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Volvulus of the transverse colon associated with organoaxial volvulus of the stomach
Volvulus of the Transverse Colon Associated with Organoaxial Volvulus of the Stomach
W. M. Jones, MCh, FRCS (G), FRCS (E), FRCS, Sheffield, England C. D. P. Jones, MBE, FRCS, Sheffield,
England
The transverse colon is the least likely part of the large bowel to be involved in a volvulus. Although lengthening and redundancy of this part is common, mesenteric fixation of the flexures during the third stage of embryonic intestinal rotation prevents any torsion of the bowel. Therefore, the number of cases recorded in the literature have been few, and usually confined to single case reports [I-4]. The papers of Kallio [5] from Scandinavia and Kerry and Ransom [6] from the United States are the only ones which deal with a significant number of collected cases. The following case is one of volvulus of the transverse colon associated with organoaxial volvulus of the stomach, presenting with an interesting triad of radiologic signs which should have led to a preoperative diagnosis. Case Report A seventy-five year old woman was admitted from a psychiatric unit complaining of severe central abdominal pain for the past twenty-four hours, associated with severe retching, but no actual vomiting, and increasing abdominal distention. During the past three to four years there had been marked mental deterioration, but no history to suggest disturbed gastrointestinal function. Bilateral fractures of the hips had been successfully treated two years previously. The clinical examination showed a thin elderly lady in a state of shock, with gross abdominal distention accompanied by diffuse tenderness. The abdomen was markedly tympanitic, and bowel sounds were increased and high
From the United Sheffield Hospitals, Sheffield, England. Reprint requests should be addressed to Mr!W. M. Jones, The Royal infirmary, Sheffield, S6 3DA. Yorkshire, England.
404
pitched. Rectal examination was negative. Results of laboratory investigations were as follows: hemoglobin, 83 per cent; white blood cell count, 7,000 per mms; packed cell volume, 27 per cent; sodium, 130 mEq/L; chloride, 99 mEq/ L; potassium, 5.5 mEq/L; urea nitrogen, 52 mg per cent. Plain radiographs of the chest and abdomen revealed marked esophageal dilatation (Figure 1) and gross colonic distention, with no evidence of gastric air bubble (Figure 2). In view of the marked abdominal tenderness barium enema examination was not carried out. Preoperative resuscitation with intravenous fluids and plasma expanders was carried out with good response for a few hours prior to operation. The passage of a nasogastric tube was attempted but was unsuccessful. The abdomen was opened through a right paramedian incision. There was marked colonic distention due to twisting of the transverse colon about its mesentery through more than 180 degrees in a counterclockwise direction. This had produced an organoaxial volvulus of the stomach, which was tightly twisted as far as the cardia. Untwisting of the transverse colon reduced the gastric volvulus. The blood supply to both stomach and colon was unimpaired and both organs were completely normal. The following anatomic points were noted: (1) there was no fixation of the flexures of the transverse colon; (2) the mesocolon was long, with a narrow base; (3) the gastrocolic ligament was normal in length. Fixation of the plexuses of the transverse colon was carried out using a modification of the technic described by McGowan, Soriano, and McCausland [;1, with fixation of the hepatic and splenic flexures to the anterior abdominal wall. Postoperatively, the patient received intravenous fluids and penicillin and streptomycin, but she collapsed twelve hours later and died. Postmortem examination showed no evidence of recurrent volvulus, and no gross organic lesion to account for her death.
The American Journal of Surgery
Volvulus of Transverse
Figure 1. with air.
The esophagus
is grossly dilated and filled
Colon
has been referred to earlier in the literaassociation ture. Borchardt [12] in 1904 suggested a further classification of volvulus of the stomach into supracolic and infracolic, depending on the position of the volvulus relative to the transverse colon. The anatomic connection between the greater curvature of the stomach and the colon through the gastrocolic ligament ensures that in volvulus of the stomach the transverse colon is pulled upwards until it lies above the twisted stomach, that is, infracolically. This will only occur if the gastrocolic ligament is normal, as in the present case. When this ligament is long or completely absent (which is a rare anatomic abnormality), volvulus of the stomach can occur independently of any ascent of the transverse colon, that is, supracolically. The evidence presented in this case would favor the hypothesis, especially in the presence of a normal gastrocolic ligament, that the volvulus of the transverse colon was the initating lesion and it secondarily produced a volvulus of the stomach in its long axis. It is of interest to note that marked distention of the colon has been suggested as a triggering mechanism in the formation of gastric volvulus [13]. Borchardt [12] described a triad which is pathognomonic of volvulus of the stomach: (1) early vomit-
Comments
Factors which are of importance in the production of volvulus of the transverse colon can be classified as primary or predisposing, supplemented by secondary or exciting factors. Predisposing causes, which were present in this case, have been listed by Gerwig [8] as follows: (1) elongation of the mesentery; (2) absence of the mesentery with a mobile bowel; and (3) closely approximated points of fixation. Exciting factors have included adhesions [I], congenital bands [9], and obstruction to the distal colon by cancer [1] and by inflammatory stricture [IO]. Volvulus has also occurred postoperatively [4] and as a complication in the postpartum period [3]. Primary factors which are of importance [11] in the formation of gastric volvulus have been described as extreme laxity and elongation of the lesser omentum and gastrosplenic ligament, together with an approximation of the cardiac and pyloric ends of the stomach. Exciting factors have been listed by Dalgaard [II] as follows: anomalies of the diaphragm, an hourglass stomach, gastric ulcer, displacement by neighboring organs such as the spleen, and habitual overfilling of the stomach. The present case would appear to be the only one described of volvulus of the transverse colon producing volvulus of the stomach, although this
Volume 124, September 1972
Figure 2. Roentgenogram shows gross colonic distention with no evidence of gastric air bubble in the stomach and no air-fluid levels.
405
Jones and Jones
ing followed by retching and an inability to vomit; (2) rapidly increasing distention of the upper abdomen; and (3) inability to pass a stomach tube. In the present case the first and last criteria were satisfied, but the distention involved the whole abdomen. Therefore, despite the inability to pass a stomach tube a clinical diagnosis of volvulus of the colon was made. However, the triad of radiologic signs demonstrated in this case, namely, (1) dilatation of the esophagus, (2) absence of a gastric air bubble, and (3) gross colonic distention, should have made a preoperative diagnosis possible. Plain radiographs of the abdomen have shown gross colonic distention, but no features which are pathognomonic of volvulus of the transverse colon. Figiel and Figiel [Z] describe in their case right colonic distention as well as distention of the proximal transverse colon which assumed a U-shaped appearance with the apex of the U directed ‘inferiorly. Air-fluid levels often described in volvulus of the colon were not seen in the present case. A single air-fluid level is common in cecal vo1vu1us, whereas two or more are usually seen in volvulus of the sigmoid and transverse colon [6]. Three air-fluid levels were seen in a case described by Singh and Kochber [14]. Plain radiography in cases of gastric volvulus usually shows marked distention of the stomach with fluid and air. Volvulus of the transverse colon carries a mortality as high as 33 per cent [6]. If the bowel wall is viable, and there are no secondary or exciting factors, then reduction and fixation can be carried out by the method described by McGowan et al [7j. Should the bowel be nonviable, then transverse colectomy with delayed colocolostomy is the treatment of choice. In the management of the presenting lesion it is important not to overlook the diagnosis and treatment of exciting factors. A new operation has recently been described for chronic volvulus of the stomach (151. This operation involves two steps: (1) separation of the colon from the stomach and (2) displacement of
406
the colon into the left subphrenic space with fixation. The reported results are good. In view of the findings presented in this case, we would make the tentative suggestion that it is separation and not displacement of the colon which makes this operation so effective in preventing recurrent volvulus. Summary
A rare case of volvulus of the transverse colon producing torsion of the stomach in its long axis is described. A triad of radiologic signs was demonstrated which should have made a preoperative diagnosis possible. References
5. 6. 7. a. 9. 10. 11. 12. 13. 14. 15.
Boley SJ: Volvulus of the transverse colon. Amer J Surg 96: 122.1958. Figiel LS, Figiel SJ: Volvulus of the transverse colon. Radiology 63: 832, 1954. Murray A: Volvulus of the transverse colon complicating labour. Brit Med J 2: 659, 1959. Zaslow J, Orloff T: Volvulus of the transverse colon occurring as a post-operative complication. Amer J Surg 87: 780, 1954. Kallio KE: ijber volvulus coli transversi. Acta Chir Stand 70: 39, 1932. Kerry RL, Ransom HK: Volvulus of the colon. Arch Surg 99: 215, 1969. McGowan JM, Soriano S, McCausland W: Volvulus of the transverse colon. Amer J Surg 93: 857, 1957. Gerwig WH Jr: Volvulus of the colon. Surg C/in N Amer 35: 1395,1955. Weir DC, Wong JC: Volvulus of the transverse colon due to congenital bands. Missouri Med 56: 908, 1959. Martin JD Jr, Ward CS: Megacolon associated with volvulus of the transverse colon. Amer J Surg 64: 412, 1944. Dalgaard JB: Volvulus of the stomach. Acta Chir Stand 103: 131,1952. Borchardt M: Zur Pathologie und Therapie des MagenvolvuIus. Arch K/in Chir 74: 243, 1904. Gottlieb Ch, Lefferets D, Beranbaum SL: Gastric volvuIus. Amer J Roentgen 72: 609, 1954. Singh A, Kochber KS: Volvulus of the transverse colon. Dis Colon Rectum 13: 397, 1970. Tanner NC: Chronic and recurrent volvulus of the stomach. Amer J Surg 115: 505, 1968.
The American Journal of Surgery
W. M. Jones, MCh, FRCS (G), FRCS (E), FRCS, Sheffield, England C. D. P. Jones, MBE, FRCS, Sheffield,
England
The transverse colon is the least likely part of the large bowel to be involved in a volvulus. Although lengthening and redundancy of this part is common, mesenteric fixation of the flexures during the third stage of embryonic intestinal rotation prevents any torsion of the bowel. Therefore, the number of cases recorded in the literature have been few, and usually confined to single case reports [I-4]. The papers of Kallio [5] from Scandinavia and Kerry and Ransom [6] from the United States are the only ones which deal with a significant number of collected cases. The following case is one of volvulus of the transverse colon associated with organoaxial volvulus of the stomach, presenting with an interesting triad of radiologic signs which should have led to a preoperative diagnosis. Case Report A seventy-five year old woman was admitted from a psychiatric unit complaining of severe central abdominal pain for the past twenty-four hours, associated with severe retching, but no actual vomiting, and increasing abdominal distention. During the past three to four years there had been marked mental deterioration, but no history to suggest disturbed gastrointestinal function. Bilateral fractures of the hips had been successfully treated two years previously. The clinical examination showed a thin elderly lady in a state of shock, with gross abdominal distention accompanied by diffuse tenderness. The abdomen was markedly tympanitic, and bowel sounds were increased and high
From the United Sheffield Hospitals, Sheffield, England. Reprint requests should be addressed to Mr!W. M. Jones, The Royal infirmary, Sheffield, S6 3DA. Yorkshire, England.
404
pitched. Rectal examination was negative. Results of laboratory investigations were as follows: hemoglobin, 83 per cent; white blood cell count, 7,000 per mms; packed cell volume, 27 per cent; sodium, 130 mEq/L; chloride, 99 mEq/ L; potassium, 5.5 mEq/L; urea nitrogen, 52 mg per cent. Plain radiographs of the chest and abdomen revealed marked esophageal dilatation (Figure 1) and gross colonic distention, with no evidence of gastric air bubble (Figure 2). In view of the marked abdominal tenderness barium enema examination was not carried out. Preoperative resuscitation with intravenous fluids and plasma expanders was carried out with good response for a few hours prior to operation. The passage of a nasogastric tube was attempted but was unsuccessful. The abdomen was opened through a right paramedian incision. There was marked colonic distention due to twisting of the transverse colon about its mesentery through more than 180 degrees in a counterclockwise direction. This had produced an organoaxial volvulus of the stomach, which was tightly twisted as far as the cardia. Untwisting of the transverse colon reduced the gastric volvulus. The blood supply to both stomach and colon was unimpaired and both organs were completely normal. The following anatomic points were noted: (1) there was no fixation of the flexures of the transverse colon; (2) the mesocolon was long, with a narrow base; (3) the gastrocolic ligament was normal in length. Fixation of the plexuses of the transverse colon was carried out using a modification of the technic described by McGowan, Soriano, and McCausland [;1, with fixation of the hepatic and splenic flexures to the anterior abdominal wall. Postoperatively, the patient received intravenous fluids and penicillin and streptomycin, but she collapsed twelve hours later and died. Postmortem examination showed no evidence of recurrent volvulus, and no gross organic lesion to account for her death.
The American Journal of Surgery
Volvulus of Transverse
Figure 1. with air.
The esophagus
is grossly dilated and filled
Colon
has been referred to earlier in the literaassociation ture. Borchardt [12] in 1904 suggested a further classification of volvulus of the stomach into supracolic and infracolic, depending on the position of the volvulus relative to the transverse colon. The anatomic connection between the greater curvature of the stomach and the colon through the gastrocolic ligament ensures that in volvulus of the stomach the transverse colon is pulled upwards until it lies above the twisted stomach, that is, infracolically. This will only occur if the gastrocolic ligament is normal, as in the present case. When this ligament is long or completely absent (which is a rare anatomic abnormality), volvulus of the stomach can occur independently of any ascent of the transverse colon, that is, supracolically. The evidence presented in this case would favor the hypothesis, especially in the presence of a normal gastrocolic ligament, that the volvulus of the transverse colon was the initating lesion and it secondarily produced a volvulus of the stomach in its long axis. It is of interest to note that marked distention of the colon has been suggested as a triggering mechanism in the formation of gastric volvulus [13]. Borchardt [12] described a triad which is pathognomonic of volvulus of the stomach: (1) early vomit-
Comments
Factors which are of importance in the production of volvulus of the transverse colon can be classified as primary or predisposing, supplemented by secondary or exciting factors. Predisposing causes, which were present in this case, have been listed by Gerwig [8] as follows: (1) elongation of the mesentery; (2) absence of the mesentery with a mobile bowel; and (3) closely approximated points of fixation. Exciting factors have included adhesions [I], congenital bands [9], and obstruction to the distal colon by cancer [1] and by inflammatory stricture [IO]. Volvulus has also occurred postoperatively [4] and as a complication in the postpartum period [3]. Primary factors which are of importance [11] in the formation of gastric volvulus have been described as extreme laxity and elongation of the lesser omentum and gastrosplenic ligament, together with an approximation of the cardiac and pyloric ends of the stomach. Exciting factors have been listed by Dalgaard [II] as follows: anomalies of the diaphragm, an hourglass stomach, gastric ulcer, displacement by neighboring organs such as the spleen, and habitual overfilling of the stomach. The present case would appear to be the only one described of volvulus of the transverse colon producing volvulus of the stomach, although this
Volume 124, September 1972
Figure 2. Roentgenogram shows gross colonic distention with no evidence of gastric air bubble in the stomach and no air-fluid levels.
405
Jones and Jones
ing followed by retching and an inability to vomit; (2) rapidly increasing distention of the upper abdomen; and (3) inability to pass a stomach tube. In the present case the first and last criteria were satisfied, but the distention involved the whole abdomen. Therefore, despite the inability to pass a stomach tube a clinical diagnosis of volvulus of the colon was made. However, the triad of radiologic signs demonstrated in this case, namely, (1) dilatation of the esophagus, (2) absence of a gastric air bubble, and (3) gross colonic distention, should have made a preoperative diagnosis possible. Plain radiographs of the abdomen have shown gross colonic distention, but no features which are pathognomonic of volvulus of the transverse colon. Figiel and Figiel [Z] describe in their case right colonic distention as well as distention of the proximal transverse colon which assumed a U-shaped appearance with the apex of the U directed ‘inferiorly. Air-fluid levels often described in volvulus of the colon were not seen in the present case. A single air-fluid level is common in cecal vo1vu1us, whereas two or more are usually seen in volvulus of the sigmoid and transverse colon [6]. Three air-fluid levels were seen in a case described by Singh and Kochber [14]. Plain radiography in cases of gastric volvulus usually shows marked distention of the stomach with fluid and air. Volvulus of the transverse colon carries a mortality as high as 33 per cent [6]. If the bowel wall is viable, and there are no secondary or exciting factors, then reduction and fixation can be carried out by the method described by McGowan et al [7j. Should the bowel be nonviable, then transverse colectomy with delayed colocolostomy is the treatment of choice. In the management of the presenting lesion it is important not to overlook the diagnosis and treatment of exciting factors. A new operation has recently been described for chronic volvulus of the stomach (151. This operation involves two steps: (1) separation of the colon from the stomach and (2) displacement of
406
the colon into the left subphrenic space with fixation. The reported results are good. In view of the findings presented in this case, we would make the tentative suggestion that it is separation and not displacement of the colon which makes this operation so effective in preventing recurrent volvulus. Summary
A rare case of volvulus of the transverse colon producing torsion of the stomach in its long axis is described. A triad of radiologic signs was demonstrated which should have made a preoperative diagnosis possible. References
5. 6. 7. a. 9. 10. 11. 12. 13. 14. 15.
Boley SJ: Volvulus of the transverse colon. Amer J Surg 96: 122.1958. Figiel LS, Figiel SJ: Volvulus of the transverse colon. Radiology 63: 832, 1954. Murray A: Volvulus of the transverse colon complicating labour. Brit Med J 2: 659, 1959. Zaslow J, Orloff T: Volvulus of the transverse colon occurring as a post-operative complication. Amer J Surg 87: 780, 1954. Kallio KE: ijber volvulus coli transversi. Acta Chir Stand 70: 39, 1932. Kerry RL, Ransom HK: Volvulus of the colon. Arch Surg 99: 215, 1969. McGowan JM, Soriano S, McCausland W: Volvulus of the transverse colon. Amer J Surg 93: 857, 1957. Gerwig WH Jr: Volvulus of the colon. Surg C/in N Amer 35: 1395,1955. Weir DC, Wong JC: Volvulus of the transverse colon due to congenital bands. Missouri Med 56: 908, 1959. Martin JD Jr, Ward CS: Megacolon associated with volvulus of the transverse colon. Amer J Surg 64: 412, 1944. Dalgaard JB: Volvulus of the stomach. Acta Chir Stand 103: 131,1952. Borchardt M: Zur Pathologie und Therapie des MagenvolvuIus. Arch K/in Chir 74: 243, 1904. Gottlieb Ch, Lefferets D, Beranbaum SL: Gastric volvuIus. Amer J Roentgen 72: 609, 1954. Singh A, Kochber KS: Volvulus of the transverse colon. Dis Colon Rectum 13: 397, 1970. Tanner NC: Chronic and recurrent volvulus of the stomach. Amer J Surg 115: 505, 1968.
The American Journal of Surgery