Volvulus

Introduction to colon torsion Colonic torsion refers to colonic dysplasia, such as moving the colon, the length of the transverse colon and the length of the sigmoid colon, and the closed bowel obstruction caused by the rotation of the intestinal fistula along the long axis of the mesentery. The colon torsion is more common with sigmoid torsion. And more elderly men. Cecal torsion is less common and can occur at any age, with a higher incidence of 20 to 40 years old. Transverse colon torsion, such as non-adhesion, is rare. The incidence of this disease varies from region to region, with more regions such as Shandong and Hebei. basic knowledge Proportion of disease: about 20% of the incidence of intestinal torsion Susceptible people: more common in older men Mode of infection: non-infectious Complications: peritonitis

Cause of colon torsion

Common factors (30%):

Some patients with chronic constipation have more intestinal contents, gas accumulation makes intestinal fistula dilate, intestinal activity during pregnancy and childbirth increases intra-abdominal organ position changes, congenital or acquired factors cause distal intestinal obstruction, history of abdominal surgery, etc., these are colonic torsion Common factors.

Other factors (10%):

Sigmoid torsion (20%):

Older patients are more common, with a longer history, more typical history of constipation and recurrent episodes. Patients can more clearly describe their seizure patterns and mitigation methods; while young patients have shorter medical history, prefer exercise or activities, often make sigmoid colon Reversal is relieved unconsciously, often without a clear history and pathogenesis.

Pathogenesis

The sigmoid colon is highly free, and the fixed points of the intestinal sac are relatively close. Therefore, the sigmoid torsion is the most common. The sigmoid torsion is mostly counterclockwise, and a few are clockwise. The sigmoid torsion is more common in elderly male patients, while younger sigmoid torsion is more common in young people. Female; cecal torsion is mostly congenital cecum and ascending mesenteric free intestinal fistula. When the intestinal peristalsis is active or vigorous, the intestinal fistula can be twisted. The mesangial axis is often twisted clockwise, and occasionally counterclockwise. Transverse colon torsion is often associated with surgical adhesions. Colon torsion is 180° to 360° for non-occlusive intestinal obstruction; if twisted 360° or more, closed intestinal obstruction can be formed. Under normal circumstances, the colon is twisted below 360°, which does not easily affect the intestinal tract. Blood transport and intestinal lumen are unobstructed, more than 180 ° often obstruction, more than 360 ° colonic torsion of the mesangial vessels are easily squeezed to reverse the intestinal venous venous obstruction, intestinal edema, bloody exudate in the abdominal cavity, followed by arteries Poor blood supply leads to ischemia and even necrosis. The greater the degree of torsion, the more chances of ischemic necrosis. In addition, the closure Blocking intestinal gas accumulation, effusion, and increased pressure will also affect blood supply. Therefore, closed colonic torsion obstruction is often prone to intestinal narrowing. Some patients may have severe infection and even shock due to intestinal necrosis. Special attention should be paid to mesenteric blood. Intestinal necrosis and severe infection and shock manifestations can occur within a short period of time after circulatory disturbance.

Colonic torsion prevention

prevention

If the colon is reversed due to non-congenital developmental factors, it is for the prevention of pathogenic factors (such as elderly people with habitual constipation), intra-abdominal adhesion after surgery, high-fiber food, and flexion after meal.

Colon torsion complications Complications peritonitis

Due to long-term vomiting, water and electrolyte metabolism disorders can occur. When the condition is severe, the abdomen with asymmetrical ablation and irregular flatulence can be seen. If it cannot be reset in time, the flatulence and intestinal fistula may cause intestinal wall necrosis due to intestinal narrowing. Perforation, peritonitis and even death.

Colon torsion symptoms Common symptoms Colonic vascular dysplasia Nausea intussusception Abdominal pain with nausea, vomiting Fecal impaction Shock bowel bloating fecal vomit constipation

Most of the patients were acutely ill, beginning with sudden abdominal pain, followed by abdominal distension, nausea, vomiting and anal without exhaustion. The twisted intestinal fistula caused asymmetrical expression of the abdomen, sometimes showing intestinal or peristaltic waves, abdominal tenderness, different colons. The degree of tenderness in different parts of the segment is different, and the clinical manifestations are not the same:

1, cecal torsion is similar to small bowel obstruction, the incidence is acute, mainly in the middle or lower right abdominal pain, sometimes can sputum and the lower right abdomen to expand the cecal airulence mass, can smell high-pitched bowel sounds and gas over water sound, when there is peritonitis Abdominal muscle tension and rebound tenderness, bowel sounds disappear; when the pulse speeds up, body temperature rises, with signs of peritonitis, even bloody ascites, it is a common manifestation of intestinal ischemia and necrosis, shock can occur quickly, the probability of death will greatly increase.

2, transverse colon torsion is characterized by upper abdominal pain, abdominal distension, and some similar to gastric dilatation.

3, sigmoid colon torsion is diversified, can be acute, and some patients with subacute or chronic onset, more history of constipation, or repeated history of intestinal torsion obstruction, and some can relieve themselves.

Colon torsion examination

Laboratory inspection

If there is a peritoneal irritation and/or intestinal necrosis, blood leukocytes increase.

Film degree exam

1, X-ray performance: under normal circumstances, the position of the abdominal plain film can be seen in the expansion of the intestines, a large number of gas-liquid level exists, the laparoscopic flat film can observe the expansion of the colon, such as cecal torsion can also be seen in the small intestine gas expansion; but not closed Because of the fact that there is only one obstruction point, the colonic torsion often has the same performance as simple colonic obstruction. It also shows the enlargement of the colonic intestine above the obstruction, so it is generally difficult to identify in fluoroscopy or plain film. Only in order to clarify the nature of colonic obstruction At the time of enema examination, the diagnosis can be confirmed. At this time, the twisted obstruction can show a spirally thinned intestine or a twisted and intersecting mucosa (along the longitudinal axis of the intestine) in the thinned intestine, and even the expectorant enters the proximal side through the obstruction. Intestinal canal, a typical X-ray manifestation of closed colonic torsion, that is, the torsional segment of the intestinal fistula can show an enlarged closed sputum on the supine abdomen flat, like an inflated elliptical balloon, especially the sigmoid colon to reverse its extremely dilated bowel The koji is in the shape of a coffee bean, and the double-lined intestinal wall shadow is visible in the middle. As the intestinal wall becomes thinner, the two sides of the sac appear as a rounded dense dense white shadow, and the enlarged intraluminal fold disappears. The sigmoid sigmoid torsion is detected, and the torso-like stenosis is seen at the torsion of the colon. The signs of multiple fillings are present and the sputum cannot pass through the stenosis. The transverse colon is torsionally dilated and the intestine is curved in the middle and upper abdomen. In the middle, there is also a double-lined intestinal wall shadow, the descending colon collapses, and the cecal torsion is mostly clockwise. In addition to the circular expansion of the cecum, the small intestine also expands significantly.

2, CT: is important for the diagnosis of colonic torsion, cecal torsion CT can be seen under the cecum and small intestine expansion, the mesenteric venous return is blocked and dilated, the mesentery together with the dilated blood vessels twisted into a swirl, called the vortex sign; the same sigmoid torsion There is also a venous dilatation and vortex sign of the mesangium under the dilated sigmoid colon.

3, low-pressure enema: is also one of the auxiliary diagnosis, such as the inability to inject 300 ~ 500ml of saline, indicating that the obstruction is possible in the sigmoid colon.

4, fiber colonoscopy: not only can assist in diagnosis, but also a method of non-surgical treatment, but these methods have limitations.

Colonic torsion diagnosis

diagnosis

It is not difficult to determine the torsion of the colon with abdominal pain, bloating, constipation symptoms, combined with etiology and medical history. Colon torsion is often accompanied by nausea, vomiting, abdominal distension, abdominal tenderness and abdominal asymmetrical intestinal gas stagnation. Acoustic hyperactivity, elevated body temperature, signs of peritonitis, shock, etc., combined with related auxiliary examinations can generally make a diagnosis of colonic torsion.

Differential diagnosis

1, colon cancer

The cecum, transverse colon and sigmoid colon or rectal cancer may have low intestinal obstruction, but the history is longer, often without a history of sudden abdominal pain, the colon cancer is hard and the boundary is clear, while the colon torsion is the swollen intestine, the texture at palpation Softer, unclear borders, easier to distinguish, of course, barium enema can be diagnosed.

2, colonic intussusception

The ileum is more common in the cecum, and can be extended to the sigmoid colon. The incidence is acute and the performance of low intestinal obstruction is more common in children from May to June. The symptoms are paroxysmal crying, nausea, vomiting, and jam-like stool. Diagnosis of the right lower abdomen emptiness, right upper abdomen sausage-like mass, barium enema can be seen in the cup of mouth shadow can be diagnosed, adult chronic intussusception, mostly caused by tumors, less common, apparently easy to distinguish with colon torsion .

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