Symptoms and first signs of volvulus in adults and children: treatment features

Causes

1. Hereditary factors and structural anomalies;
2. Severe increase in intra-abdominal pressure (due to injury, heavy physical activity);
3. Hernias with weakness of the anterior abdominal wall and peritoneum;
4. The presence of foreign bodies in the intestinal lumen;
5. Tumors, cysts;
6. Scars and adhesions;
7. Overeating after prolonged fasting, which causes increased intestinal motor function. Physical activity immediately after eating;
8. 8.Increased intestinal motility: when consuming large amounts of fiber (this disease is often found in vegetarians), using medications that affect the contractile function of the gastrointestinal tract (laxatives, psychotropic drugs - pathology is often found among patients in psychiatric hospitals);
9. Intestinal infections (increased motility, prolonged fasting);
10. Chronic constipation;
11. Complication of endoscopic examination due to violation of the technique;
12. Inflammatory bowel disease (mesosigmoiditis);
13. In rare cases - massive infestation with worms.

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What is volvulus

This is called torsion of a loop of intestine around the axis of the mesentery. What does this mean?

The mesentery is a serous membrane in which the vessels feeding the intestines pass, as well as nerves and lymphatic vessels. It consists of two layers of peritoneum (a membrane that envelops the intestines from above in the form of a thin film), between which there is adipose tissue and many vessels pass through.

The mesentery is not only a feeding organ, but also a fixing organ. This is part of the peritoneum that moved to the intestine, enveloped it on all sides and returned to the posterior wall of the abdominal cavity. As a result, the intestine seems to hang on such a ligament.

The mesentery, which approaches the intestinal loops, has different lengths. So, the small intestine is held on a fairly long section, which allows the entire mass of intestines to move. The mesentery of the large intestine is short, so the colon seems to be soldered to the posterior wall of the abdominal cavity.

Volvulus in adults is when a loop of intestine turns around its axis. As a result of this twisting, the vessels located in the mesentery are also compressed. The intestine, not receiving nutrition, dies, and the products of its death poison the entire body.

Volvulus can be:

• partial: if the mesentery has rotated up to 270°;
• complete: if the twisting occurred at 270-360°;
• double or triple full (shown in the picture).

Symptoms

When torsion of the sigmoid colon occurs, the following manifestations are observed:

• There is a sharp cutting and stabbing pain in the lower abdomen. It radiates to the lower back and sacrum. It is constant in nature, less often cramping, occurs at the moment of intestinal volvulus and is associated with a violation of the blood supply.

• 2-3 times vomiting with bile, which does not improve the condition. With the onset of peritonitis, it may be mixed with feces (in later stages).
• At the time of volvulus, increased peristalsis is noted, followed by intestinal paresis, gases and feces cease to pass away.
• The abdomen is greatly distended and asymmetrical - the upper right sections protrude due to displacement of the sigmoid colon.
• Difficulty breathing and irregular heart rhythm: the volume of the transverse colon increases due to gases. The intestine puts pressure on the diaphragm, it moves upward, which in turn compresses the heart and lungs, their work is disrupted. Also, increased intra-abdominal pressure interferes with normal blood flow, which puts extra strain on the heart. Manifested by arrhythmia, tachycardia and chest pain.

In the subacute form, the symptoms are less pronounced.

With volvulus of the small intestine and cecum, the symptoms are similar. Initially, acute intense pain occurs, which increases, and it becomes difficult to endure. It can be either constant or cramping, has a stabbing or cutting character. Concentrated in the upper abdomen. The patient takes a lying position with his knees bent and pressed to his stomach, but this does not bring relief. The behavior is restless, patients may scream in pain or rush around the bed.

• The abdomen is swollen and asymmetrical, with a protrusion in the navel area;
• Intensified waves of peristalsis are visible on its surface, cramping pain and rumbling appear;
• Repeated vomiting, first with food and bile, and at a later stage with feces;
• Retention of feces and gases may not be observed, since peristalsis of the underlying parts of the colon is preserved. And if treatment is carried out in a timely manner, there will be no bowel dysfunction. If several hours have already passed from the onset of the disease, a symptom may develop.
• General intoxication of the patient and his serious condition.

Danger of intestinal obstruction

With advanced obstruction, feces are sometimes thrown into the stomach. In this case, intussusception in children makes itself known by vomiting with a characteristic odor. The phenomenon is considered extremely unfavorable for the body, because it is poisoned by waste and toxins. If parents hesitate to go to the clinic, twisting of the intestine will lead to such consequences as:

• sepsis;
• peritonitis;
• dehydration;
• necrosis of intestinal tissues;
• rupture of the problematic intestine;
• violation of water-salt balance.

In the worst cases, death occurs from volvulus of the large or small intestine. But even if the child survives, intussusception affects his further development and causes diarrhea or constipation.

Diagnostics

It is important to make a correct diagnosis and begin treatment as soon as possible. If the patient’s condition does not allow it, then the diagnosis is made based on the results of a patient interview and examination data. The final clarification of the cause of intestinal obstruction is carried out on the operating table.

The clinical picture and physical examination findings have characteristic features.

Bloating, asymmetry, abdominal pain, increased peristalsis are detected, and an emptiness is felt in the place where the intestine should be. At the site of the inversion there is a dense round formation.

An important diagnostic measure is a digital rectal examination, which reveals an enlarged and empty rectal ampulla. If the patient's condition allows, you can check the Tsege-Manteuffel symptom.

Blood and urine tests are prescribed. From instrumental studies - survey radiography (the intestine is swollen above the site of volvulus, below - collapsed loops).

If colonic obstruction is suspected, intestinal radiography with contrast is performed only by introducing a barium suspension through the rectum. For small intestinal diseases, on the contrary, orally.

Usually the results of these studies are sufficient to make a diagnosis. When examining a pregnant woman, diagnosis begins with ultrasound.

Treatment

Doctors quickly identify volvulus in children based on general symptoms. After treatment, the child should be monitored over time. As soon as changes in the pulse and intoxication are noted, the condition should be diagnosed immediately.

The main therapy consists only of surgery. Moreover, any intestinal volvulus is a reason that requires urgent hospitalization of the patient. The disease interferes with small intestinal and large intestinal patency. Therefore, if a child develops atypical bowel function, parents should urgently show it to a pediatric surgeon in order to prevent tissue necrosis and death of the baby.

Typically, intestinal volvulus requires unwinding of the problem area and adhesive dissection. It is worth noting that sigmoid colon volvulus can recur, manifesting itself again in a subacute or acute form. Therefore, it is precisely in cases of volvulus of the sigmoid colon that surgery is required to eliminate the obstruction with the prevention of relapse.

In surgery, the most common practice is to remove a volvulus of any intestine using the simultaneous “Greeks II” resection method. After resection, antibiotics, swabs and drainage are administered. Almost 100% of children recover completely after such a procedure. A timely operation is an action aimed primarily at eliminating death, and only then at preventing relapse. Understanding this and taking urgent measures, parents ensure their child a speedy recovery. In addition, the faster treatment is performed, the lower the risk of relapse of the disease.

Why is bloat dangerous?

Normally, a large amount of fluid is released into the lumen of the gastrointestinal tract. For adults this is:

• about 1.5 liters of saliva;
• 2 liters of gastric juice;
• 1.5-2.5 liters of pancreatic secretion;
• 3 liters of intestinal juice;
• up to 1.5 liters of bile.

90% of this mixture of fluids should be absorbed into the blood.

When the intestine twists around its axis, it stops both forming new intestinal juice and absorbing everything that was already in it at that moment. The fluid contained in the intestine causes swelling of its wall, and blood from the vessels begins to leak into the intestinal lumen. Already on the first day of illness, 5-6 liters of liquid may remain in the intestines, and some more liquid will be in the abdominal cavity. This means that for this it must come out of the vessels and tissues.

When tissues are dehydrated and the amount of fluid in the vessels decreases, the adrenal glands are commanded to produce aldosterone and ADH. These hormones make it so that a lot of sodium remains in the body, and its antagonist, potassium, must accordingly be released - with urine and vomit. This imbalance of sodium and potassium changes the pH of the blood and tissues. Because of this, cells are damaged. As their death increases, the amount of potassium in the blood increases, and it blocks the spread of impulses from the nerve to the muscles, and also greatly worsens the functioning of the heart (when potassium rises above 6 mmol/l, the risk of cardiac arrest increases sharply).

Not just water, but a protein-rich liquid (from cell destruction) sweats into the lumen of the twisted intestine. It becomes an excellent breeding ground for microorganisms living there. As a result:

• the more aggressive ones are activated;
• some of them are displaced to other parts of the intestine, which are not adapted for this.

As a result of their vital activity, microbes secrete an increased amount of substances, which, together with inflammatory molecules, are massively absorbed into the blood. Intoxication is increasing.

After some time, microorganisms overcome the intestinal barrier and enter the abdominal cavity. Purulent peritonitis (inflammation of the peritoneum) develops, further increasing intoxication and leading to serious disruptions in the functioning of all vital organs.

Poor circulation of the twisted intestine and overstretching it with fluid lead to a hole appearing in the intestinal wall. The contents of the intestine exit through this opening, increasing the symptoms of peritonitis.

Prevention of relapse

Unfortunately, volvulus can recur. More often it is not volvulus that recurs, but another type of intestinal obstruction associated with the formation of adhesions in the abdominal cavity. To prevent this, after discharge from the hospital, you need to keep in touch with the doctors at the clinic or hospital: they should prescribe procedures and medications that prevent the formation of adhesions. It is also important in the postoperative period to follow the diet prescribed by the doctor and avoid constipation.

Volvulus is a fairly common form of intestinal obstruction. This phenomenon occurs due to torsion of any part of the intestine around its own axis with impaired blood circulation.

The subsequent condition of a person depends on the degree of torsion - intestinal volvulus can cause peritonitis or intestinal necrosis, and in some cases even death. Volvulus is a dangerous condition that should be treated immediately at the first manifestations of the pathology.

How is volvulus treated?

Treatment for volvulus in adults is surgical only. Doctors make a large incision, through which they remove and examine the swollen intestines. They quickly find the place of the volvulus, and then their task is not to untwist the intestine, but to assess its viability and remove the part of the intestine that has died. If it is the sigmoid colon, then it is removed, and the overlying section of the intestine is brought to the anterior abdominal wall in the form of a stoma - so that feces and gases are released from there. If the volvulus was in the area of ​​the small intestine, then after removing the dead intestine, the remaining parts are stitched together (anastomosis is performed).

If peritonitis is detected, a stoma can be used to remove the cecum. Then, after treating inflammation of the peritoneum, after 3 months you can perform a reconstructive operation - reconnecting the removed intestine with the large intestine remaining in the abdominal cavity.

After the operation, a probe is passed through the entire intestine, which is removed through the nose. Based on the discharge from the probe, they can see how intestinal motility has been restored. Also, in the postoperative period, antibiotics and drips with the introduction of saline solutions and glucose are necessarily prescribed. The abdominal cavity is washed through drains installed during the intervention.

It must be said that the less time has passed from the moment of illness to surgery, the greater the chances of a favorable prognosis. Why? Because there will be fewer disturbances in water, electrolyte and acid-base balances, and this means that the operation can be started as soon as possible, without lengthy preliminary preparation. That is, to quickly stop the death of an even larger section of the intestine.

Statistics

Most often, the sigmoid colon is twisted (80% of all intestinal twists), then the small intestine (in 15% of cases), less than 5% occurs in the large intestine, which is located near the spleen.

The intestinal volvulus itself accounts for only 4-6% of all intestinal obstruction. The remaining cases occur when the intestinal lumen is blocked by adhesions or a tumor. People over 60 years of age are most often affected.

For all types of intestinal obstruction, the mortality rate is 3-10%. After operations, unfortunately, a third of people around the world die.

Why does volvulus develop?

The causes of volvulus are a combination of one of the predisposing and one of the producing factors.

Predisposing factors are:

These are all congenital factors. They can cause bloat, not necessarily in childhood, but also in adults - it all depends on when the producing factor of the required strength acts.

Additional predisposing factors that are more typical for adults are:

• abdominal adhesions;
• scars on internal organs;
• pregnancy, most often - the 3rd trimester, when the uterus displaces the intestines, especially the sigmoid colon;
• intestinal infection, as a result of which the lymph nodes located under the mucous membrane of the small intestine become enlarged;
• cystic fibrosis of the intestine;
• bowel prolapse;
• Meckel's diverticulum.

Volvulus often accompanies pathologies of the nervous system: multiple sclerosis, mental illness, senile dementia.

Now about the producing factors. They are:

• eating large amounts of vegetables or fruits, which causes intestinal activity to sharply increase or flatulence to develop;
• fasting, after which a person began to immediately eat roughage or large amounts of it;
• taking medications that enhance peristalsis (laxatives, psychotropics);
• heavy physical activity, which increases intra-abdominal pressure;
• inflammation of the intestines, which occurs, for example, when bacteria enters food (for example, salmonella or dysentery bacillus);
• prolonged constipation;
• acute appendicitis.

The main cause of intestinal volvulus in infants is the introduction of complementary foods. In this case, an acute condition can develop even without predisposing factors, especially if the child was given a large amount of complementary foods or took too rough food for this. In some cases, a child becomes ill when they return to complementary feeding without waiting 4-5 weeks after an intestinal infection (including rotavirus). In this case, the lymph nodes have not yet had time to shrink, and roughage already causes the intestines to work actively, and in some cases the loop begins to wrap.