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Splenic flexure volvulus presenting with gangrene
Norman O. Machado, MBBS, MS, Pradeep J. Chopra, MBBS, MS, Sureshkannan K. Subramanian, MS, MRCS.
Large 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. ree 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: 37.5oC; pulse: 80/min; blood pressure:
126/78 mm Hg. Abdomen was devoid of scars, grossly
distended, soft and tympanic with no tenderness. Bowel
sounds were feeble and rectum was empty. Serum
electrolytes showed low levels of sodium (131 mmol/L,
normal range 135-145), potassium (3.3 mmol/L, normal
range 3.5-5.1) and chloride (93 mmol/L, normal range
98-107). His hemoglobin was 15 gm%, white blood
cells 11.3 x 109/L with a neutrophilia of 83.2%. Plain
x-ray of the abdomen showed 2 widely separated air fluid
levels, one in the distended splenic flexure and other
in the cecum (Figure 1), and markedly dilated air filled
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ABSTRACT
2%
32
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 releasing these ligaments.
A preoperative diagnosis can be established based on
the characteristic radiological findings on plain x-ray
abdomen and CT scan. We present a case of SFV in
a young man who presented with acute abdominal
pain, and distension, and illustrate the usefulness of
CT scan, and plain x-ray of the abdomen in making
a preoperative diagnosis. Laparotomy revealed a
gangrenous SFV, which was resected and primary
anastomosis was carried out. Literature is reviewed
with regards to predisposing factors, presentation,
investigation, and management among the more than
32 cases reported so far.
Saudi Med J 2009; Vol. 30 (5):
From the Department of Surgery, Sultan Qaboos University Hospital,
Muscat, Oman.
Received 25th february 2009. Accepted .
Case Reports
Address correspondence and reprint request to: Dr. Norman O.
Machado, Department of Surgery, Sultan Qaboos University
Hospital, PO Box 38, Muscat, Oman. Fax. + (968) 24413851.
E-mail: oneilnorman@gmail.com
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Splenic flexure volvulus ... Machado et al
colon in the left hypochondrium, and mid abdomen
(Figure 2). is had a coffee bean appearance with
concavity facing to the left upper abdomen causing
elevation of left diaphragm, and abrupt termination
at the anatomic splenic flexure (Figure 2). Volvulus of
the splenic flexure of the colon was suspected, and a
computerised tomography (CT) scan of the abdomen
was performed. e CT scan confirmed the diagnosis
of SFV, and showed a grossly dilated splenic flexure
with a characteristic whirl sign at the site of twist of
the mesentery (Figure 3). A diagnosis of large bowel
obstruction secondary to the volvulus of splenic flexure
was made. After correcting the fluid and electrolyte
deficit, the patient underwent emergency laparotomy.
e splenic flexure was grossly distended, gangrenous,
and measured 20 cms (Figure 4). It had a clockwise 3600
twist on itself and involved the adjoining transverse,
and descending colon. e leno-colic and phreno-colic
ligaments were absent and the proximal descending
colon was intraperitoneal. e patient had a double
closed loop obstruction. e other being dilated
proximal large bowel with a competent ileo-cecal valve.
e gangrenous splenic flexure was resected, and the
ends of the proximal transverse and distal descending
colon were primarily anastomosed in 2 layers with vicryl.
After a thorough peritoneal lavage the abdomen was
Figure 4 - Laparotomy revealing the distended gangrenous splenic flexure
volvulus.
Figure 1 - Plain x-ray of abdomen showing 2 widely separated air fluid
level in the cecum and distended splenic flexure (arrows).
Figure 2 - CT scout film showing coffee bean shaped dilated splenic
flexure with concavity of bean facing to the left upper abdomen
(arrow). CT-computerised tomography.
Figure 3 - CT scan revealing the 2 dilated loops of the splenic
flexure (straight arrows) with the characteristic whirl sign
(curved arrow). CT-computerised tomography.
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Splenic flexure volvulus ... Machado et al
Saudi Med J 2009; Vol. 30 (5) www.smj.org.sa
closed. e postoperative period was uneventful except
for pyrexia due to superficial surgical site infection,
managed by local drainage and antibiotics. A swab
failed to grow any organisms. Histology was reported
as large bowel volvulus consistent with infracted bowel.
e patient remained well when followed up the second
postoperative week at the outpatient clinic.
Discussion. e SFV is extremely rare and
Ballantyne et al2 in his colonic volvulus series reported
an incidence of less than 2% of all colonic volvulus.
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 e
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. e 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 e elongated mesentery of the transverse
colon rotates in a clockwise direction, and presses the
distal part of the colon of splenic flexure. In a review
of 5 children with SFV ranging from 26 months to 13
years of age, Osuka et al8 reported motility disorders
to be the underlying cause in 3 of them. Recently,
eventration of the diaphragm has been reported to be
the cause for chronic recurrent SFV.9 However, in our
patient it appeared that the congenital absence of the
leno-colic and phreno-colic, Confirm spelling? ligament
and intraperitoneal location of the proximal part of the
descending colon as the predisposing factor.
ough, there are reported cases of SFV in children,8
the median age of SFV is 53 years, with female
preponderance.2,4 e usual presentation of these
patients is non-acute, and non-specific, and includes
recurrent episodes of abdominal pain, distension, and
vomiting.2,4,5,7-9 In such cases, the diagnosis of SFV is
usually not suspected due to the rarity of this condition.
Acute presentation with features of gangrene is rare
(Figure 4). If radiological investigations are carried out
a preoperative diagnosis could be suggested based on
certain characteristic findings.4,10 ese radiological
signs were illustrated in our patient and included:
1) Two widely separated air fluid levels, one in the
distended splenic flexure and the other in the ceacum
(Figure 1). 2) Markedly dilated air filled colon with
abrupt termination at the anatomic splenic flexure.
3) An empty descending, and sigmoid colon. 4) A
characteristic beak at the anatomical splenic flexure
on barium enema examination when carried out. 5)
A coffee bean appearance of the dilated splenic flexure
is seen, and in SFV the concavity of the bean faces to
the left upper abdomen (Figure 2) unlike in sigmoid
volvulus where it faces to the left lower abdomen. 6)
e CT scan will reveal dilated splenic flexure with
a characteristic whirl sign at the site of twist in the
mesentery (Figure 3).
e first priority is given to adequate resuscitation
of the patient as in other cases of large bowel
obstruction.1-4 e options available for treatment
include decompressing, colopexy, or resection.2-10
If the patient with SFV does not have peritonitis
or suspected gangrene, deflation by colonoscopy
could be attempted.2,4,8 Simple deflation however,
without operative fixation or resection is followed by
subsequent episodes of volvulus with its own attendant
complications, and mortality. In the event the volvulus
cannot be reduced endoscopically or there are signs
of mucosal ischemia, immediate surgery is indicated.
Hence the timing, and nature of surgery for SFV are
determined by 2 main factors. ese include suspected
presence of ischemia or necrotic bowel and the success
or failure of colonoscopic reduction.4
When resection is carried out in the presence of
gangrenous bowel with prior perforation of the sigmoid
colon and significant peritoneal soiling, primary
anastomosis is avoided. Exteriorization of the proximal
and distal colon may then be necessary.4 A primary
anastomosis when carried out in such patients leads to
a high incidence of anastomotic leak. However, as in
our case in the absence of peritoneal soiling, and viable
bowel ends, primary anastomosis can be safely carried
out. Non resectional colopexy by fixing the splenic
flexure to the surrounding structures (pexy of the splenic
flexure) in order to prevent the volvulus1,2,4,8 can be tried
in a high risk or elderly patient who is a poor surgical
candidate.4 is is achieved by using non absorbable
suture materials, and prevents recurrent twisting of the
colon without the need for resection or colostomy.4,9
e colon could also be fixed using Gore-tex strips
or extraperitonealisation to anchor the redundant
colon.2,4,9 Okusa8 et al in a review of 5 SFV cases in
children reported resection to have been carried out in
2 patients, and colopexy in one of them. In a review of
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Splenic flexure volvulus ... Machado et al
one of the large series of 14 cases of SFV, Ballantyne
found spontaneous reduction in 2 patients while 11
of them required emergency surgery.4 ree of these
patients had operative derotation, one exterioration of
splenic flexure as loop colostomy and in 6 patients a
partial colectomy was carried out. ere was only one
death in their series.4 us, the choice of treatment is
varied and depends upon the type of presentation and
has to be tailored to each patient.
In summary, SFV is a rare cause of intestinal
obstruction. While most of them may have subacute
presentation, an acute presentation with gangrene is
a potential complication. Preoperative diagnosis is
aided by radiological investigations. Treatment options
depend on the presence or absence of gangrene with
resection of splenic flexure having a good long-term
outcome. Awareness of the clinical entity will help in
early diagnosis and appropriate management.
References
1. Jones IT, FazioVW. Colonic volvulus etiology and management.
Dig Dis 1989; 7: 203-209.
2. Ballantyne GH, Brandner MD, Beart RW, Illstrup DM.
Volvulus of the colon. Incidence and mortality. Ann Surg
1985; 202: 83-92.
3. Alam MK, Fahim F, Al-Akeely MH, Qazi SA, Al-Dossary NF.
Surgical management of colonic volvulus during same hospital
admission. Saudi Med J 2008; 29: 1438-1442.
4. Mittal R, Samarasam I, Chandran S, Mathew G. Primary
splenic flexure volvulus. Singapore Med J 2007; 48: 87-89.
5. Halliday KE, Bellamy E, Ellis BW. Volvulus of the splenic
flexure and spleen. Eur J Surg 1993; 159: 383-384.
6. Moorthy K, Despande A, Rao P, Vyas S, Supe A. Wandering
spleen causing splenic flexure volvulus and obstruction. Indian
J Gastroenterol 1998; 17: 67-68.
7. Havenstrite KA, Harris JA, Rivera DE. Splenic flexure
volvulus in association with chilaiditi syndrome report of
a case. Am Surg 1999; 65: 874-876.
8. Osuka A, Ikegami R, Watanabe Y. Splenic flexure volvulus in
a child with chronic idiopathic intestinal pseudo-obstruction
syndrome. Pediatr Surg Int 2006; 22: 833-835.
9. Kim KS, Yoo JS, Han SJ, Park H. Chronic recurrent volvulus
of the colonic splenic flexure associated with eventeration of left
hemidiaphragm. Korean J Gastroenterol 2007; 49: 37-40.
10. Mindelzun RE, Stone JM. Volvulus of the splenic flexure
radiographic features. Radiology 1991; 181: 221-223.
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