Endoscopic detorsion of sigmoid volvulus in a young female: a case report

Abstract

Background

A volvulus refers to the torsion or rotational twisting of a portion of the gastrointestinal tract, with a predilection for impacting the caecum and sigmoid colon, often resulting in the development of bowel obstruction. The risk factors associated are old age, chronic fecal impaction, psychiatric disorders, colonic dysmotility, prior abdominal surgical procedures, diabetes, and Hirschsprung's disease. Elderly are most commonly affected with sigmoid volvulus but there are few cases among young adults that culminate in grave complications. Although it is rare, but young individuals presenting with acute abdomen secondary to sigmoid volvulus need urgent attention. To prevent more invasive surgical procedures, endoscopic detorsion is preferred nowadays with complete recovery of patients. We present a case of young female who was successfully managed with endoscopic detorsion.

Case presentation

27 years old Asian Pakistani female presented with worsening abdominal distention, constipation and vomiting since 2 days. On examination she was afebrile, vitally stable. Abdomen was distended, tympanic percussion with generalized tenderness. Abdominal radiograph was obtained which showed dilated bowel loops followed by Computed tomography of abdomen which was suggestive of Sigmoid volvulus causing intestinal obstruction. Patient was immediately moved to endoscopy unit and endoscopic detorsion of volvulus was done. For individuals who present with sigmoid volvulus and do not exhibit signs of peritonitis or colonic gangrene, the recommended course of action involves acute endoscopic detorsion, followed by scheduled surgical intervention.

Conclusion

This case report emphasizes the significance of clinicians considering sigmoid volvulus as a rare but important cause when evaluating abdominal pain in young and otherwise healthy patients. A delay in diagnosis and treatment extending beyond 48 hours leads to colonic necrosis, amplifying the associated morbidity and mortality. Swift intervention is imperative to mitigate these complications and attain a conclusive remedy.

Background

A volvulus, in simplified terms, denotes the torsion or twisting of a segment of the gastrointestinal tract, with the caecum and sigmoid colon being the most frequently affected areas, frequently culminating in bowel obstruction [1, 2]. Intestinal volvulus, irrespective of its anatomical location, represents an uncommon pathological condition. However, it demands a heightened sense of clinical suspicion and expeditious diagnosis due to the elevated risk of intestinal necrosis and the potential for life-threatening consequences [3]. The precise etiology of a sigmoid volvulus remains elusive, though it is associated with various risk factors. These factors encompass a familial predisposition, a diet rich in dietary fiber, prolonged institutionalization, chronic fecal impaction, psychiatric disorders, colonic dysmotility, prior abdominal surgical procedures, diabetes, and Hirschsprung’s disease [4, 5].

Sigmoid volvulus usually occurs in older adults. As shown by Esra Dişçi, the mean age of sigmoid volvulus patients was 61.2 and most common risk factors were excessive eating after prolonged fasting and increased bowel motility [6]. Another study by Trigui Emna showed the average age of the patients was 62 years, with an age range spanning from 42 to 95 years. The highest frequency of occurrence was observed in the age bracket of 61–70 years. Additionally, 46.87% of the patients presented concomitant medical conditions, such as hypertension, diabetes mellitus, neurological disorders, and chronic obstructive pulmonary disease [7]. We present a unique case of sigmoid volvulus in young female with no prior comorbid illness successfully managed endoscopically.

Case presentation

27 years old Asian Pakistani female presented with worsening abdominal distention, constipation and vomiting since 2 days. She had a recent history of spontaneous vaginal delivery two days back. The pregnancy was uneventful and she did not have any prior medical or surgical history. On examination she was afebrile, vitally stable. Abdomen was distended, tympanic percussion with generalized tenderness. Digital rectal examination revealed an empty rectum, with no obvious pathology. Abdominal radiograph was obtained which showed dilated bowel loops in left hemi abdomen, measuring 17 cm (Fig. 1). Blood workup was sent which revealed Hemoglobin of 12.5 g/dl, WBC of 11.2, Platelets of 439, Creatinine of 0.6 mg/dl, Na of 145, K of 3, CL of 105 and Bicarbonate of 16.1, Lactate of 1.4. Urgent CT Scan abdomen and pelvis was done which showed significant distention of large bowel involving ascending, transverse and descending colon, with abrupt point of transition in sigmoid colon without any evidence of mass lesion. There was twisting of mesentry and mesenteric vessels (whirl sign) in the region of sigmoid colon with part of sigmoid and rectum being collapsed (Figs. 2, 3). Findings were suggestive of sigmoid volvulus resulting in large bowel obstruction. Patient was immediately moved to endoscopy unit and endoscopic detorsion was attempted. Sigmoidoscopy showed volvulus obstructing lumen with no ulcerated or ischemic changes. Successful colonic decompression and endoscopic detorsion of volvulus was done (Fig. 4,5). The rectal tube was placed which was taken out the following day, and the patient was discharged when she could tolerate oral feeding without experiencing abdominal pain or distension. Surgical follow up was given. Patient remained stable for one year and did not require any surgical intervention. She is still under follow up and being managed for constipation with laxatives.

Fig. 1

Abdominal radiograph showing dilated bowel loops in left hemi abdomen, measuring 17 cm approximately

Fig. 2

CT scan image showing Twisting of sigmoid colon giving a whirl appearance suggestive of sigmoid volvulus

Fig. 3

CT Scan showing dilated bowel loops

Fig. 4

Endoscopic view of volvulus obstructing lumen with no ulcerated or ischemic changes

Fig. 5

Post endoscopic detorsion view

Discussion

For individuals who present with sigmoid volvulus and do not exhibit signs of peritonitis or colonic gangrene, the recommended course of action involves acute endoscopic detorsion, followed by scheduled surgical intervention. This approach is advocated in light of the elevated recurrence rates (43–75%) and mortality rates (15–40%) associated with reliance on conservative management alone [8]. Study conducted by Atamanalp showed a success rate of 77% with non-surgical detorsion of sigmoid volvulus, while surgical procedures were only done for patients who developed complications [9]. Although there exist certain controversies and constraints, particularly concerning the approach to cases involving ischemia or gangrene, as well as considerations related to factors influencing the procedure's success, instrument selection, technical nuances, the utilization of flatus tubes, and specialized situations such as sigmoid volvulus in pediatric or pregnant populations, endoscopic decompression remains the primary therapeutic modality for carefully selected patients with sigmoid volvulus [10]. The rate of unsuccessful colonoscopic decompression displayed a marked association with a history of prior abdominal surgery and a cecal diameter exceeding 10 cm [11].

A shift in paradigm has been noticed with younger age group being affected these days. There have been few case reports of sigmoid volvulus among young adults with no previous significant medical or surgical history [12,13,14]. Some case reports of pregnant females have been published with complicated sigmoid volvulus [15,16,17]. While the precise occurrence rate of intestinal obstruction during pregnancy remains undefined, estimates suggest it may manifest in approximately 1 in 1500 to 1 in 66,431 birth cases. The etiology of intestinal obstruction in pregnancy mirrors that observed in non-pregnant individuals and encompasses factors such as adhesions, abdominal wall hernias, left colon cancer, internal hernias, Meckel’s diverticulum, volvulus of the sigmoid colon, and intussusceptions [15]. Sigmoid volvulus is the most common cause of intestinal obstruction during pregnancy [18]. Although it is yet to be established if it can predispose patients to develop sigmoid volvulus during postpartum period. Sarfaraz et al. has described similar cases in his case series and has concluded that although acute sigmoid volvulus is a frequently considered diagnostic possibility in older patients who are confined to bed or have psychiatric comorbidities, however, it is equally imperative to include this condition as differential for younger patients experiencing paroxysmal abdominal pain and complete constipation [19]. Our patient did not have significant risk factors other than intermittent constipation during pregnancy. Post-delivery sudden development of intestinal obstruction raises the possibility of vaginal delivery as a potential cause of sigmoid volvulus and warrants further research in this area.

Conclusions

This case report emphasizes the significance of clinicians considering sigmoid volvulus as a rare but important cause when evaluating abdominal pain in young and otherwise healthy patients. A delay in both diagnosing and initiating treatment surpassing the 48-h threshold precipitates colonic necrosis, thereby exacerbating the consequential morbidity and mortality. Swift intervention is imperative to mitigate these complications and attain a conclusive remedy.