A Rare Metachronous Colonic Volvulus by Philip Ade Ekhaiyeme in Journal of Clinical Case Reports MedicaI Images and Health Sciences

 A Rare Metachronous Colonic Volvulus by Philip Ade Ekhaiyeme in Journal of Clinical Case Reports MedicaI Images and Health Sciences 

Abstract

Introduction: Colonic volvulus is a common cause of large bowel obstruction with the sigmoid colon most commonly affected. Volvulus of the transverse colon is an uncommon occurrence. Rarer still is a transverse colon volvulus developing after surgery for a sigmoid colon volvulus. Early diagnosis is critical as delay in detection and intervention is associated with the risk of complications – perforation, peritonitis, and death.

We discuss the case of an 86-year-old man presenting with features of large bowel obstruction 14 months following a sigmoid colectomy for a sigmoid colon volvulus. An erect abdominal radiograph showed massively dilated large bowel loops with multiple air-fluid levels, a gasless pelvis, and no free air under the diaphragm. Obstruction did not resolve with initial non-operative measures necessitating surgical intervention. Following resuscitation, he had an exploratory laparotomy with findings of a transverse colon volvulus twisted 5400 in an anticlockwise manner with a perforation on the descending colon for which he had a left hemicolectomy. The postoperative course was uneventful.

Conclusion: A metachronous transverse colonic volvulus is uncommon. Pre-operative diagnosis is challenging as there are no defining radiographic features compared to the volvulus of the sigmoid colon with the classical omega sign. Most cases are diagnosed intra-operatively. Bowel resection and anastomosis in a single stage is a safe option.

INTRODUCTION

Colonic volvulus is the torsion of the colon on its mesentery, with the sigmoid colon the most affected (75%).[1,2] There are a few cases of volvulus reoccurring in the same patient after treatment for an initial one.[3] We share our experience in the management of a patient with metachronous colonic volvulus.

Case Presentation

An 86-year-old man, with no known comorbidity, presented with a five-day history of colicky abdominal pain, worsening distension, and associated constipation which progressed to obstipation. The pain worsened significantly but with no associated vomiting. His last bowel movement was 4 days before presenting to the hospital. There was no history of fever, jaundice, early satiety, spurious diarrhea, the passage of pellet-like stools, or weight loss.

At admission, he was pale, not dehydrated, and tachycardic with a pulse rate of 120 per minute. His blood pressure was consistently high from presentation although he was not previously diagnosed as hypertensive. His abdomen was markedly distended with a midline longitudinal scar and hypoactive bowel sounds. There was no rebound tenderness. A digital rectal examination revealed scanty hard feces.

Past medical history showed he had a similar presentation fourteen months prior, with complaints of recurrent, worsening abdominal distension over a preceding 6 months period with associated pain, anorexia, and weight loss. Abdominal radiograph and ultrasound scan confirmed abdominal distension with volvulus.

The full blood count revealed neutropenia and eosinophilia. Further workup tests for surgery were all within normal limits, including the electrolytes, urinalysis, and clotting profile. A plain abdominal x-ray revealed the classic omega sign (shown in Fig. 1). He had an exploratory laparotomy and the findings were markedly dilated sigmoid colon rotated about 2700 anticlockwise along its mesentery and it appeared pink and normal and contained hard feces (shown in Fig. 2). The caecum, ascending colon and transverse colon were noted to be mildly dilated. He had a one-stage sigmoidectomy with end-to-end anastomosis

With the current admission, a provisional diagnosis of adhesive bowel obstruction was made. Resuscitation was commenced with a nasogastric tube passed for immediate decompression. Evaluations were done to rule out a possibility of a second volvulus in this patient or Ogilvie syndrome as a second alternative. He was rehydrated with intravenous fluids and had a trial of enema done with minimal improvement.

He had a normal white cell count with a neutrophil predominance of 80.6% and a hematocrit value of 39.3%. Biochemical parameters were essentially normal except for a potassium level of 3.0mmol/L which was corrected before surgery. Viral markers were all negative and the clotting profile was not deranged. Urinalysis showed proteinuria, ketonuria, and haematuria. He had an erect abdominal radiograph done which showed multiple air-fluid levels and a gasless pelvis and a supine view showed massively dilated (>10cm) bowel loops peripherally located, with haustra markings (shown in Fig. 3).

Carcinoembryonic antigen was not elevated. Glycated hemoglobin was done after random plasma glucose was noted to be elevated. This was normal -5.9%. There were no abnormalities on the plain chest radiograph. His ejection fraction on echocardiography was 67%.

He underwent an exploratory laparotomy after the correction of hypokalaemia. Intraoperatively, findings included a massively dilated transverse colon that was twisted 5400 in the anticlockwise direction, perforation in the descending colon with spillage of intestinal contents (shown in Fig. 4). The bowel was viable and a left hemicolectomy was done with one-layered end-to-end anastomosis using 2-0 VicrylTM.

Following surgery, the clinical course was uneventful and he was discharged home 8 days after surgery.

Discussion

Colonic volvulus is the third leading cause of large bowel obstruction. [1] The sigmoid colon is the most affected site. [2] Though relatively uncommon, cases of recurrence of a colonic volvulus have been reported, particularly among younger age groups. [3,4]

Synchronous colonic volvulus is when different segments of the colon are affected simultaneously[5,6]. Few cases have been reported. [7,8,9] Metachronous colonic volvulus affects another segment of the colon at least six months after surgical resection of the previously affected segment of the colon in the same patient. Faranisi reported a similar presentation in a 28-year-old man who presented 3 years apart, with a transverse colon following the occurrence of sigmoid volvulus.[10]

The major risk factor in our patient was a long mesentery. Similarly, in the patient reported by Faranisi, the transverse colon also had a long mesentery. Besides, his ascending and descending colons were notably very mobile – described by the author to be ‘almost as if they had a mesentery’.[10] Both the congenital failure of the right and left colons to be fixed retroperitoneally and his long transverse Meso colon were thought to be probable causative factors. [10]

Several surgical options might be considered in the management of a metachronous volvulus. The patient described here had a surgical decompression at the initial facility where he received care before subsequent sigmoidectomy at his first presentation at our facility and left hemicolectomy after his second presentation

The management of colonic volvulus depends on the clinical status of the patient.[10] The decision to do a left hemicolectomy following representation with a transverse volvulus, in this case, was because of the patient’s age and the need to reduce the risk of short bowel syndrome.

An initial attempt at non-operative treatment might be unsuccessful. The patient presented had a surgical decompression which failed. Several authors also report failed attempts at non-operative management. As such, the definitive treatment of metachronous volvulus should always be surgical and one-staged. [11] Non-operative treatment should not be considered beyond the emergency.

Conclusion

A metachronous colonic volvulus is a rare form of colonic volvulus. Operative treatment offers the best outcomes.

Conflict of Interest : The authors have no conflicts of interest to declare.

Funding Sources: No funding was sought for this study

Author Contributions:

Dr. P. A Ekhaiyeme: Conceptualization, care of patient and writing.

Dr. N. A Olagunju: Care of patient, writing and review.

Dr. O. A Ajagbe: Care of patient and review.

Dr. O. J Bello: Care of patient and writing.

Dr. P. H Yatu: Care of patient.

Dr. O. O Afuwape: Review.

Prof. D. O Irabor: Care of patient, supervision, review and resource.

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