mesenteric lipoma)
• Pregnancy
• Laxative use before colonoscopy
• Congenital mesocolic hernia
• Ingestion of magnets by a one year old child was reported recently (2005) as causing small bowel volvulus and perforation)
The pain could start off suddenly or gradually and worsen over a period of time. There would be associated vomiting and distension of the tummy.
The patient may be very shocked, more than can be explained by the physical findings. Patient may pass blood in stool. Fever sets in quickly from colonisation of the dying small bowel by gut occupying bacteria.
If treatment and urgent surgery is not undertaken, death is imminent.
Many surgeons would increasingly want to confirm the diagnosis of small bowel obstruction in intestinal volvulus by arranging and having an urgent CT (computed tomography)scan done. This is a special form of X-ray where the patient lies on on trolley and is passed through a huge donut-like machine. It is extremely helpful in confirming diagnosis of bowel obstruction.
This highlights the point that small intestinal volvulus is a very serious problem.
In those with chronic small bowel volvulus, the small bowel (intestine) could keep twisting and untwisting. When there is difficulty in untwisting, chronic small intestinal volvulus can present as an acute problem. The treatment here is nothing but surgery.
The cause of the volvulus is sort and dealt with. Mesenteric lipomas, swallowed foreign objects like magnet, are remediable causes.
Any gangrenous part of the small intestine is removed. If length of small intestine removed is two much, patient may need to be feed for life through the vein.
There is also the option of small intestine transplantation.
Small intestine transplantation is not as successful as kidney or liver transplantation.
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