Fig 2 - uploaded by Inian Samarasam
Content may be subject to copyright.
Source publication
Primary splenic flexure volvulus is a rare entity. We report an acute presentation of primary splenic flexure volvulus with gangrene in a 24-year-old man. Radiograph showed a massively-dilated large bowel loop with a coffee-bean sign. At emergency laparotomy, a distended and gangrenous splenic flexure was found, with absence of all three ligamentou...
Context in source publication
Context 1
... emergency laparotomy, a distended and gangrenous splenic flexure, which had twisted two and half times in the clockwise direction, was found (Fig. 2). All three ligamentous attachments of the splenic flexure (phrenicocolic, gastrocolic and splenocolic ligaments) were absent. The spleen was normal in position and there was no associated support, but otherwise had an uneventful postoperative recovery. He was discharged and advised to return for stoma closure and restoration of bowel ...
Similar publications
We report a case of colonic volvulus in a 7-year-old child with normal development. Operative findings at laparotomy showed a 270-degree transverse colonic volvulus (TCV), with colonic ligamentous attachment abnormalities. A loop ileostomy was formed following detorsion, with delayed laparoscopic colopexy. This is the first case to describe decompr...
Volvulus of the splenic flexure is very rare cause of
colonic obstruction constituting 2% of cases of colonic
segmental volvulus. Primary splenic flexure volvulus
(SFV) is due to congenital absence or laxity of the
phrenocolic, gastro colic, and splenocolic ligaments
while secondary volvulus is due to other causes
including some prior surgery relea...
Citations
... [6] If a gangrenous bowel is discovered endoscopically or during laparotomy, resection and creation of a Prasad-type colostomy is advised. [3,7] Primary anastomosis is not recommended given the high risk of anastomotic leak in this setting. [2] In the absence of ischemic bowel, resection of the involved colon is performed through a standard left hemicolectomy with primary anastomosis. ...
... The reason that this condition is so unusual stems from the fact that the splenic flexure of the colon is held in a fairly stable position in the left hypochondrium [3]. The causes of the colonic volvulus at the splenic flexure are either thought to be congenital or acquired [2,4,5]. Due to the high risk of mortality of this condition, clinical awareness needs to be further acknowledged [6]. ...
... The transverse colon is an atypical location for intestinal volvulus to occur, with an incidence rate of 3%. Lastly, the rarest location is at the splenic flexure where the incidence rate is only 1 -2% of cases in adults [5,7,9]. Up until 1953, splenic flexure volvulus was an unrecognized cause of intestinal obstruction with the first case being reported by Glazer and Adlersberg [2,3]. ...
... Congenital causes most often present in the paediatric population with the reasoning being that there is absence or malformation of the ligaments mentioned above [3,4]. On the other hand, acquired causes may be prior abdominal surgery leading to adhesions, pregnancy, colonic dysmotility and chronic constipation [2,5,7,10]. All these factors give result in laxity of splenic flexure which pre-disposes the patient to volvulus. ...
Citation: Mirza Faraz Saeed., et al. "Splenic Flexure Volvulus in a Young Woman; Atypical Presentation". EC Gastroenterology and Digestive System 8.7 (2021): 69-75. Abstract Splenic flexure volvulus is a rare clinical entity making up less than 2% of colonic volvulus cases. Due to the rarity of this condition the index of suspicion is low, making its prompt diagnosis and management unlikely. Splenic flexure volvulus may happen in children due to the absence or malformation of the ligaments that hold the splenic flexure in place. On the other hand, it may also occur in adults due to laxity of those ligaments, for example, secondary to previous abdominal surgery. In most cases if patients are presenting acutely they will present with large bowel obstruction otherwise in the chronic setting they may present with chronic abdominal pain and chronic constipation. Here, we will present a splenic flexure volvulus case report about a middle-aged female who presented to the emergency department with acute abdominal pain, abdominal distention and vomiting. Computed Tomography (CT) renal without contrast was useful and illustrated the radiological signs of the splenic flexure volvulus. Urgent laparotomy was ultimately performed on the patient which revealed a gangrenous splenic flexure volvulus. It was resected with transverse end colostomy formation. Literature review is done in this case report taking into consideration the common etiologies, predisposing factors, clinical presentation, investigation and management of patients that presented with splenic flexure volvulus.
... Nevertheless, female predominance, and a median age of 53 years have been reported. The SFV is more common in regions of Africa, Southern Asia and South America [7]. ...
... The primary SFV is characterized by recurrent signs and symptoms of colonic obstruction or abdominal pain in a patient without a previous history of abdominal surgery. In some cases, the primary SFV has been associated with congenital anomalies including congenital bands, wandering spleen, the Triad syndrome and Chilaiditi syndrome [7]. Also, motility disorders, including chronic idiopathic intestinal pseudo-obstruction syndrome, increase the length and width of the transverse colon and its mesentery gradually in time [8]. ...
... In most cases, SFV occurs as a non-acute and non-specific recurrent abdominal pain with distension and vomiting; however, acute onset abdominal pain with rapid development to colonic ischemic signs and gangrene with subsequent peritonitis is rare [7]. ...
Introduction
Splenic flexure volvulus (SFV) occurs as a result of twisting or torsion of a redundant colon around its mesentery. The SFV can be divided into primary and secondary types.
Presentation of case
An 82-year-old woman with a previous history of Parkinson's disease, diabetes mellitus and hypertension presented with a primary complaimt of obstipation and progressive abdominal pain. Abdomen was grossly distended and tympanic with generalized tenderness. The rectum was empty on digital rectal examination. Complete blood count showed leuckocytosis and neutrophlia. Plain abdominal X-rays showed distented cecum and ascending colon without any air in the gut distal to the splenic flexure. Regarding her unstable condition even aftre fluid resuscitation, she was transferred to the operating room. SFV was found and the standard left hemicolectomy was performed and bowel continiuity was established with primary anastomis of remained colonic ends. Postoperative period was uneventfull.
Discussion
The splenic flexure is strictly attached to the adjacent organs so its volvulus is rare. Most cases of adult SFV have an underlying disease associated with chronic constipation. Diagnosis of volvulus is suspected based on the history, clinical exam, and imaging. The initial and urgent treatment of SFV, if there are no signs of ischemia or perforation, may be conservative with endoscopic detorsion. Gangrenous bowel should not be detorted and should be resected with primary anastomosis or a diverting stoma.
Conclusion
SFV should be considered as a possible diagnosis of chronic constipation which might be diagnosed with plain abdominal Xray in non emergent condition. Special attention should be given to the medication history of the patient as the anticholinergic agents propagate normal pristaltis.
... Colonic volvulus is a common cause of large bowel obstruction accounting for 1-5% of large bowel obstructions. 1 The sigmoid colon, caecum and ascending colon are common sites of volvulus. The splenic flexure is, however, a rare site of volvulus due to its attachments by phrenico-colic, gastro-colic, and spleno-colic ligaments. ...
... Volvulus is an axial twist of a portion of the gastrointestinal tract along its mesentery, potentially causing a luminal obstruction and associated venous and arterial occlusion. 1 The incidence of volvulus of large bowel varies widely. In the western population, large bowel volvulus accounts for 1-5 % of all large bowel obstructions. ...
Splenic flexure volvulus is rare and results from congenital or postoperative laxity of splenic attachments. A 34 year old female presented with features of large bowel obstruction due to splenic flexure volvulus. She underwent laparotomy with detorsion and colopexy of the volvulus.
... 4,[6][7][8][9][10][11] Clinical symptoms can be acute or chronic; acute presenting as large bowel obstruction and chronic as intermittent pain in abdomen. 2 Radiographical signs suggesting this rare diagnosis are: (a) a markedly dilated, air-filled colon with an abrupt termination at the anatomic splenic flexure; (b) an empty descending and sigmoid colon; (c) a characteristic beaking at the anatomical splenic flexure at a barium enema examination; (d) "coffee bean" appearance of the dilated colon with the concavity of the "bean" facing the left upper abdomen; (e) two widely separated air-fluid levels, one in the transverse colon and the other in the cecum; (f) absence of rectal gas. 12,13 Management begins with resuscitation followed by definitive steps. 12 Actual diagnosis is often not achieved until on the operation table. ...
... 12,13 Management begins with resuscitation followed by definitive steps. 12 Actual diagnosis is often not achieved until on the operation table. 5,14 The options available for treatment include per rectal decompression with a flatus tube or sigmoidoscope or colonoscope, colopexy, or resection of the involved segment. 2 Simple deflation may be attempted, if successful should be followed by elective operation. ...
... The colopexy techniques may include the usage of non-absorbable sutures, Gore-Tex strips, or extraperitonealisation to anchor the redundant colon. 12 Even after an exhaustive search for metachronicity of volvulus of the splenic flexure in the past literature, only a handful of case reports could be retrieved and mostly they have discussed of sigmoid and caecal volvulus. [15][16][17][18][19][20][21][22] None of the reports described of splenic flexure volvulus as a metachronous event to sigmoid volvulus. ...
Intestinal obstruction due to volvulus is a well-known entity in India, one of the ‘volvulus belt’ countries; but volvulus of the splenic flexure is a rare condition, even more so when metachronous. Only about half a century of citations has been mentioned in the surgical history since its first mention in literature. Our patient, a young man with a history of previous two abdominal operations presented with signs of intestinal obstruction which were confirmed by radiological findings to be volvulus of splenic flexure. Following failed attempted derotation by flatus tube, he underwent laparotomy, intraoperative derotation of the volvulus followed by resection of the involved segment and colo-colic anastomosis with diverting loop ileostomy. Apart from surgical site infection, his postoperative recovery was uneventful.
... Mortality depends on certain factors such as location of the volvulus, the presence of peritonitis and the viability of the bowel. 7 The surgical treatment depends on the viability of the bowel and stability of the patient. If the bowel is not viable, resection is mandatory with either ostomy formation or primary anastomosis. ...
SUMMARY
Colonic volvulus involving the caecum and splenic flexure
of the colon is an extremely rare surgical entity and, as a
result, it is rarely entertained as a differential diagnosis
for large bowel obstruction. The most common site of
volvulus is located at the sigmoid colon (75%) followed
by caecum (22%). Rare sites of colonic volvulus include
the transverse colon (about 2%) and splenic flexure
(1–2%). Synchronous double colonic volvulus is very
rare. The presentation of this condition can be similar to
the signs and symptoms of large bowel obstruction. CT
imaging of the abdomen can be diagnostic; however,
the diagnosis is often missed due to the rarity of this
condition—in such cases, it can only be made at
laparotomy. Management of this condition should be
expedited to prevent a fatal outcome. We present the
case of a 56-year-old woman with synchronous volvulus
of the caecum and splenic flexure of the colon.
... Among over 32 cases of SFV that have been reported in the literature, to date most are secondary to mobilization of the splenic flexure during previous surgery. 2,4 The rarity of SFV is due to the fact that this part of the large bowel has limited mobility due to its attachment to phrenocolic, gastrocolic, and splenocolic ligament and the intraperitoneal position of the descending colon. 2,4,5 For SFV to occur some or all of these anatomical factors should be congenitally absent or altered by surgery, thus rendering the flexure unusually mobile. ...
... 2,4 The rarity of SFV is due to the fact that this part of the large bowel has limited mobility due to its attachment to phrenocolic, gastrocolic, and splenocolic ligament and the intraperitoneal position of the descending colon. 2,4,5 For SFV to occur some or all of these anatomical factors should be congenitally absent or altered by surgery, thus rendering the flexure unusually mobile. The SFV has been reported with other associated congenital anomalies including wandering spleen causing volvulus of the splenic flexure by partial obstruction of the large intestine by the splenic pedicle, 5,6 and in Chilaiditi syndrome (hepatodiaphragmatic interposition of the intestine) where splenic flexure is redundant due to absence of peritoneal attachments. ...
... 7 Congenital bands, and acquired adhesions due to previous surgeries have also been postulated as etiological factors of this rare problem. 4,7 Other predisposing factors that find mentioned in the literature include underlying motility disorders associated with chronic idiopathic intestinal pseudo-obstruction syndrome resulting in the transverse colon and the mesentry gradually increasing in length and width. 4,8 The elongated mesentery of the transverse colon rotates in a clockwise direction, and presses the distal part of the colon of splenic flexure. ...
L arge bowel volvulus accounts for 1-7% of all the large bowel obstructions in the western world. 1 However, it is more common in regions of Africa, Southern Asia, and South America. 1,2 Over 50-80% of large bowel obstruction, in the volvulus belt of Africa and the Middle East are due to volvulus almost exclusively of the sigmoid colon. 2,3 While the most common site of volvulus includes sigmoid colon (80%), caecum (15%), and transverse colon (3%), the incidence of splenic flexure volvulus (SFV) is around 2%. 1-3 It is the rarity of this condition that makes the clinical diagnosis difficult, leading to delay in the treatment and influencing its outcome. We report this case to illustrate that SFV is to be considered as one of the rare differential diagnoses in a patient presenting with acute abdomen and progressive upper abdominal distension, and demonstrate the usefulness of radiological investigations in establishing a preoperative diagnosis, and discuss the various management options based on literature review. Case Report. A 43-year-male was admitted with 3 days history of colicky abdominal pain, progressive distension, and absolute constipation. Three months back he had a similar but milder episode, which resolved spontaneously. He did not vomit and denied alteration of bowel habit or loss of weight. His appetite was normal. Clinical assessment revealed mild dehydration, temperature: 37.5 o
... The splenic fl exure (SFV) is the least common site of colonic volvulus (4). Primary SFV is a rare entity (5). Primary SFV is due to congenital absence or laxity of the phrenocolic, gastro colic, and splenocolic ligaments while secondary volvulus is due to other causes including some prior surgery releasing these ligaments. ...
The definition of volvulus is an axial twist of a portion of the gastrointestinal tract along its mesentery. The involved bowel is obstructed partially or completely with a variable degree of arterial and venous occlusion. The colon is the most common site for volvulus. The splenic flexure is the least common site of colonic volvulus. Splenic flexure volvulus (SFV) is a very rare cause of colonic obstruction, constituting 1-2 % of colonic volvulus. Mortality rate of the SFV cases is low.
We experienced a SFV case who was a 20-year-old male soldier. The case had come to the state hospital with complaints of severe left abdominal and lumbar pain and a medical history of relapsing urinary infection and nephrolithiasis. The doctor had hospitalized him with the diagnosis of paralytic ileus caused by nephrolithiasis. He had died after 14 hours and 35 minutes from hospitalization. Autopsy findings showed out that the death cause was generalized peritonitis due to gangrenous SFV.
In this paper, we presented this case and discussed its properties in the light of the literature data (Fig. 2, Ref. 7).
... The splenic flexure volvulus is rare with an incidence of less than 2% of all colonic volvulus with approximately 32 cases being reported in the literature so far(Ballantyne GH 1985). The rarity of the splenic flexure volvulus is due to the fact that this part of large bowel has limited mobility due to its attachment to phrenocolic, gastrocolic and splenocolic ligament and intraperitoneal position of the descending colon(Ballantyne GH 1985,Mittal R 2007, Osuka A 2006). For splenic flexure volvulus to occur some or all of these anatomical factors should be congenitally absent or altered by surgery thus rendering the flexure unusually mobile. ...
... For splenic flexure volvulus to occur some or all of these anatomical factors should be congenitally absent or altered by surgery thus rendering the flexure unusually mobile. The splenic flexure volvulus has also been reported with other congenital anomalies including wandering spleen causing volvulus of the splenic flexure; this causes partial obstruction of the large intestine by the splenic pedicle(Ballantyne GH 1985,Mittal R 2007). Congenital bands and acquired adhesions due to previous surgeries could be other etiological factors (Ballantyne GH 1985, Mittal R 2007, Osuka A 2006) . ...
... Though there are reported cases of splenic flexure volvulus in children(Osuka A 2006) the median age of these patients is 53 years with a female preponderance (Ballantyne GH 1985, Mittal R 2007). The usual presentation of these patients is non acute and nonspecific and include recurrent episodes of abdominal pain, distension and vomiting and is usually not suspected because of the rarity of this condition. ...
... Although colonoscopic decompression is described for both conditions, they are best treated via resection with either an extended right hemicolectomy or left colectomy in those patients with splenic flexure volvulus. 24 In our case of splenic volvulus, patient had congenital Meckel's diverticulum and abnormally long mesentery of left colon with chronic constipation. This caused internal herniation of left colon & twist of the colon to cause splenic flexure volvulus. ...
