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Emergency and Acute Medicine: Volvulus
Volvulus is an axial twisting of a segment of the gastrointestinal tract around its mesentery, resulting in partial or complete bowel obstruction. This twisting can compromise venous outflow and eventually arterial inflow, leading to bowel ischemia, gangrene, and possible perforation. It is a life-threatening surgical emergency, particularly when vascular compromise is present. Volvulus accounts for approximately 10–15% of colonic obstructions and is most commonly seen in the cecum and sigmoid colon. Cecal volvulus typically affects younger adults due to congenital mobility of the cecum, whereas sigmoid volvulus is more common in elderly, institutionalized patients with chronic constipation, neurologic disease, or psychiatric illness. In children, especially neonates, midgut volvulus occurs due to congenital malrotation and often presents early with bilious vomiting.
The clinical presentation varies depending on the location and severity but generally reflects bowel obstruction. Patients commonly report colicky abdominal pain, abdominal distention, obstipation, nausea, and vomiting. The onset may be acute or more insidious, particularly in sigmoid volvulus, where symptoms may recur intermittently over weeks or months. In contrast, midgut volvulus in infants presents abruptly with bilious vomiting and abdominal pain. Signs of bowel ischemia or gangrene include fever, tachycardia, hypotension, peritoneal signs (guarding, rebound), hematochezia, and shock, indicating advanced disease and the need for immediate surgical intervention.
Diagnosis relies on clinical suspicion supported by imaging. Plain abdominal radiographs may demonstrate characteristic findings such as the “coffee bean” sign in sigmoid volvulus or a displaced, dilated cecum. However, CT imaging is the preferred modality in adults and may reveal the classic “whirl sign” of twisted mesenteric vessels. In pediatric patients, an upper gastrointestinal contrast study is the most sensitive initial test and may show a “corkscrew” appearance of the twisted bowel. A barium enema may demonstrate a “bird’s beak” deformity, though it must be used cautiously due to the risk of perforation.
Initial management focuses on rapid stabilization. Patients should be kept nil per os (NPO), and aggressive fluid resuscitation should be initiated with isotonic fluids such as 0.9% saline (2 L bolus in adults or 20 mL/kg in children). A nasogastric tube should be inserted for decompression, and electrolyte abnormalities should be corrected. Early consultation with surgery and gastroenterology is essential. Definitive management depends on the type of volvulus and the patient’s condition. In stable patients with sigmoid volvulus, endoscopic decompression may be attempted and is often successful, although recurrence is common and elective surgical resection is usually required. In unstable patients or those with cecal volvulus, urgent surgical intervention with bowel resection is necessary. In children with midgut volvulus, emergency surgery (Ladd procedure) must be performed promptly to prevent bowel necrosis.
Medication management is supportive and aimed at preventing or treating complications such as infection, ischemia, or perforation. Broad-spectrum intravenous antibiotics should be administered when there is concern for sepsis or bowel compromise. Options include Ampicillin-sulbactam at a dose of 3 g IV every 6 hours (pediatric: 100–200 mg/kg/day divided every 6 hours), or Cefoxitin at 2 g IV every 6 hours (pediatric: 80–160 mg/kg/day divided every 6 hours). Another commonly used regimen is Ceftriaxone 1–2 g IV every 12–24 hours combined with Metronidazole 500 mg IV every 8 hours (pediatric metronidazole: 30 mg/kg/day divided every 6 hours). Alternatively, Piperacillin-tazobactam may be used at 3.375–4 g IV every 4–6 hours (pediatric: 200–300 mg/kg/day of the piperacillin component divided every 6–8 hours). These regimens provide essential coverage against gram-negative and anaerobic organisms commonly involved in bowel infections.
All patients with suspected volvulus require hospital admission and urgent surgical evaluation, as there are no safe discharge criteria. Delayed diagnosis significantly increases morbidity and mortality, particularly if bowel ischemia develops. Early recognition, aggressive resuscitation, appropriate antibiotic therapy, and timely surgical intervention are critical to improving outcomes and preventing life-threatening complications.
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