Volvulus

1. Disease Description (Causes and Symptoms)

• Definition: Volvulus is a condition in which part of the intestine twists around the mesentery, blocking the passage of intestinal contents and cutting off blood flow, resulting in intestinal obstruction and intestinal ischemia (necrosis).
• Causes and pathophysiology:
  • Congenital intestinal malrotation (e.g., malrotation in children) or excessive intestinal mobility due to an abnormally long mesentery
  • Structural abnormalities such as intra-abdominal adhesions (after surgery or peritonitis), megacolon, severe constipation, and diverticula
  • Features by location: the sigmoid colon (especially in older adults) may develop sigmoid volvulus; the appendix and ileocecal region may develop cecal/ileocecal volvulus; midgut volvulus may occur in children
  • Intestinal obstruction due to twisting → increased intraluminal pressure → venous obstruction → reduced arterial blood flow → ischemic necrosis → perforation and peritonitis
• Main symptoms:
  • Sudden, severe abdominal pain (intermittent pain initially → persistent pain)
  • Vomiting (sometimes projectile vomiting; bilious or non-bilious), constipation or inability to pass stool or gas (symptoms of obstruction)
  • Abdominal distension, bloody stool (when ischemia occurs), dehydration, generalized weakness and shock (as the condition progresses)
  • Newborns/infants: abdominal distension, pallor and lethargy, irregular breathing, jaundice, etc.

2. Treatment Methods and Precautions

• Emergency principle: Volvulus is an emergency condition, and immediate surgical treatment is required when ischemia or necrosis is suspected.
• Initial nonsurgical treatment (when stable):
  • Fluid replacement and electrolyte correction, fasting, and gastrointestinal decompression with nasogastric (NG) tube insertion
  • Antibiotics: empirical intravenous broad-spectrum antibiotics when intestinal ischemia or perforation is suspected
  • In cases of sigmoid volvulus, stable patients may undergo temporary reduction with painless transrectal tube decompression/endoscopic decompression (flexible colonoscopy or enema)
  • Because the recurrence rate is high after successful decompression, planned surgery (adhesiolysis/fixation or resection and anastomosis) is typically recommended
• Surgical treatment:
  • Detorsion of the intestine by laparoscopy or laparotomy, with resection of necrotic intestine
  • Depending on the condition after resection, immediate primary anastomosis or a proximal stoma (temporary ileostomy/colostomy) is selected
  • Midgut volvulus due to malrotation in children requires a Ladd procedure (lysis of intestinal adhesions and correction of intestinal positioning)
• Complications and prognosis:
  • With delayed treatment, intestinal necrosis can progress to perforation → peritonitis → sepsis and shock, increasing the mortality rate
  • Short bowel syndrome or long-term decline in intestinal function may occur after intestinal resection
  • The prognosis is favorable with early treatment, but it varies depending on whether necrosis or perforation is present and on the patient’s overall condition
• Self-care and precautions:
  • Visit the emergency department immediately for abdominal pain, vomiting, or abnormal bowel movements (especially inability to pass stool or gas)
  • If you have underlying conditions (severe constipation or a history of intestinal surgery), receive regular care and prevent constipation (dietary fiber, fluids, and regular bowel habits)
  • Because recurrence is common after endoscopic decompression, consult a specialist about the need for surgical treatment

3. Checklist Before an Outpatient Visit (Including Example Questions)

• Items and information to prepare:
  • List of medications currently being taken (including anticoagulants, antiplatelet agents, etc.)
  • Surgical history (abdominal surgery and possible adhesions) and existing diagnoses (such as megacolon or intestinal malrotation)
  • Allergy history (medications, latex, etc.)
  • Recent symptom progression: when the pain started and its pattern (intermittent/persistent), presence and characteristics of vomiting, whether stool or gas can be passed, fever, dizziness, etc.
  • Bring copies of previous test results, if available (abdominal X-rays, CT scans, colonoscopy, etc.)
• Expected tests and preparation:
  • If you have emergency symptoms (severe pain, vomiting, inability to pass stool, or fever), go directly to the emergency department rather than an outpatient clinic
  • When scheduling an outpatient visit, keeping a recent symptom diary (changes by time of day) can help with diagnosis

4. General Example Questions to Ask the Doctor

• "Given my current condition, do I need immediate surgery? Is observation or endoscopic treatment possible?"
• "What are the advantages and disadvantages of each recommended treatment option, and how long is the recovery period?"
• "If I undergo surgery, how high is the risk of complications (infection, fistula, short bowel syndrome, etc.)?"
• "What lifestyle habits should I follow to prevent recurrence after surgery or endoscopic treatment?"
• "How long is the expected hospital stay, and when can I expect to return to daily activities (exercise, driving, and work)?"

5. Examples of Condition-Specific Questions

• If sigmoid volvulus is suspected: "If initial treatment with endoscopic decompression (enema/colonoscopy) is planned, what is the recurrence rate, and would subsequent surgery be recommended?"
• If midgut volvulus (malrotation) is suspected in a child/infant: "If intestinal malrotation (or malrotation) is suspected, is immediate surgical (Ladd) treatment necessary? How likely is it that the intestine can be preserved during surgery?"