Volvulus: A Comprehensive Understanding

Introduction

The term volvulus derives from the Latin word ‘volvere,’ meaning ‘to roll,’ and it accurately depicts this condition wherein a portion of the digestive tract twists upon itself, disrupting blood flow and normal functioning. Volvulus, though not a common medical term heard in daily life, has been documented throughout medical history, with cases reported as early as the 16th century. This article aims to elucidate what volvulus is, its progression, prevalence, and key risk factors associated with its development. Understanding this condition is crucial for early detection, intervention, and effective management, reducing potential complications.

Description of Volvulus

Volvulus is a serious condition characterized by the twisting of a loop of the intestine around its mesenteric axis, which leads to a closed-loop obstruction. This rotation can compromise the blood flow to the affected area, potentially causing ischemia, gangrene, and subsequent perforation if not promptly treated.

The progression of volvulus is contingent upon several factors such as location, degree of rotation, and individual health status. Symptoms can range from mild discomfort to severe abdominal pain, bloating, nausea, vomiting, constipation, and even shock, depending upon the severity of the condition.

Statistically, volvulus primarily affects the elderly, with sigmoid volvulus being more common in this population. However, it can occur at any age, including in neonates, where midgut volvulus is a life-threatening condition. Geographically, it’s more prevalent in certain regions, such as South America, Africa, and the Middle East, where high-fiber diets are common.

Risk Factors for Developing Volvulus

Lifestyle Risk Factors

Lifestyle-related risk factors largely pertain to dietary habits. Diets high in fiber can increase the risk of developing volvulus, particularly sigmoid volvulus, as large amounts of undigested material can weigh down the colon and predispose it to twist. Additionally, chronic constipation, related to low physical activity or inadequate hydration, can also contribute to the condition.

Medical Risk Factors

Several medical conditions may predispose an individual to volvulus. These include prior abdominal surgery leading to adhesions, Hirschsprung disease, Chagas disease, and other conditions that affect intestinal motility. Prolonged bed rest, particularly in the elderly, can also be a risk factor due to decreased intestinal motility.

Genetic and Age-Related Risk Factors

While volvulus is not directly linked to specific genetic factors, certain congenital malformations, like malrotation of the intestines, can increase the risk. Age is also a significant factor. In adults, particularly those aged over 65, the incidence of sigmoid volvulus is higher due to age-related changes in the body. Conversely, neonates can develop midgut volvulus as a result of intestinal malrotation, emphasizing the importance of early detection and intervention.

Clinical Manifestations

Severe Abdominal Pain

One of the primary clinical manifestations of volvulus is severe abdominal pain, experienced by approximately 70% of patients. The pain results from the twisting of the intestine, leading to ischemia, or inadequate blood supply. The severity may be influenced by the degree of rotation and the rapidity of onset. Notably, this pain might be more prevalent in the early stage of the disease.

Abdominal Distension

Abdominal distension is observed in approximately 80% of volvulus cases. As the twisted segment of the intestine blocks the passage of gas and stool, it leads to an accumulation, thereby causing the abdomen to swell or distend. This is a common symptom regardless of disease stage and can be particularly pronounced in patients with sigmoid volvulus.

Nausea and Vomiting

Approximately 50% of patients with volvulus experience nausea and vomiting, often a body’s response to severe pain and distension. As the intestinal obstruction worsens, the body may attempt to expel its contents upwards, leading to these symptoms. Nausea and vomiting tend to occur later in the disease course, usually when the obstruction becomes more severe.

Constipation

Constipation, defined as an inability to pass stools, is a common manifestation, seen in around 60% of cases. With the progression of the disease, the obstruction caused by the volvulus can lead to a complete halt in the passage of stools. This symptom is more common in later stages of the disease, often signaling a need for immediate medical attention.

Bloating

Bloating, experienced by approximately 80% of patients, is often a result of gas accumulation upstream of the obstruction site. The feeling of fullness or pressure in the abdomen can be quite uncomfortable. Similar to abdominal distension, bloating can be especially pronounced in sigmoid volvulus and is common throughout all stages of the disease.

Abdominal Tenderness

Abdominal tenderness is seen in nearly 75% of volvulus patients. The ischemia caused by the volvulus can lead to inflammation and sensitivity in the abdominal region. It’s a common symptom across all stages of the disease, and it may be particularly noticeable when the abdomen is touched or pressure is applied.

Inability to Pass Gas or Stool

Approximately 90% of volvulus patients may face an inability to pass gas or stool due to the obstruction created by the twisted intestine. This can be a particularly uncomfortable symptom and often coincides with bloating and constipation. It’s usually seen in the later stages of the disease, signaling a severe or complete obstruction that requires immediate medical attention.

Diagnostic Evaluation

The diagnosis of volvulus primarily involves the evaluation of clinical symptoms and specific diagnostic tests to confirm the condition. Understanding these tests, their utility, and interpretation will help in a patient’s journey towards accurate diagnosis and treatment.

Abdominal X-ray

One of the first-line investigations in suspected cases of volvulus is an abdominal X-ray. This non-invasive test uses a small amount of radiation to create images of structures within your abdomen. It can help identify signs of intestinal obstruction, such as distended loops of bowel or the characteristic “coffee bean” sign seen in sigmoid volvulus. Abdominal X-rays are important because

they are quick, readily available, and provide a good first step in identifying the issue.

Results indicative of volvulus on an X-ray could include dilated loops of bowel, air-fluid levels, or a “whirl” sign, which shows the twisting of the bowel around its blood supply. If these signs are not present, it doesn’t completely rule out volvulus, but it does make it less likely. In such cases, further diagnostic testing is usually needed.

Computed Tomography (CT) Scan

A CT scan, also known as a CAT scan, uses a combination of X-rays and computer technology to provide detailed images of your abdomen. The CT scan can provide more detailed images than a standard X-ray, making it useful for detecting volvulus, especially in more complex cases. It allows physicians to visualize the specific site of the obstruction, the degree of twisting, and any complications such as bowel ischemia.

In a volvulus diagnosis, a CT scan can show the “whirl” sign more clearly and can also detect reduced blood flow to the affected segment of the intestine. If the CT scan is negative but symptoms persist, it may be necessary to proceed with additional diagnostic procedures to rule out other possible causes of the symptoms.

Barium Enema

A barium enema is a type of X-ray test that involves filling the colon with a contrast material called barium, which makes the colon more visible on X-ray images. This test is particularly useful for diagnosing sigmoid volvulus as it allows visualization of the “twist” and helps in differentiating volvulus from other causes of bowel obstruction.

A positive result for volvulus in a barium enema would typically show a “bird’s beak” sign, which is the narrowing of the colon at the site of the twist. A negative result might suggest that the obstruction has resolved spontaneously or point to another cause of the patient’s symptoms.

Upper Gastrointestinal (GI) Series

An upper GI series is a series of X-rays of the upper digestive system. It requires the ingestion of a contrast material, usually barium, to visualize the esophagus, stomach, and small intestine. While not typically the first choice for diagnosing volvulus, it can be helpful in cases of suspected gastric or small bowel volvulus.

Results indicative of volvulus could show a corkscrew appearance of the contrast-filled bowel, suggestive of the twisting. If this test is negative, the symptoms might be due to a condition outside the upper GI tract or could indicate that the volvulus has spontaneously resolved.

Sigmoidoscopy or Colonoscopy

Sigmoidoscopy or colonoscopy are procedures that use a thin, flexible tube with a light and camera attached to visualize the rectum and colon. They are especially useful in diagnosing sigmoid volvulus and can sometimes be used to untwist the bowel at the same time.

During these procedures, the presence of a volvulus may be indicated by the discovery of a twisted segment of bowel. In some cases, these procedures can also reveal damage to the bowel wall caused by reduced blood flow. If these tests are negative, it may mean that the volvulus has resolved on its own or that the symptoms are due to another cause.

What if all Tests are Negative but Symptoms Persist?

If all tests come back negative but symptoms continue, it’s crucial not to dismiss the discomfort. Persistent symptoms warrant further investigation as they can signal other underlying

conditions. In such scenarios, patients should consult with their healthcare provider about the next steps, which might include a review of the previous tests, further diagnostic testing, or referrals to specialists. Understanding that each patient’s journey can be unique is integral to the diagnostic process.

Health Conditions with Similar Symptoms to Volvulus

Intestinal Obstruction

Intestinal obstruction is a condition that occurs when the intestines become blocked, hindering the movement of food or fluids through the digestive tract. This blockage can result from several factors, including impacted feces, hernias, or tumors. It shares many symptoms with volvulus, including abdominal pain, bloating, and inability to pass gas or stool.

However, the pattern and onset of symptoms may help differentiate between the two. Unlike volvulus, intestinal obstruction often starts with crampy, intermittent pain that gradually becomes constant. Imaging tests, such as abdominal X-rays and CT scans, can typically distinguish between the two conditions. A ‘whirl sign’ on a CT scan might suggest volvulus, whereas an obstruction might show a transition point with dilated bowel loops above the obstruction.

Gastroenteritis

Gastroenteritis, often called stomach flu, is inflammation of the stomach and intestines, usually caused by a viral or bacterial infection. Symptoms include nausea, vomiting, diarrhea, and abdominal cramping, which are also present in volvulus. However, gastroenteritis typically also includes a low-grade fever and lasts only a few days, while volvulus does not usually cause fever and its symptoms persist until treated.

Diagnosing gastroenteritis often relies on symptoms and possibly stool tests, especially if a bacterial or parasitic infection is suspected. Volvulus, on the other hand, is typically diagnosed via imaging tests such as an abdominal X-ray or CT scan, which can reveal the characteristic ‘whirl sign’ of twisted intestines.

Appendicitis

Appendicitis is an inflammation of the appendix, a small organ attached to the large intestine. It presents with severe abdominal pain that often starts around the navel and then moves to the lower right abdomen, which is similar to volvulus. However, unlike volvulus, appendicitis pain usually gets worse over a period of 12 to 24 hours and is often accompanied by loss of appetite, nausea, vomiting, and fever.

Appendicitis can often be distinguished from volvulus through physical examination and imaging studies. While CT scans or ultrasound can both detect an inflamed appendix, a volvulus might show the ‘whirl sign’ or dilated bowel loops in imaging studies.

Hernia

A hernia occurs when an organ pushes through an opening in the muscle or tissue that holds it in place. If the intestine or fatty tissue in the abdomen bulges out, it can cause a noticeable lump and pain similar to volvulus. However, the presence of a visible or palpable lump is more indicative of a hernia and doesn’t occur with volvulus.

To differentiate between the two, imaging studies are often helpful. An X-ray or CT scan may show the protrusion of organs typical in a hernia. A volvulus, on the other hand, might display a ‘whirl sign’ or twisted loop of bowel on imaging studies.

Inflammatory Bowel Disease (IBD)

Inflammatory bowel disease (IBD) is a term that primarily refers to two conditions: ulcerative colitis and Crohn’s disease. These conditions are characterized by chronic inflammation of the digestive tract, leading to symptoms such as abdominal pain, bloating, diarrhea, and weight loss, which can mimic volvulus. However, IBD often causes additional symptoms not typically seen with volvulus, including rectal bleeding, fatigue, and unintended weight loss.

To differentiate IBD from volvulus, doctors often use a combination of tests, including blood tests, stool tests, endoscopic procedures like a colonoscopy, and imaging studies. While the presence of inflammation or ulcers on colonoscopy may suggest IBD, the characteristic ‘whirl sign’ or twisted bowel loop in imaging studies is more indicative of volvulus.

Diverticulitis

Diverticulitis is a condition where small pouches or diverticula in the digestive tract become inflamed or infected. This condition can cause severe abdominal pain, fever, nausea, and a change in bowel habits, mirroring some symptoms of volvulus. However, diverticulitis often causes pain in the lower left side of the abdomen, while volvulus pain is often more generalized or located in other parts of the abdomen.

Diverticulitis can be distinguished from volvulus through imaging studies. While CT scans can reveal inflamed or infected pouches characteristic of diverticulitis, they can also display the characteristic ‘whirl sign’ or twisted bowel loop in cases of volvulus.

Bowel Ischemia

Bowel ischemia is a serious condition that occurs when blood flow to your intestines is reduced, often due to a blocked blood vessel. This can cause pain, bloating, and an inability to pass gas or stool, similar to volvulus. However, bowel ischemia often presents with a sudden onset of severe pain and may also cause rectal bleeding or bloody stool, which is not typical in volvulus.

To differentiate bowel ischemia from volvulus, healthcare providers rely heavily on imaging tests. While CT scans can reveal areas of diminished blood flow characteristic of bowel ischemia, they might also display the ‘whirl sign’ or a twisted loop of bowel in cases of volvulus.

Treatment Options

Medications

Pain medications (analgesics) and antibiotics are often used to manage symptoms and prevent or treat infection in volvulus cases.

• Pain Medications (Analgesics): These are used to help manage the severe abdominal pain associated with volvulus. The specific type and strength of medication used will depend on the severity of the pain.
• Antibiotics: These may be given to prevent infection if the twisted part of the intestine is feared to be or is already gangrenous.

Procedures

In most cases, a procedure will be required to treat volvulus. The choice of procedure depends on the severity and location of the volvulus, and the patient’s overall health.

• Detorsion (Manual Untwisting): This procedure is often performed during a colonoscopy. The healthcare provider uses the colonoscope to untwist the affected portion of the intestine. This is often used as a temporary measure to relieve symptoms until surgery can be performed.
• Surgical Resection: This surgery involves removing the affected part of the intestine and reconnecting the healthy sections. This is often necessary if the twisted portion of the intestine has become gangrenous.
• Bowel Resection: This is a type of surgical resection where a portion of the large or small intestine is removed. It is used in severe cases where there is a risk of recurrence or when the twisted section cannot be safely untwisted.
• Volvulus Reduction: This term refers to any procedure, whether manual or surgical, that untwists the intestine. The specific procedure chosen often depends on the location and severity of the volvulus.

Each of these treatments has different expected outcomes. Pain medications can offer immediate but temporary relief, while antibiotics can help prevent or treat infections. The procedural interventions can provide a more definitive solution, although they also carry greater risks. The expected outcome and recovery time vary based on the individual’s health and the specific treatment used. It’s crucial to discuss all these factors and treatment options with your healthcare provider to choose the best plan for your condition.

Improving Volvulus and Seeking Medical Help

Given the serious nature of volvulus, home remedies are not recommended. It’s important to remember that volvulus is a medical emergency and requires immediate professional attention. Trying to treat volvulus at home could delay critical medical treatment and potentially lead to severe complications, such as bowel ischemia, gangrene, and even life-threatening sepsis.

Prevention and Management of Volvulus: When to Seek Medical Help

Preventing volvulus primarily involves managing risk factors. Leading a healthy lifestyle, including maintaining a balanced diet and regular exercise, can help improve overall gut health. Individuals with known risk factors, such as chronic constipation or advanced age, should discuss with their healthcare provider how to best manage their risk.

If you or a loved one experiences symptoms of volvulus, such as severe abdominal pain, abdominal bloating, nausea, vomiting, or the inability to pass gas or stool, it is essential to seek immediate medical help. The convenience of telemedicine means you can reach out to a healthcare professional without the need to travel, and they can guide you on the next steps to take.

Living with Volvulus: Tips for Better Quality of Life

Living with volvulus, particularly after surgical treatment, may require adjustments to diet and lifestyle. Regular follow-up appointments with your healthcare provider, adherence to prescribed medication regimens, and prompt reporting of any new or worsening symptoms can contribute to a better quality of life.

Conclusion

Volvulus is a serious medical condition characterized by the twisting of a part of the digestive tract, which can obstruct blood flow and lead to severe complications. Symptoms include severe abdominal pain, bloating, nausea, vomiting, and inability to pass gas or stool. Diagnosis is usually confirmed with imaging tests, and treatment often involves surgical intervention.

Early diagnosis and prompt treatment are crucial for minimizing the risk of complications and improving outcomes. Therefore, if you are experiencing symptoms of volvulus, it is important to seek immediate medical attention. Our primary care practice, available via telemedicine, is well-equipped to help you understand your symptoms and guide you towards the appropriate next steps in your healthcare journey. Remember, your health is our top priority, and we’re here to provide the care you need, when you need it.

Brief Legal Disclaimer: This article is for informational purposes only and not intended as medical advice. Always consult a healthcare professional for diagnosis and treatment. Reliance on the information provided here is at your own risk.