Annals of Nigerian Medicine

CASE REPORT
Year
: 2013  |  Volume : 7  |  Issue : 2  |  Page : 86--89

Primary volvulus of the small intestine


Nuhu Ali1, Mohammed Mubarak2, Yakubu Ali2,  
1 Department of Surgery, University of Maiduguri Teaching Hospital, Maiduguri, Borno State, Nigeria
2 Department of Surgery, College of Medical Sciences, University of Maiduguri, Maiduguri, Borno State, Nigeria

Correspondence Address:
Nuhu Ali
Department of Surgery, University of Maiduguri Teaching Hospital, P.M.B. 1414, Maiduguri, Borno State
Nigeria

Abstract

Small bowel volvulus is an occasional cause of mechanical intestinal obstruction in our practice causing diagnostic problems. We report a case of primary small bowel volvulus with gangrene. A 30-year-old farmer who presented with features of acute intestinal obstruction, which at laparotomy revealed a primary small bowel volvulus with a gangrenous loop of ileum. The patient was resuscitated and had exploratory laparotomy; with operative findings of a twisted loop of gangrenous ileum adjoining the ileocecal valve. This was resected and an end to end ileotransverse anastomosis effected. The patient made an uneventful recovery and was discharged on the 7 th postoperative day. Primary small bowel volvulus should be suspected in acute intestinal obstruction. It presents as an acute abdomen due to occlusion of bowel lumen alone or with obstruction of its blood supply leading to gangrene. Treatment includes resection and end to end anastomosis, which can help to reduce mortality and morbidity.



How to cite this article:
Ali N, Mubarak M, Ali Y. Primary volvulus of the small intestine.Ann Nigerian Med 2013;7:86-89


How to cite this URL:
Ali N, Mubarak M, Ali Y. Primary volvulus of the small intestine. Ann Nigerian Med [serial online] 2013 [cited 2020 Aug 13 ];7:86-89
Available from: http://www.anmjournal.com/text.asp?2013/7/2/86/133104


Full Text

 Introduction



Volvulus is a form of mechanical intestinal obstruction that results when a loop of the bowel is twisted around the axis of its own mesentery. It is most common in the sigmoid colon. It can affect the small intestine by two mechanisms; primary, when the cause is unknown and it occurs in a normal abdomen with no underlying anatomic defects or predisposing factors. This type is common among certain populations of Africa, Asia, and the Indian subcontinent, and postulated by some workers [1],[2] to be associated with ingestion of high-bulk vegetable diets, especially after prolonged interval of fasting. The abrupt transit of a large bulky meal into the proximal jejunum causes the resultant heavier segment of the bowel to migrate into the left lower quadrant because of the absence of resistance in the pelvis. The empty loops of distal jejunum and ileum are therefore forced in a clockwise rotation into the right lower quadrant predisposing to torsion of the mesentery. The typical patient of primary small bowel volvulus is a young adult male, who is muscular, a farmer from a rural area whose diet is mainly cereal and high fiber. [1] Among the predisposing factors to primary small bowel volvulus are, the presence of long mobile mesentery and a short mesenteric base, which makes the bowel loop susceptible to twisting. [3] The secondary type of small bowel volvulus has predisposing lesions like anatomic malformations and malrotations, bands and postoperative adhesions. [4] The clinical features of primary small bowel volvulus are those of acute abdomen with pain as a cardinal symptom due to obstruction of the bowel lumen and subsequently strangulation of its blood supply leading to ischemia and infraction. Little attention has been focused on this lesion, so there are only few specific detailed reports. Preoperative diagnosis may be improved on by exclusion of other common causes of acute abdomen. A clear case can be made for exploratory laparotomy after a thorough workup, and the results are gratifying. We report a case of acute primary small bowel volvulus that was diagnosed at laparotomy, and managed in our hospital.

 Case Report



NMG a 30-year-old Nigerian male presented with 1 week history of severe colicky, generalized and nonradiating abdominal pain, accompanied by moderate distension, high grade fever and vomiting. Pain was aggravated by movement with no relieving factors. There was associated constipation which started with reduced fecal quantity, with no hematochezia or passage of mucus. He had neither a history of previous laparotomy nor any intercurrent medical illness. There is no family history of similar illness; and is married to two wives with two children. On examination, he was restless and in painful distress, febrile with an axillary temperature of 37.7°C, dehydrated, not pale, anicteric, acyanosed with no pedal edema. The pulse rate was 96 beats/min regular and small volume and the blood pressure was 100/60 mmHg. The first (S1) and second (S2) heart sounds were normal with no murmurs or added sounds. The respiratory rate was 26 cycles/min, with normal breath sounds and air entry. Examination of the abdomen revealed moderate distension, with minimal movement on respiration and marked guarding preventing further palpation. There was marked renal angle tenderness and the bowel sounds were diminished. Digital rectal examination could not be concluded because of pain. A plain abdominal radiograph revealed dilated loops of small bowel with multiple air-fluid levels and relatively less gas shadows in the regions of the distal colon [Figure 1]. The packed cell volume was 42%. There was proteinuria of 2+ on urinalysis with other parameters being normal. The serum sodium (140 mmol/L), chloride (96 mmol/L), bicarbonate (26 mmol/L) and creatinine (94 mmol/L) were within normal limits; however, there were elevated serum levels of potassium (5.3 mmol/L) and urea (6.4 mmol/L). The thick film was positive for malaria parasites (++). The Widal test was not significant (Salmonella typhi as 1: 80 and Salmonella paratyphi as 1:20). A preoperative diagnosis of typhoid perforation was made with a differential diagnosis of upper bowel obstruction. The patient was resuscitated with intravenous (IV) normal saline, nasogastric tube decompression, and urethral catheter for monitoring the urine output with an optimum of 30-40 ml/h. Parenteral antibiotics used were 500 mg of metronidazole 8 hourly, and IV ceftriazone 1 g daily with a dose of both drugs given preceding induction of anesthesia. He had exploratory laparotomy and the findings at operation included a segment of ileum about 30 cm black in color, with no peristalsis on stimulation twisted 360° on its mesentery. The mesentery of the ileum was thrombosed in multiple sites [Figure 2] and [Figure 3]. The caecum and ileocecal valves were part of the mass though viable. The patient had right hemicolectomy and end to end ileotransverse anastomosis. He was transfused two pints of whole blood postoperatively. He did well and was discharged from the hospital 7 days after the surgery.{Figure 1}{Figure 2}{Figure 3}

 Discussion



Primary small bowel volvulus is a rare cause of small intestinal obstruction in Northern Nigeria, where the most common causes of intestinal obstruction are, obstructed or strangulated external abdominal hernia; closely followed by postoperative intestinal adhesions and congenital causes in children. [5] This contrasts sharply with reports from rural Nepal and the Gonder region of Ethiopia, where primary small bowel volvulus is reported to be the most common cause of intestinal obstruction and indication for laparotomy. [6],[7] These same reports [6],[7] indicated that young adult males are more affected and despite late presentation and the common finding of several centimeters of ischemic terminal ileum, the mortality was low. [8]

Roggo and Ottinger [9] described acute small bowel volvulus as a sporadic form of small intestinal obstruction, which is uncommon but important, with the risk of bowel ischemia and infection. Delay in diagnosis and therefore surgical intervention results in high morbidity and mortality which calls for surgeon awareness, accurate workup of the patient, and prompt surgical intervention. All 35 patients reported by Roggo and Ottinger [9] were confirmed at laparotomy just as in the index patient. The symptoms of abdominal pain, distention and vomiting are nonspecific and common to other causes of upper intestinal obstruction. No specific diagnostic clinical signs or abnormalities in the laboratory or radiologic findings are typical of primary small bowel volvulus. Matsuki et al. [10] described some useful computerized tomography findings that could help in the preoperative diagnosis and this included; a U-shaped configuration or radial distribution of distended, and fluid filled loops of small bowel converging toward the point of torsion (the Whirl sign), fusiform tapering loop of the small intestine or a beak sign in longitudinal section. The near impossibility of preoperative diagnosis based on clinical examination and plain radiographs alone is generally acknowledged and diagnosis is usually suspected by excluding other common causes of acute abdomen.

Immediate laparotomy is advocated in these patients, and there is no room for conservative management because the twisted loop of bowel carries a high risk of gangrene. Early diagnosis and surgical intervention offers the only possibility for minimizing an otherwise excessive mortality. Resection and primary anastomosis is reported to be a safe procedure. [11] The extent of resection varies based on the involved segment of small bowel. In this case, the terminal ileum juxtaposed to the caecum was involved warranting a right hemicolectomy with ileotransverse anastomosis. The prognosis of primary small bowel volvulus is good because the majority of affected patients are young and perforation is uncommon. [7],[11]

 Conclusion



Primary small bowel volvulus, a rare cause of small bowel obstruction in Europe and America is common in some parts of Africa and Asia; has no clear predisposing factors and no specific signs and symptoms, nor clear diagnostic imaging or laboratory parameters. Diagnosis is that of exclusion of the common causes of acute abdomen in the particular environment. Surgeons should always consider it in patients with features of acute abdominal pain due to upper intestinal obstruction and offer the patients immediate laparotomy based on that. Resection and primary anastomosis of the involved segment is the treatment of choice with a good prognosis. Kim et al. [12] have reported a case where diagnostic laparoscopy was used to confirm strangulation of primary small bowel volvulus and also offer prompt treatment. This suggests that in uncertain instances, diagnostic laparoscopy is a valuable tool for definitive diagnosis and prompt treatment. The postoperative complications are minimal, but there have been few reports of stricture formation at sites of anastomosis and recurrent torsion. [13]

References

1Ghebrat K. Trend of small intestinal volvulus in north western Ethiopia. East Afr Med J 1998;75:549-52.
2Duke JH Jr, Yar MS. Primary small bowel volvulus: Cause and management. Arch Surg 1977;112:685-8.
3Vaez-Zadeh K, Dutz W, Nowrooz-Zadeh M. Volvulus of the small intestine in adults: A study of predisposing factors. Ann Surg 1969;169:265-71.
4Welch GH, Anderson JR. Volvulus of the small intestine in adults. World J Surg 1986;10:496-500.
5Madziga AG, Nuhu AI. Causes and treatment outcome of mechanical bowel obstruction in north eastern Nigeria. West Afr J Med 2008; 27:101-5.
6Tegegne A. Small intestinal volvulus in adults of Gonder Region, northwestern Ethiopia. Ethiop Med J 1992;30:111-7.
7Parkes G. Primary small bowel volvulus in rural Nepal. Trop Doct 1997;27:156-8.
8Huang JC, Shin JS, Huang YT, Chao CJ, Ho SC, Wu MJ, et al. Small bowel volvulus among adults. J Gastroenterol Hepatol 2005;20:1906-12.
9Roggo A, Ottinger LW. Acute small bowel volvulus in adults. A sporadic form of strangulating intestinal obstruction. Ann Surg 1992;216:135-41.
10Matsuki M, Narabayashi I, Inoue Y, Yamasaki K. Two adult cases of primary small bowel volvulus: Usefulness of computed tomographic diagnosis. Radiat Med 1997;15:181-3.
11Gürleyik E, Gürleyik G. Small bowel volvulus: A common cause of mechanical intestinal obstruction in our region. Eur J Surg 1998;164:51-5.
12Kim KH, Kim MC, Kim SH, Park KJ, Jung GJ. Laparoscopic management of a primary small bowel volvulus: A case report. Surg Laparosc Endosc Percutan Tech 2007;17:335-8.
13Ray D, Harishchandra B, Mahapatra S. Primary small bowel volvulus in Nepal. Trop Doct 2004;34:168-70.