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Sigmoid volvulus in a young patient
CASE REPORT sigmoid volvulus
Sigmoid Volvulus in a Young Patient The case of an 18-year-old man with sigmoid volvulus and recurrent abdominal pain is presented. He was seen in the emergency department three times in a 4-month period, each time complaining of cramping left lower quadrant pain of one to two hours duration without vomiting or diarrhea. Physicial examination on each occasion revealed left lower quadrant tenderness without mass, guarding, or rebound. Radiologic evaluation on the first visit revealed sigmoid volvulus, which was reduced by barium enema. Despite identical clinical presentation on two subsequent occasions, radiologic studies showed no evidence of recurrent volvulus. During the ensuing two years, the patient has had no further symptoms. [Cook ES, Allison EJ Jr: Sigmoid volvulus in a young patient. Ann Emerg Med October 1984;13:963966.] INTRODUCTION Sigmoid volvulus is an unusual cause of abdominal pain in the young. 1 It may present either as the "acute abdomen" or, more commonly, as recurrent abdominal pain relieved by passage of stool or flatus. Radiologic presentation on plain films is, unlike that in the elderly patient, variable. When evidence of large bowel obstruction is present on plain abdominal films, barium enema is performed initially for confirmation of the diagnosis and attempted hydrostatic reduction of the volvulus. If this is unsuccessful, decompression may be achieved by sigmoidoscopy-directed placement of a rectal tube. If this approach fails, surgical reduction of the volvulus, or colon resection, is undertaken. Laparotomy is performed initially in the presence of peritoneal signs. Surgical consultation for chronic pain should be obtained only following repeated demonstration of volvulus by barium enema. Our case is presented to make the emergency physician aware of this unusual entity in the differential diagnosis of intestinal obstruction; to stress the success of nonoperative reduction; and to emphasize the pitfall of attributing repeated identical clinical findings to recurrent volvulus, leading to inappropriate surgical referral.
Elisabeth S Cook, MD E Jackson Allison, Jr, MD, MPH, FACEP Greenville, North Carolina From the Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina Received for publication November 14, 1983. Revision received February 17, 1984. Accepted for publication March 9, 1984. Address for reprints: Elisabeth S Cook, MD, Emergency Department, Beaufort County Hospital, Washington, North Carolina 27889.
CASE REPORT An otherwise healthy 18-year-old man presented to the emergency department complaining of left lower quadrant pain of 30 minutes duration. The pain was sudden in onset, unaccompanied by nausea or vomiting, and of increasing intensity. His last bowel movement had been five days prior to admission, which was normal for the patient. Physical examination revealed a temperature of 36.9 C; pulse, 90/min; respirations, 18/min; and blood pressure, 120/76 m m Hg. He appeared in moderate distress due to pain. Mucous membranes were moist and skin turgor was normal. He was persistently tender to palpation in the left lower quadrant. There was no abdominal distention and no mass was palpated. There was no guarding or rebound. Bowel sounds were absent. Complete blood count showed a hemoglobin of 14.6; hematocrit, 43.5; and white blood cell count, 8,600. Plain films of the abdomen showed a single loop of distended large bowel in the left upper quadrant (Figure 1). This roentgenographic finding led to suspicion of large bowel volvulus, and a barium enema was performed. The sigrnoid colon was shown to be redundant {Figure 2). The closed sigmoid loop was well demonstrated and opened with a rush of barium, followed by
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SIGMOID VOLVULUS Cook & Allison
Fig. 1. Plain film of the a b d o m e n shows closed large bowel loop in the left upper quadrant. Fig. 2. Barium enema shows detorsion of volvulus with barium seen proximal to site of bowel obstruction. i m m e d i a t e relief of the patient's symptoms. The patient was observed overnight in the emergency department, and was discharged the following morning. The patient remained asymptomatic for six weeks, at which time he again presented with the same symptoms as on his previous admission. His last bowel movement had been four to five days earlier. Physical examination again demonstrated persistent left lower quadrant tenderness without distention, mass, or guarding. Bowel sounds were normal. Flat and upright films of the abdomen showed a sentinel loop of small bowel gas in the rnidline (Figure 3). The colon was distended throughout and was filled w i t h stool. Barium e n e m a again showed a redundant sigmoid, but no obstruction (Figure 4). Following evacuation of the colon, symptoms were relieved and the patient was discharged. 148/964
Eight weeks following the second episode the patient returned after four hours of cramping lower abdominal pain, identical to his previous symptoms. Physical examination revealed left lower quadrant tenderness without mass, guarding, or rebound. Bowel sounds were normal. Plain films of the a b d o m e n were unremarkable, and symptoms were relieved following, a soapsuds enema. The patient was placed on a regimen of high fiber diet and stool softeners, and he has had no recurrence of symptoms in six months.
DISCUSSION In the United States, sigmoid volvulus is an unusual cause of abdominal pain in adults, accounting for only 2% to 8% of all intestinal obstruction. 1 It is even more unusual in children and adolescents, with only 12% of reported cases of sigmoid volvulus occurring in patients less than 50 years of age. 2 In a review of intestinal obstruction in pediatric patients, sigmoid volvulus was implicated in only 0.8%. 3 In the elderly the most common presentation of sigmoid volvulus is recurrent, colicky abdominal pain. 4 In the young this entity may present as the acute abdomen or, more cornAnnals of Emergency Medicine
monly, as recurrent pain with spontaneous detorsion of the involved segment, manifested clinically by passage of large amounts of liquid stool or flatus. Because of the chronic nature of their symptoms, many of these patients have been diagnosed erroneously as having "irritable bowel syndrome" or chronic cholecystitis, S.and have been treated inappropriately for many years. Analysis of English language case reports of sigmoid volvulus presenting as the acute abdomen3, 6-12 reveals the most c o m m o n p r e s e n t a t i o n to be cramping or steadily intensifying left lower quadrant or diffuse abdominal pain. Abdominal distention was present in 90% of the patients described. Vomiting was present in only 12%. Fever was an unusual finding. In infants vomiting and dehydration were prominent,3, 6 with ischemic changes in the bowel producing significant third space losses. The only deaths reported were in 14-day-old6 and 10month-old3 boys, both of whom were in hypovolemic shock on initial presentation. In older children physical examination typically revealed distention, left lower quadrant tendemess with guarding, and often a palpable mass. Bowel s o u n d s were high13:10 October 1984
pitched, typical of intestinal obstruction. Intussusception was the most common initial impression. In sigmoid volvulus initial roentgenographic findings were nondiagnostic in one-third of the cases reviewed by Agrez and Cameron33 In younger children flat and upright abdominal films often reveal only distended small bowel loops. In older children and young aduks the classic appearance of the distended sigmoid loop filling most of the upper abdomen is seldom seen. z Barium enema demonstrates the obstruction high in the sigmoid, in' contrast to the rectosigmoid loop usually seen in the elderly.7 Initially a static column of barium appears, tapering at the distal point of obstruction (the "bird's beak" or "ace of spades" deformity), followed by a rush of barium as the segment untwists. 7 Lillard, Allen, and Nordstrom8 r e p o r t e d successful b a r i u m enema reduction of sigmoid volvulus in six of seven pediatric patients. Arnold and N a n c e 14 r e c o r d e d nonoperative reduction in 110 of 145 patients following sigmoidoscopy, barium enema, saline enema, or rectal tube. Analysis of case reports of sigmoid volvulus presenting as chronic abdom13:10 October 1984
inal pain4,5,15-19 consistently revealed descriptions of multiple episodes of colicky central or left lower quadrant pain relieved by passage of diarrheal or melanotic stools and/or flatus. Duration of pain varied from several minutes to several days, with a frequency ranging from one or two episodes annually to two to three episodes weekly. 16 The majority of patients noted abdominal distention accompanying pain. Most gave a history of chronic constipation. Weight loss, nausea, and vomiting were not described. At the time of presentation for evaluation of r e c u r r e n t pain, m o s t p a t i e n t s are clinically well; therefore, radiologic evaluation commonly shows only redundancy of the sigmoid colon. While a long sigmoid, a long, mobile rnesosigmoid, and close proximity of proximal and distal sigmoid limbs are necessary c o n d i t i o n s for v o l v u l u s to occur, they do not provide proof of its existence. According to Campbell and Blank, is and Lillard, Allen and Nordstrom, 8 a redundant sigmoid colon often is seen on barium enema in children who have not had obstructive episodes. As our case illustrates, not all episodes of the patient's characteristic pain represent volvulus. Symptoms Annals of Emergency Medicine
Fig. 3. Plain film shows a single loop of s m a l l bowel. No closed loop obstruction is visualized. Fig. 4. Barium enema shows no evidence of obstruction. Sigmoid colon is redundant. may be caused by constipation alone. In both acute and recurrent sigmoid volvulus the emergency physician is responsible for obtaining appropriate surgical consultation. If fever, absent bowel sounds, rebound tenderness, or other evidence of bowel ischemia are present, surgical referral should be immediate. If these signs are absent, nonoperative reduction of the volvulus should be attempted. Surgical consultation for subsequent management should be based on meticulous documentation of the diagnosis, and consideration of the likelihood and consequences of recurrence. In the elderly, Strom, Stone and Fabian 2o reported recurrent volvulus in only 10% of patients undergoing sigmold resection as treatment of their initial episode. In younger patients, however, repeated episodes of severe abdominal pain are unusual. Krausz and Ureszky 4 cited only one recurrence in a 19-year-old woman three 965/149
SIGMOID VOLVULUS Cook & Allison
years following p r e s e n t a t i o n w i t h an acute abdomen and subsequent detorsion of the volvulus. In their review of the literature, A n d e r s o n et al 9 could find no additional recurrences in young patients. In only one case did a patient w i t h chronic pain proceed to present w i t h a surgical abdomen3 s The likelihood of preventing recurrent episodes of acute volvulus, w i t h its risk of bowel ischemia, by elective sigmoid resection would n o t appear to be great. In the treatment of chronic symptoms, the benefit of elective surgery is even less c e r t a i n . T h e incidence of progression of recurrent pain is low in young patients. Chronic disease is difficult to diagnose w i t h certainty, as patients usually are clinically w e l l at t h e t i m e of e v a l u a t i o n . T h e r e a r e n o s i g n s or s y m p t o m s p a t h o g n o m o n i c of t h e disease, and roentgenographic findings usually are nonspecific. Episodes of transient volv u l u s , t h e r e f o r e , s h o u l d be d o c u m e n t e d repeatedly by b a r i u m e n e m a before e l e c t i v e s i g m o i d r e s e c t i o n is considered.
REFERENCES 1. Prather JR, Bowers RF: Surgical management of volvulus of the sigmoid. Arch
150/966
Surg 1962;85:869-874. 2. Drapanas T, Stewart JD: Acute sigmoid volvulus: Concepts in surgical treatment. A m J Surg 1966;101:70-74. 3. Taneja SB, Kalsar A, Aygar RD: Sigmoidal volvulus in childhood: Report on two cases. Dis Colon Rectum 1977;20: 62-64. 4. Krausz MM, Uretzky G, Charizl L: Sigmoidal volvulus in young adult patients. Dis Colon Rectum 1979;22:200-204. 5. van Langenberg AS: Elective resection for recurrent sigmoidal volvulus: Report of a case. Dis Colon Rectum 1976;19:7-12. 6. Carter R, Hinshaw DB: Acute sigmoidal volvulus in children. Am J Dis Child 1961;101:123-129.
7. Allen RP, Nordstrom JE: Volvulus of the sigmoid in children. Am J Roentgenol 1964;91:690-691. 8. Lillard RL, Allen RP, Nordstrom JE: Sigmoid volvulus in children: A case report. AJR 1966;97:223-225. 9. Andersen JF, Eklof O, Thomasson B: Large bowel volvulus in children. Pediatr Radiol 1981;11:129-130. 10. Hunter JG Jr, Keats TE: Sigmoid volvulus in children: A case report. A m J Roentgenol Rad Ther Nucl Med 1970; 108:621-623. 11. Keramidas DC, Skondras C, Anag:
Annals of Emergency Medicine
nostu D, et al: Volvulus of the sigmoid colon. J Pediatr Surg 1979;14:479-480. 12. Wilk PJ, Ross M, Leonidas J: Sigmoid volvulus in an ll-year-old girl. Am J Dis Child 1974;127:400-403. 13. Agrez M, Cameron D: Radiology of sigmoid volvulus. Dis Colon Rectum 1981;24:510-513. 14. Arnold GJ, Nance FC: Volvulus of the sigmoid colon. Ann Surg 1973;177:527529. 15. Campbell JR, Blank E: Sigmoid volvulus in children. Pediatrics 1974;53: 702-705. 16. Sturzaker HG: Recurrent sigmoid volvulus in young people: A missed diagnosis. Br Med J 1975;4:338-340. 17. Smith RB, Kettlewell MG, Gough MH: Intermittent sigmoid volvulus in the younger age group. Br J Surg 1977;64: 406-409. 18. Myers NA: Recurrent volvulus of the sigmoid colon in a young patient. Aust NZ J Surg 1964;33:189-192. 19. Boerema WJ: Intermittent volvulus of the sigmoid colon. Med J Aust 1980;1:223. 20. Strom PR, Stone HH, and Fabian TC: Colonic atony in association with sigmoid volvulus. South Med I 1982;75: 933-936.
13:10 October 1984
Sigmoid Volvulus in a Young Patient The case of an 18-year-old man with sigmoid volvulus and recurrent abdominal pain is presented. He was seen in the emergency department three times in a 4-month period, each time complaining of cramping left lower quadrant pain of one to two hours duration without vomiting or diarrhea. Physicial examination on each occasion revealed left lower quadrant tenderness without mass, guarding, or rebound. Radiologic evaluation on the first visit revealed sigmoid volvulus, which was reduced by barium enema. Despite identical clinical presentation on two subsequent occasions, radiologic studies showed no evidence of recurrent volvulus. During the ensuing two years, the patient has had no further symptoms. [Cook ES, Allison EJ Jr: Sigmoid volvulus in a young patient. Ann Emerg Med October 1984;13:963966.] INTRODUCTION Sigmoid volvulus is an unusual cause of abdominal pain in the young. 1 It may present either as the "acute abdomen" or, more commonly, as recurrent abdominal pain relieved by passage of stool or flatus. Radiologic presentation on plain films is, unlike that in the elderly patient, variable. When evidence of large bowel obstruction is present on plain abdominal films, barium enema is performed initially for confirmation of the diagnosis and attempted hydrostatic reduction of the volvulus. If this is unsuccessful, decompression may be achieved by sigmoidoscopy-directed placement of a rectal tube. If this approach fails, surgical reduction of the volvulus, or colon resection, is undertaken. Laparotomy is performed initially in the presence of peritoneal signs. Surgical consultation for chronic pain should be obtained only following repeated demonstration of volvulus by barium enema. Our case is presented to make the emergency physician aware of this unusual entity in the differential diagnosis of intestinal obstruction; to stress the success of nonoperative reduction; and to emphasize the pitfall of attributing repeated identical clinical findings to recurrent volvulus, leading to inappropriate surgical referral.
Elisabeth S Cook, MD E Jackson Allison, Jr, MD, MPH, FACEP Greenville, North Carolina From the Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina Received for publication November 14, 1983. Revision received February 17, 1984. Accepted for publication March 9, 1984. Address for reprints: Elisabeth S Cook, MD, Emergency Department, Beaufort County Hospital, Washington, North Carolina 27889.
CASE REPORT An otherwise healthy 18-year-old man presented to the emergency department complaining of left lower quadrant pain of 30 minutes duration. The pain was sudden in onset, unaccompanied by nausea or vomiting, and of increasing intensity. His last bowel movement had been five days prior to admission, which was normal for the patient. Physical examination revealed a temperature of 36.9 C; pulse, 90/min; respirations, 18/min; and blood pressure, 120/76 m m Hg. He appeared in moderate distress due to pain. Mucous membranes were moist and skin turgor was normal. He was persistently tender to palpation in the left lower quadrant. There was no abdominal distention and no mass was palpated. There was no guarding or rebound. Bowel sounds were absent. Complete blood count showed a hemoglobin of 14.6; hematocrit, 43.5; and white blood cell count, 8,600. Plain films of the abdomen showed a single loop of distended large bowel in the left upper quadrant (Figure 1). This roentgenographic finding led to suspicion of large bowel volvulus, and a barium enema was performed. The sigrnoid colon was shown to be redundant {Figure 2). The closed sigmoid loop was well demonstrated and opened with a rush of barium, followed by
13:10 October 1984
Annals of Emergency Medicine
963/147
SIGMOID VOLVULUS Cook & Allison
Fig. 1. Plain film of the a b d o m e n shows closed large bowel loop in the left upper quadrant. Fig. 2. Barium enema shows detorsion of volvulus with barium seen proximal to site of bowel obstruction. i m m e d i a t e relief of the patient's symptoms. The patient was observed overnight in the emergency department, and was discharged the following morning. The patient remained asymptomatic for six weeks, at which time he again presented with the same symptoms as on his previous admission. His last bowel movement had been four to five days earlier. Physical examination again demonstrated persistent left lower quadrant tenderness without distention, mass, or guarding. Bowel sounds were normal. Flat and upright films of the abdomen showed a sentinel loop of small bowel gas in the rnidline (Figure 3). The colon was distended throughout and was filled w i t h stool. Barium e n e m a again showed a redundant sigmoid, but no obstruction (Figure 4). Following evacuation of the colon, symptoms were relieved and the patient was discharged. 148/964
Eight weeks following the second episode the patient returned after four hours of cramping lower abdominal pain, identical to his previous symptoms. Physical examination revealed left lower quadrant tenderness without mass, guarding, or rebound. Bowel sounds were normal. Plain films of the a b d o m e n were unremarkable, and symptoms were relieved following, a soapsuds enema. The patient was placed on a regimen of high fiber diet and stool softeners, and he has had no recurrence of symptoms in six months.
DISCUSSION In the United States, sigmoid volvulus is an unusual cause of abdominal pain in adults, accounting for only 2% to 8% of all intestinal obstruction. 1 It is even more unusual in children and adolescents, with only 12% of reported cases of sigmoid volvulus occurring in patients less than 50 years of age. 2 In a review of intestinal obstruction in pediatric patients, sigmoid volvulus was implicated in only 0.8%. 3 In the elderly the most common presentation of sigmoid volvulus is recurrent, colicky abdominal pain. 4 In the young this entity may present as the acute abdomen or, more cornAnnals of Emergency Medicine
monly, as recurrent pain with spontaneous detorsion of the involved segment, manifested clinically by passage of large amounts of liquid stool or flatus. Because of the chronic nature of their symptoms, many of these patients have been diagnosed erroneously as having "irritable bowel syndrome" or chronic cholecystitis, S.and have been treated inappropriately for many years. Analysis of English language case reports of sigmoid volvulus presenting as the acute abdomen3, 6-12 reveals the most c o m m o n p r e s e n t a t i o n to be cramping or steadily intensifying left lower quadrant or diffuse abdominal pain. Abdominal distention was present in 90% of the patients described. Vomiting was present in only 12%. Fever was an unusual finding. In infants vomiting and dehydration were prominent,3, 6 with ischemic changes in the bowel producing significant third space losses. The only deaths reported were in 14-day-old6 and 10month-old3 boys, both of whom were in hypovolemic shock on initial presentation. In older children physical examination typically revealed distention, left lower quadrant tendemess with guarding, and often a palpable mass. Bowel s o u n d s were high13:10 October 1984
pitched, typical of intestinal obstruction. Intussusception was the most common initial impression. In sigmoid volvulus initial roentgenographic findings were nondiagnostic in one-third of the cases reviewed by Agrez and Cameron33 In younger children flat and upright abdominal films often reveal only distended small bowel loops. In older children and young aduks the classic appearance of the distended sigmoid loop filling most of the upper abdomen is seldom seen. z Barium enema demonstrates the obstruction high in the sigmoid, in' contrast to the rectosigmoid loop usually seen in the elderly.7 Initially a static column of barium appears, tapering at the distal point of obstruction (the "bird's beak" or "ace of spades" deformity), followed by a rush of barium as the segment untwists. 7 Lillard, Allen, and Nordstrom8 r e p o r t e d successful b a r i u m enema reduction of sigmoid volvulus in six of seven pediatric patients. Arnold and N a n c e 14 r e c o r d e d nonoperative reduction in 110 of 145 patients following sigmoidoscopy, barium enema, saline enema, or rectal tube. Analysis of case reports of sigmoid volvulus presenting as chronic abdom13:10 October 1984
inal pain4,5,15-19 consistently revealed descriptions of multiple episodes of colicky central or left lower quadrant pain relieved by passage of diarrheal or melanotic stools and/or flatus. Duration of pain varied from several minutes to several days, with a frequency ranging from one or two episodes annually to two to three episodes weekly. 16 The majority of patients noted abdominal distention accompanying pain. Most gave a history of chronic constipation. Weight loss, nausea, and vomiting were not described. At the time of presentation for evaluation of r e c u r r e n t pain, m o s t p a t i e n t s are clinically well; therefore, radiologic evaluation commonly shows only redundancy of the sigmoid colon. While a long sigmoid, a long, mobile rnesosigmoid, and close proximity of proximal and distal sigmoid limbs are necessary c o n d i t i o n s for v o l v u l u s to occur, they do not provide proof of its existence. According to Campbell and Blank, is and Lillard, Allen and Nordstrom, 8 a redundant sigmoid colon often is seen on barium enema in children who have not had obstructive episodes. As our case illustrates, not all episodes of the patient's characteristic pain represent volvulus. Symptoms Annals of Emergency Medicine
Fig. 3. Plain film shows a single loop of s m a l l bowel. No closed loop obstruction is visualized. Fig. 4. Barium enema shows no evidence of obstruction. Sigmoid colon is redundant. may be caused by constipation alone. In both acute and recurrent sigmoid volvulus the emergency physician is responsible for obtaining appropriate surgical consultation. If fever, absent bowel sounds, rebound tenderness, or other evidence of bowel ischemia are present, surgical referral should be immediate. If these signs are absent, nonoperative reduction of the volvulus should be attempted. Surgical consultation for subsequent management should be based on meticulous documentation of the diagnosis, and consideration of the likelihood and consequences of recurrence. In the elderly, Strom, Stone and Fabian 2o reported recurrent volvulus in only 10% of patients undergoing sigmold resection as treatment of their initial episode. In younger patients, however, repeated episodes of severe abdominal pain are unusual. Krausz and Ureszky 4 cited only one recurrence in a 19-year-old woman three 965/149
SIGMOID VOLVULUS Cook & Allison
years following p r e s e n t a t i o n w i t h an acute abdomen and subsequent detorsion of the volvulus. In their review of the literature, A n d e r s o n et al 9 could find no additional recurrences in young patients. In only one case did a patient w i t h chronic pain proceed to present w i t h a surgical abdomen3 s The likelihood of preventing recurrent episodes of acute volvulus, w i t h its risk of bowel ischemia, by elective sigmoid resection would n o t appear to be great. In the treatment of chronic symptoms, the benefit of elective surgery is even less c e r t a i n . T h e incidence of progression of recurrent pain is low in young patients. Chronic disease is difficult to diagnose w i t h certainty, as patients usually are clinically w e l l at t h e t i m e of e v a l u a t i o n . T h e r e a r e n o s i g n s or s y m p t o m s p a t h o g n o m o n i c of t h e disease, and roentgenographic findings usually are nonspecific. Episodes of transient volv u l u s , t h e r e f o r e , s h o u l d be d o c u m e n t e d repeatedly by b a r i u m e n e m a before e l e c t i v e s i g m o i d r e s e c t i o n is considered.
REFERENCES 1. Prather JR, Bowers RF: Surgical management of volvulus of the sigmoid. Arch
150/966
Surg 1962;85:869-874. 2. Drapanas T, Stewart JD: Acute sigmoid volvulus: Concepts in surgical treatment. A m J Surg 1966;101:70-74. 3. Taneja SB, Kalsar A, Aygar RD: Sigmoidal volvulus in childhood: Report on two cases. Dis Colon Rectum 1977;20: 62-64. 4. Krausz MM, Uretzky G, Charizl L: Sigmoidal volvulus in young adult patients. Dis Colon Rectum 1979;22:200-204. 5. van Langenberg AS: Elective resection for recurrent sigmoidal volvulus: Report of a case. Dis Colon Rectum 1976;19:7-12. 6. Carter R, Hinshaw DB: Acute sigmoidal volvulus in children. Am J Dis Child 1961;101:123-129.
7. Allen RP, Nordstrom JE: Volvulus of the sigmoid in children. Am J Roentgenol 1964;91:690-691. 8. Lillard RL, Allen RP, Nordstrom JE: Sigmoid volvulus in children: A case report. AJR 1966;97:223-225. 9. Andersen JF, Eklof O, Thomasson B: Large bowel volvulus in children. Pediatr Radiol 1981;11:129-130. 10. Hunter JG Jr, Keats TE: Sigmoid volvulus in children: A case report. A m J Roentgenol Rad Ther Nucl Med 1970; 108:621-623. 11. Keramidas DC, Skondras C, Anag:
Annals of Emergency Medicine
nostu D, et al: Volvulus of the sigmoid colon. J Pediatr Surg 1979;14:479-480. 12. Wilk PJ, Ross M, Leonidas J: Sigmoid volvulus in an ll-year-old girl. Am J Dis Child 1974;127:400-403. 13. Agrez M, Cameron D: Radiology of sigmoid volvulus. Dis Colon Rectum 1981;24:510-513. 14. Arnold GJ, Nance FC: Volvulus of the sigmoid colon. Ann Surg 1973;177:527529. 15. Campbell JR, Blank E: Sigmoid volvulus in children. Pediatrics 1974;53: 702-705. 16. Sturzaker HG: Recurrent sigmoid volvulus in young people: A missed diagnosis. Br Med J 1975;4:338-340. 17. Smith RB, Kettlewell MG, Gough MH: Intermittent sigmoid volvulus in the younger age group. Br J Surg 1977;64: 406-409. 18. Myers NA: Recurrent volvulus of the sigmoid colon in a young patient. Aust NZ J Surg 1964;33:189-192. 19. Boerema WJ: Intermittent volvulus of the sigmoid colon. Med J Aust 1980;1:223. 20. Strom PR, Stone HH, and Fabian TC: Colonic atony in association with sigmoid volvulus. South Med I 1982;75: 933-936.
13:10 October 1984