Definition

Volvulus is when one or more parts of the digestive tract are twisted. This twist can cause intestinal obstruction or blockage. Intestinal obstruction will hinder blood flow to the intestine and is an emergency condition that requires immediate surgical treatment. If not treated, the part of the intestine that does not get enough blood supply will die.

Small and stomach intestinal volvulus usually occurs in infants and children. In adults, volvulus tends to occur in the large intestine, especially in the sigmoid and cecum areas. The sigmoid is the lowest part of the large intestine, while the cecum is the border area between the large intestine and the small intestine. So, the most common in adults is sigmoid volvulus and cecum volvulus.

Volvulus can be treated through surgery. Babies who have been free of volvulus can grow and develop normally. Volvulus is reported by countries in Africa, Asia, the Middle East, Eastern Europe, and South America. In Africa and the Middle East, 50% of large bowel obstructions are due to volvulus, mainly sigmoid volvulus. Volvulus is less common, 10-15% of all volvulus cases, and often in women around 60 years of age.

Cause

In infants, small bowel volvulus often occurs due to malrotation. Malrotation occurs when there is a mistake in the position of the intestine during its formation and development so that the intestine occupies the wrong place in the stomach. This position error can cause the intestine to twist and become blocked. Malrotation occurs in 1 out of 6000 newborns.

In adults, the causes of volvulus include:

• Large and long large intestine
• Adhesions of the abdominal organs after surgery, injury, or infection
• Diseases of the large intestine, such as Hirschsprung's disease. In this disease, there is a segment of the large intestine that does not have nerve cells. This segment is prone to be punctured 
• Large intestine that does not stick to the abdominal wall
• Chronic constipation (long-term)
• Pregnancy

Volvulus usually occurs because there is another underlying condition. However, sometimes it can occur on its own. 

Risk Factors

Risk factors for volvulus include:

• Air travel with a low-pressure cabin
• Weakness of the colon muscle (atony) 
• Enlargement of the large intestine
• Hirschsprung's disease. In this disease, the large intestine is inflamed and causes constipation and obstruction
• Infection
• Pelvic tumors
• Pregnancy (especially in the third trimester)
• History of abdominal surgery that causes organ adhesions
• Severe cough

Additional factors known to increase the risk of volvulus include:

• Male
• Over 60 years old
• Living in a nursing home or long-term care facility
• Patients with neuropsychiatric disorders such as Parkinson's disease or multiple sclerosis
• Muscular dystrophy disease
• Elderly patient who is lying on the floor

Symptoms

The symptoms of volvulus are considered severe and appear suddenly, so patients usually go directly to the emergency room. Symptoms of volvulus include:

• Abdominal pain and abdominal pressure pain
• Green vomit
• Nausea
• The stomach is distended.
• Bloody stool
• Constipation 
• Can't pass gas
• Shock, that is, the flow of blood to the whole body is disturbed so that the oxygen supply is reduced.

Babies with volvulus may show additional signs and symptoms, such as:

• Crying suddenly.
• Pulling the legs when crying because of pain.
• Lesu
• Heart rate and breathing increase

There are times when children experience intermittent volvulus, which is a condition where symptoms reappear periodically and then disappear on their own. Sometimes, the symptoms of volvulus are also similar to the symptoms of other digestive diseases such as irritable bowel syndrome or inflammatory bowel disease.

Diagnosis

A quick and accurate diagnosis will help determine the right treatment steps. If someone shows signs of volvulus, the doctor will ask about symptoms and health history, then do a physical examination. Patients may have a history of previous volvulus that has disappeared on its own.

To support the diagnosis, the doctor may also recommend the following examinations:

• Blood test
• Blood in the stool examination
• Barium examination and X-ray examination of the upper or lower gastrointestinal tract. With this examination, the doctor can find out the location of the puncture
• Computed tomography (CT) scan to see abnormalities in the stomach
• Sigmoidoscopy

Procedure

Volvulus requires immediate treatment and generally requires surgery. During surgery, the doctor will make a small incision in the abdominal wall near the location of the twisted intestine, then free the twist.

After that, the doctor will repair the blood flow to the previously twisted area. If the twisted part of the intestine has been without a blood supply for too long and its tissues have died, the doctor can cut and remove the dead part of the intestine.

Sometimes, many parts of the intestine have been damaged and must be removed. This causes doctors to have difficulty connecting the remaining intestine, which tends to be short. If this happens, doctors need to do a colostomy, which is connecting the two ends of the intestine to a hole (stoma) in the abdominal wall. If someone uses a stoma, feces will come out through the hole and enter the colostomy bag attached to the outside of the stomach. Colostomy can be permanent or temporary.

Sometimes, this procedure for repairing a volvulus can change the location of the appendix in the stomach. If this happens, the doctor can remove the appendix at the same time during surgery. If the appendix is left in place, it will be difficult to diagnose the appendix later. By removing the appendix, this will be prevented. 

Complications

Volvulus must be treated as soon as possible to prevent the risk of complications. Complications of volvulus can include any of the following problems:

• Constipation is heavy
• The stomach is getting bigger.
• Death of intestinal tissue, which cannot improve again
• Severe infections that spread throughout the body through the blood, called sepsis
• Malabsorption disorder called short bowel syndrome, caused by a reduction in the small intestine after surgery.
• Infection of the abdominal wall or secondary peritonitis
• Death if volvulus is not immediately treated. The mortality rate due to volvulus reaches 40% in patients who are late diagnosed and not treated in time.

There are several possible complications after surgery for volvulus, including:

• Recurrence (40-50%) after surgery using endoscopy alone
• Post-operative wound infection (8-12%)
• Leakage in the operated intestinal anastomosis (3-7%)
• Colostomy fistula, i.e. abnormal channel between the abdomen and the skin (2-3%)
• Abscess or pus accumulation in the abdomen or pelvis (1-7%)
• Sepsis or severe infection (2%)
• Death (12-15%)

Prevention

Until now, there is no definitive way to prevent volvulus. What can be done is to prevent volvulus from becoming heavier and threatening life and not recurring. This can be done by immediately seeing a doctor if you experience signs and symptoms of volvulus so that diagnosis and treatment can be carried out quickly.

When should you see a doctor?

Immediately visit the emergency unit if you experience any of the symptoms or signs of volvulus as mentioned above. Do not delay treatment because the longer the puncture, the more it will reduce blood flow to the intestine and can cause intestinal tissue death.

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