Analysis of clinical diagnosis and treatment of intestinal volvulus ... - BMC Gastroenterology

The incidence of intestinal volvulus is high in Asia, with 24–60 cases per 100,000 people [4]. The causes are mainly related to anatomical factors such as adhesion, intestinal diseases, and physical factors such as tumors and ascariasis. No matter where it occurs, it has the characteristics of acute onset, severe condition and rapid development, which is easy to cause intestinal blood circulation disorders, and can lead to intestinal ischemic necrosis, perforation, and even septic shock and death in the early stage [5]. Therefore, early diagnosis and timely treatment are very important.

Abdominal pain is one of the most common and typical clinical manifestations of intestinal volvulus. Abdominal pain is generally manifested as sudden and persistent abdominal pain, which is colic in nature and can radiate to the lower back, accompanied by nausea, vomiting, cessation of exhaust, cessation of defecation, ascites, etc. [6]. In this study, it was found that all patients had abdominal pain of different degrees, and 63.3% of them were accompanied by symptoms of anal exhaust cessation. Abdominal distension generally occurred in the late stage, which may be caused by the expansion of the intestinal tube above the site of intestinal obstruction. When the signs of peritonitis appear, it often indicates that there are adverse complications. In this study, 26 patients were found to have signs of peritonitis, but statistical analysis showed that there was no significant relationship between intestinal necrosis and signs of peritonitis, which may be related to the small sample size.

Previous studies have shown that small intestinal volvulus can occur at any age, while sigmoid colon volvulus is more common in elderly men, mainly due to the long sigmoid colon and relatively short mesangial vessels, or caused by inflammation and adhesion, which is related to long-term constipation [7]. We found that elderly patients accounted for 44.4% of the 9 patients with sigmoid volvulus. Acute small intestinal torsion is more common in young adults. In this study, among 21 patients with small intestinal volvulus, young and middle-aged patients accounted for 76.2%. Considering that this study is a small sample study, large sample studies are needed to confirm the incidence of volvulus in all ages.

Early imaging examination after admission can clarify the diagnosis of volvulus. Orthostatic abdominal plain film is an important imaging method for the initial screening of suspected intestinal obstruction. Patients with intestinal obstruction generally present with large isolated intestinal loops with general intestinal distensions or obvious inflation and stair-steping multiple air-fluid levels. In this group, 15 patients underwent abdominal upright plain radiography examination, and 8 patients showed intestinal obstruction. This indicates that for patients with abdominal pain and suspected intestinal obstruction, abdominal upright plain film has a high diagnostic value for intestinal obstruction. In the case of highly suspected volvulus based on clinical symptoms and imaging examinations, plain abdominal scan or enhanced CT is an essential imaging method for the definite diagnosis of volvulus. The obvious "sign of whirlpool, sign of beak, and target loop" found in abdominal CT can be considered for the diagnosis of volvulus [8,9,10]. We found that the positive diagnosis rate of abdominal CT plain scan for volvulus was 69.6% (16/23). In addition, due to the characteristics of "high resolution", the accuracy rate of intestinal dual-source CT for the diagnosis of intestinal volvulus can reach 80%. It can not only find the morphological changes of the lesions, but also determine the location, range, degree of the lesions and the causes of some diseases. In our study, the diagnostic rate of intestinal dual-source CT for volvulus was 80%, which was similar to the rate reported in previous literature [9]. This study shows that orthostatic abdominal plain radiography for patients with abdominal pain is beneficial for early screening of patients with volvulus, and CT examination is preferred for patients with highly suspected volvulus in clinic.

The treatment of volvulus includes non-surgical treatment, endoscopic treatment and surgical treatment. Non-surgical treatment includes symptomatic and supportive treatment such as gastrointestinal decompression, fluid replacement, anti-infection, and correction of electrolyte acid-base balance disorder. It is suitable for mild conditions without severe symptoms such as intestinal ischemia. Once the disease progresses or becomes worse, emergency surgery should be performed immediately [11]. Laparoscopic colorectal surgery has been the subject of discussions in terms of indications and results. Previous studies find that the use of laparoscopy for the management of sigmoid volvulus is safe, feasible and associated with a low prevalence of complications (operative duration, infection, blood loss, hospital stay, recurrence, conversion, morbidity, mortality). Laparoscopy was used for different situations to treat sigmoid volvulus. The most frequent indication was uncomplicated sigmoid volvulus after endoscopic detorsion (96.5%) [12]. Since our hospital has not carried out colonoscopy examination and reduction of sigmoid colon torsion, colorectal resection are still performed open. In our study, the condition of the 30 patients did not improve significantly under supportive treatment, all the 30 patients underwent surgical treatment. In surgical treatment, the small intestinal volvulus should be treated as soon as possible. During surgical exploration, the intestinal tube should be decompress and reduced, and then the blood supply of the intestinal canal and mesentery should be observed. If there is a necrotic intestinal tube, the necrotic intestinal segment should be resected to prevent abdominal infection caused by endotoxin in the intestinal cavity. When removing the intestinal tube, it should be reasonably selected according to the necrotic tissue and local intestinal blood supply, and it should not be too long to avoid the occurrence of postoperative short bowel syndrome. Generally, the resection range should be 3 ~ 5 cm beyond the necrotic site [13]. In this study, among the 17 patients with intestinal volvulus, 11 patients without intestinal necrosis underwent surgical reduction, while 6 patients with intestinal necrosis underwent resection of necrotic bowel. For volvulus of the sigmoid colon, if it is a congenital anatomical abnormality, it can be treated with reduction and fixation without resection after evaluation. Simple reduction of sigmoid colon has a high recurrence rate of 50%. Intraoperative reduction and the second-stage sigmoid colon resection are the most effective methods. In this group of 9 patients with sigmoid colon torsion, 7 patients with sigmoid colon volvulus underwent partial intestinal resection with volvulus reduction of sigmoid colon and fistulation, and 7 patients underwent ostomy reentry operation. 2 patients underwent sigmoid volvulus reduction.

Intestinal necrosis is one of the serious complications after intestinal volvulus [14]. In this study, 11 of the 30 patients had intestinal necrosis with an incidence of 36.7%. The length of intestinal necrosis ranged from 30 to 70 cm. Intestinal necrosis must be excised. If not, it will cause more serious complications such as peritonitis, infection, toxic shock and so on. However, excessive resection of necrotic bowel can also cause short bowel syndrome and reduce the quality of life of patients. Therefore, early identification and prevention of intestinal necrosis is also very important. Through statistical analysis, we found that the occurrence of intestinal necrosis and the cause of intestinal torsion were not significantly related to the presence or absence of signs of peritonitis, while the longer course of disease (> 24 h), massive ascites, and the significant increase in white blood cell count and neutrophil percentage were often accompanied by the occurrence of intestinal necrosis. We think because of the small sample size, conclusions about peritonitis are not necessarily accurate. Therefore, in clinical practice, we should be alert to the above clinical manifestations and laboratory test results of patients with volvulus, and perform surgery as soon as possible to avoid the occurrence of intestinal necrosis and improve the prognosis of patients.