How to listen your body in crisis with Volvulus ?

VOLVULUS  ( Twisting of intestine )

VOLVULUS  refers to the winding of a assets of the intestine around itself or a stalk of mesentery tissue to cause an obstruction. Volvulus occurs most ofttimes in the colon, although the breadbasket and small bowel crapper also twist. The conception of the digestive grouping above the volvulus continues to function and haw swell as it fills with digested food, fluid, and gas. A condition called strangulation develops if the mesentry of the bowel is twisted so tightly that murder line is cut off and the tissue dies. This condition is called gangrene.

VOLVULUS IS A SURGICAL EMERGENCY because gangrene crapper amend quickly, cause a mess in the wall of the bowel (perforation), and become life-threatening.

ITS AXIAL ROTATION HAS DIFFERENT TYPES

Volvulus Neonatorum

Volvulus of Small Intestine

Volvulus of Cecum

Volvulus of Sigmoid Colon

VOLVULUS NEONATORUM an intestinal obstruction in a new born resulting from a twisting of the bowl caused by malrotation or nonfixation of the colon .Floating of cecum , together with whole of small intestine which has a narrow attachment ,revolves.

Arrested rotation  , in which cecum remains in left hypochondrium ,and a peritoneal band is found running from cecum to right side of abdomen and then across the 2nd part of duodenum ( transduodenal band of Ladd )

In the clinical fearures ,there is some symptoms of Repeated vomiting , which will be bile stained .can also cause abdominal distension .

It can cause some signs of Dehydration and abdominal distension.
Few diagnostic test ,that shows or revealed a diseased portion.For this reason we can do PLAIN ABDOMINAL X-RAY it reveal stomach and upper part of duodenum are greatly distended ith air ,so called 'double stomach.

This condition needs immediate surgery included :

Early Laprotomy
Whole of the midgut is delivered on to the surface .
Untwisting is done in opposite direction .
Transduodenal band of Ladd is divided .
Abdomen is closed in layers .

VOLVULUS OF CECUM  nearly always occur in a clockwise direction. First twist obstructs the ascending colon  ,if a 2nd twist occurs ,it obstructs the ileum also .Axial torsion, the most common form of volvulus, occurs with the development of a twist of 180-360^o; along the longitudinal axis of the ascending colon. This form has a high mortality rate because the obstructive process is associated with vascular compromise, which can lead to gangrene and perforation, often on the antimesenteric border, where the ischemic changes may be most pronounced.

Nonspecific abdominal symptoms occasionally occur with abnormalities of fixation. Traction on the superior mesenteric artery with partial compression of the duodenum, gallbladder, pylorus, or kidneys has been implicated. The most important complication of the abnormalities of fixation is a volvulus of the right side of the colon and/or cecum.

The common presentation of a cecal volvulus is an acute abdomen, with colicky abdominal pain of sudden onset. Most cases of cecal volvulus reportedly occur in patients with a mobile, defectively fixed right colon while they are asleep. Normal movement of the patient from side to side during sleep may result in displacement of the right colon to an ectopic or abnormal location. When gaseous distention occurs, the displaced right colon is trapped, resulting in symptomatic acute volvulus.

The diagnosis is mostly based on plain abdominal radiographic findings aided by those of single-contrast barium enema examination. CT is useful in identifying signs of ischemia, which include mural thickening, infiltration of the mesenteric fat, and pneumatosis intestinalis. Treatment is surgical, but reduction of the volvulus has been reported after barium enema examination.colonoscopy may be considered for the purpose of decompression. Simple abdominal radiographs had a low diagnostic accuracy but revealed bowel obstruction. 

TREATMENT 

Laprotomy should be done ,Deflate the ballooned cecum by insertion of a needle .Untwisting is accomplished in opposite direction ,ie anticlockwise . Cecostomy is performed  , which relieves the distension  , and fixes the organ to abdominal wall ( preventing recurrence ) ,If cecum is gangrenous ,right hemicolectomy is performed .Abdominal wound is closed .

VOLVULUS OF SIGMOID COLON  

This  is the terminal section of the colon. Two body differences can increase the risk of colon volvulus. One is an elongated or movable colon colon that is unengaged to the left sidewall of the abdomen. Another is a narrow mesentery that allows winding at its base. Sigmoid volvulus, however, can occur modify without an body abnormality.

This type of twisting in the sigmoid can occur due to Band or Adhesions ( peridiverticulitis ) ,Overloaded pelvic colon ,Long pelvic mesocolon .Narrow attachment of pelvic mesocolon.

Loop  may rotate  half a turn , in which event spontaneous rectification sometimes occur .After the loop has rotated 1 1/2 turns ,veins involved in torsion are compressed  ,and loop becomes greatly congested .if it rotates more than 1 1/2 turns ,blood supply is cut off entirely and loop becomes gangrenous .Rotation nearly always occur in anticlockwise direction .

In clinical fearures ,it can shows the sumptoms of  sudden severe abdominal pain ,often coming on while the patient is straining at stool .Abdominal distension  ,hiccough and retching occur early ,Vomiting occur late ,absolute constipation .

some sgns of abdominal distension ,abdominal guarding and tenderness

DIAGNOSTIC INVESTIGATION

PLAIN ABDOMINAL X-RAY 
A connatural stark abdominal x-ray will demonstrate a huge air filled distended bowel like the appearance of an inverted U, with the convexity of the U covering the right upper abdominal quadrant. This appearance has been described as the kidney noodle shape, coffee noodle shape, bent inner plaything shape, ace of spades or ‘Omega loop Sign’. You can wager an example down in the inventiveness section.
  

BARIUM ENEMA 

With a water solvable metal enema, the distention in the sigmoid colon can be demonstrated to be cod to a twist, as it will show an Atlantic of rank obstruction with some twisting in the so called shuttle beak or shuttle of beast sign. 

TREATMENT

DEFLATION AT SIGMOIDOSCOPY 

Sigmoidoscopy is carried out and when obstruction is reached an attempt  is made to coax a soft rectal tube into twisted gut .This will immediately deflate the gut and operation can be delayed for a few days until the patient is more fit.

OPERATION 

Laparotomy is performed ( immediately if dilation is not successful ) .Untwist the gas filled viscus in aclockwise direction .Simultaneously ,a rectal tube is passed to deflate the colon .Resection and end-to-end anastomosis is carried out .Abdominal wound is closed.

Diverticular disease of colon common in western society

WHERE REFINED DIETS ARE MORE COMMON THAN RICH IN FIBRE

DIVERTICULAR DISEASES OF COLON 

Diverticula of colon are acquired rupture of colonic mucosa ,protruding through broadside muscle at points where murder vessels understand colonic surround .They consist of mucosa and submucosa that have cut the muscular coats . They are pulsion diverticula being pushed out by increased intraluminal push .Although they haw involve the whole of the colon .They are most ordinary in the colon

Diverticular disease is most ordinary in Western society ,where civilised diets are more ordinary than diets rich in fibre and hence the stool is inferior bulky . Patients with diverticular disease have shortened ,thickened colonic muscle which reflects work hypertrophy from years of  a baritone fibre diet and resulting small hard stools .High intra-luminal pressure occur ,pushing the diverticulae out through the surround .The inclination of divertculae to form in the colon colon is explained by Laplace's law which states that the push within a tube is

inversely proportional to the radius.

PATHOGENESIS 

DIVERTICULOSIS two factors are essential 1.exaggerated peristaltic contractions with abnormal elevation of intraluminal push ,and foci of muscle imperfectness in colonic surround.

DIVERTICULITIS it is the secondary land and is cod to rousing of one or more diverticula.

MICROSCOPIC FEATURES

DIVERTICULOSIS 

Muscular hypertrophy in colonic segments affected by diverticular changes.saccule are found penetrating between the mesentric and lateral teniae at points where entering arterioles branch out into submucosa .Diverticulae are small ,flask like or spherical outpouchings usually 0.5 to 1 cm in diameyer .Walls of diverticula are usually thin ,made up of mucosa and submucosa enclosed within fat or an intact peritoneal covering .

DIVERTCULITIS 


Inflammatory changes are present ,to produce both diverticulitis and periverticulitis and sometimes localized peritonitis .

SIGN AND SYMPTOMS OF DIVERTICULOSIS AND DIVERTICULITIS

Most patients with diverticulosis have no symptoms. Many will never know they have the condition until it is discovered during an endoscopic or radiographic (Xray) examination. While most people have no symptoms, some individuals may experience pain or discomfort in the left lower abdomen, bloating, and/or a change in bowel habits.

Other conditions such as irritable bowel syndrome and stomach ulcers cause similar problems, so the symptoms do not always mean a person has diverticulosis. People with chronic symptoms should visit their doctor or health care provider.

The most common symptom of diverticulitis is abdominal pain. The most common sign on examination is tenderness in the lower left side of the abdomen. Usually, the pain is severe and comes on suddenly, but it can also be mild and become worse over several days. The intensity of the pain can fluctuate. A person may experience cramping, nausea, vomiting, fever, chills, or a change in bowel habits...... read more