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05-02-2008, 11:44 AM
m Definition:Twisting of a loop of the gut around its own mesentry.
A) Volvulus of the Small Intestine:
· Incidence: Uncommon.
· Cause: Rotation of S.I. with mesentery on an axis of bands, tumors or TB. lymph nodes, or Mickle's diverticulitis.
· Clinical picture and diagnosis
- Strangulated intestinal obstruction.
· Treatment:
- N/G. suction. - Fluids
- Exploration ® Viable loops ® deal with the cause
® Gangrenous loops ® resection anastomosis
B) Volvulus of the Caecum;
· Incidence: Rare
· Cause: Long mesentery of the caecum
· Pathology: Proximal & distal ® see strangulated intestinal obstruction.
at the site: - Rotation in a clockwise direction.
- The caecum distends and may burst.
- Usually distal ileum is involved
· Clinical Picture: of strangulated intestinal obstruction.
· Treatment:
- N/G suction - I.V. fluids.
- Operation: Exploration ® Untwisting and fixation if viable.
® Rt. hemicolectomy if gangrenous.
- If the involved segment is large ® shock occurs due to loss of blood into the lumen.
C) Volvulus of Sigmoid Colon " Pelvic Colon"
·Incidence: The commonest volvulus in Egypt.
Commonest in 40:60 ys. Male > female.
·Predisposing factors:
1-Dolichocolon (long colon with tall mesentery).
2- Narrow attachment to post. abd. wall.
3- Huge distention of colon with faecal masses due to habitual constipation.
4- Adhesive band attached to the anterior abdominal wall and the colon acts like an axis for rotation.
·Pathology:
- Proximal; (see before)
- Distal; (see before)

- At site; Rotation of the colon in anti clockwise direction ® Obstruction of the colon at both ends ® marked distention and strangulation of the wall ® gangrene.
- Incomplete rotation can be reduced spontaneously ® red currant jelly stool.
·Clinical Picture:
* Pain, vomiting, constipation, abd. distention, visible peristalsis, rebound tenderness with dehydration as any strangulated colonic obstruction.
* Hyperresonant (tympanitic) mass starting in the Lt. lower abdomen and may reach Lt. copula of diaphragm.
* Hicough due to irritation of the diaphragm.
* Inspite of being low obstruction, the vomiting is marked due to twisting and strangulation of the colon and sudden onset.

·Investigations:
1- P. R. ® to exclude cancer colon or rectum.
® blood on the finger may be detected.
2- Plain X-ray: Distended colon with gas (Haustration) which may reach Lt. copula of diaphragm.
3- Barium enema: Barium arrest.
4- Double enema test: 2nd enema without "3f" force, faeces, flatus
·Treatment:
- N/G suction - I.V. fluid
Then try rectal tube admission with caution
1) if it succeeded to pass into sigmoid ® copious amount of F. F.
Leave it for 48 hour
2) if failed do exploration
® Viable loop ® clockwise untwisting & fixation.
® Gangrinous loop ® Paul Mikulcz technique.
SOURCE: DR. AYMAN SALEM'S BOOK
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