Volvulus refers to the abnormal twisting of a section of intestine around its axis. It is therefore also commonly referred to as intestinal tangling. This twisting or tangling causes an undersupply of blood to the affected section of the intestine. This can result in intestinal obstruction or death of the intestinal segment (intestinal gangrene).
What is a volvulus?
If certain sections of the intestine are knotted or tangled together, it is called intestinal volvulus. This condition can be life-threatening. Intestinal tangles are often congenital, in which case the natural development of the intestine was already disturbed in the womb. The prenatally necessary rotations were then not or only incorrectly executed by the intestine. Parts of the intestine rotate around the stalk. This carries the supplying or draining blood vessels. This change in the position of the intestine can lead to a partial or complete obstruction of the intestinal tube. There are two main forms of intestinal entanglement. In intussusception, the invagination of one part of the intestine into another part of the intestine occurs. The invagination is longitudinal and causes blood stasis and swelling. It leads to intestinal obstruction. The second main form of intestinal entanglement is axial twisting. In this case, one loop of bowel rotates up to 180 degrees, wraps around another loop, and thus squeezes off the blood supply. Due to a resulting intestinal obstruction, the intestine can no longer fulfill its functions. Vital organs may be undersupplied and a life-threatening condition may result.
Causes
One known cause of intestinal volvulus is malrotation, a faulty rotation of the small and large intestines during prenatal human development. Infants are more likely to suffer volvulus, and this is an emergency that requires immediate treatment. Infants in the first year of life are most commonly affected. Intestinal inflammation can also cause intestinal volvulus. Intestinal inflammation occurs bacterially, chemically, from radiation, as an allergic reaction, or as an immune response. Intestinal cancer can also be a triggering disorder. Furthermore, adhesions are among the causes of volvulus. These are connective tissue-like strands between sections of the intestine that normally have no connection. Exact causes for these adhesions in the intestine are not known. It is thought they may be reactions to a foreign body, previous inflammation, or even surgery. Surgeries themselves can also cause intestinal tangles.
Symptoms, complaints, and signs
Intestinal volvulus is more common in babies and young children than in adults. Prenatal forms of volvulus are also observed. Typical symptoms include constipation, colicky abdominal pain, flatulence,nausea, and vomiting. Depending on the site of engorgement, vomiting of bile and feces may occur. After vomiting, symptoms temporarily improve. The symptoms often even disappear completely for a time. However, this is again followed by constipation, vomiting and bloody stools. A distinction can also be made between acute and chronic volvulus. In acute volvulus, the symptoms of vomiting, distended upper abdomen, and severe colicky abdominal pain appear suddenly. In severe cases, there is often even shock or peritonitis. Chronic recurrent (recurring) volvulus is more characterized by nonspecific abdominal pain and chronic constipation. Furthermore, the body becomes undersupplied with nutrients because their absorption in the intestines no longer functions properly. Due to malnutrition, the organism becomes weaker and weaker. However, there can also be symptom-free intervals between the individual episodes of the disease. In severe cases, the supply to the intestine is often so restricted by the interruption of blood flow that the affected section of the intestine dies. Then the intestinal entanglement has developed into an intestinal obstruction. In this situation, there is the highest danger to life due to intestinal perforation and bacterial infection of the abdominal cavity (peritonitis). Intestinal entanglement can usually only be treated surgically.
Diagnosis and course
Symptoms of intestinal engorgement include sudden, cramping abdominal pain, a distended upper abdomen, bilious greenish vomiting, and diarrhea-like bloody stools. The upper abdomen is tender to pressure, while the lower abdomen is more sunken. Diagnosis is difficult for the physician.It is usually made according to the presenting symptoms, a thorough physical examination, and imaging studies. Sometimes a correct diagnosis can only be made during surgery. Imaging studies include X-ray and ultrasound. In the case of intestinal tortuosity of the posterior colon, the massive overinflation of the intestinal part can be seen on the X-ray by a kind of coffee bean sign. The overinflated part of the intestine then often has the contour of a coffee bean. The course of intestinal engorgement is life-threatening, as it leads to life-threatening intestinal obstruction and therefore must be treated as an emergency.
Complications
Volvulus can cause serious complications. Intestinal volvulus initially causes severe abdominal pain, which increases in intensity as the condition progresses and severely limits the affected person in his or her daily life. Major complications are to be expected if the entanglement leads to an undersupply of a section of the intestine. This can lead to the death of the intestinal section or to intestinal obstruction. This is often accompanied by peritonitis, which in the further course spreads to other internal organs and quickly develops into a life-threatening condition. If the volvulus is not treated immediately with intensive care, there is a risk of circulatory shock. In the worst case, intestinal volvulus can be fatal. Treatment is also fraught with danger. Surgery always carries the risk of injuring parts of the intestine or causing infection. Injuries to the intestinal walls can lead to functional disorders that may be permanent. Sometimes an artificial bowel outlet must be placed, which carries the risk of herniation and injury. Last, side effects and drug interactions may occur due to the administration of medications.
When should you see a doctor?
In case of abdominal pain, irregularity in the abdomen, nausea or vomiting, the cause of the complaints should be clarified. If a significant relief of the disturbances is already apparent after a short time, it is often a short-term health impairment. A doctor is not required if the symptoms are permanently relieved. If the symptoms reoccur, persist over a longer period of time, or are characterized by an increasing character, a doctor must be consulted. Particularly in the case of a chronic course of the disease, there is a need for action, since intestinal obstruction can lead to serious health developments. Flatulence, constipation or a strong feeling of pressure in the abdomen indicate irregularities that should be investigated. If blood can be perceived from the anus when going to the toilet or if there are sudden health impairments, consultation with a physician should be immediate and as soon as possible. In the event of intestinal obstruction, there is a potential threat to one’s own life. For this reason, rapid and unexpected health impairments in particular should be discussed with a physician. Disturbances in mobility, hypersensitivity to pressure in the area of the stomach or intestines, and sweating are warning signals of the human organism. Sudden changes in the circulation, an irritability or a rapid decrease in physical performance must be investigated and treated.
Treatment and therapy
To treat intestinal tangling, it is necessary to return the affected section of intestine to its original position as quickly as possible. This can only be accomplished by means of surgery. Time is of the essence in such operations because the cut-off blood supply to the affected section of intestine quickly leads to tissue death. The intestinal section that has been twisted back is fixed during the operation to prevent it from twisting again. If the part of the intestine in question is already so damaged that recovery of function is unlikely, portions of the damaged tissue are removed. Under certain circumstances, it may be necessary to place an enterostoma (artificial bowel outlet). In a more conservative approach, the volvulus is first acutely decompressed. A flexible colonoscope is used. The important thing here is to determine whether the bowel is still vital or not. If the bowel is still vital, an examination of the anal canal is performed as an initial measure. Following the examination, an intestinal tube is placed.A reduction in the size of the volvulus is then indicated by a noisy discharge of gas and stool. The type of therapy always depends on how severely the blood flow to the intestine or affected section of the intestine is impaired.
Prevention
Sensible prevention of intestinal engorgement means ensuring good intestinal health. This includes a healthy diet with valuable fiber, plenty of fruits and vegetables. The acid-base household should be balanced. Furthermore, it is important for the intestines to supply sufficient fluids – preferably water or drinks with low sugar levels. It is better to avoid foods that are difficult to digest. Furthermore, regular exercise is important for a healthy intestine.
Follow-up
Once intestinal volvulus has been treated, no medical follow-up is required. After the recovery period, the patient is fit for duty. The duration of the recovery phase depends on the age of the affected person. During recovery, exercise is important, but no physical exertion. A change in diet lowers the risk of recurrence. Sufficient fiber combined with vitamins and minerals keep the intestines healthy. Increasing fluids daily in sufficient amounts supports bowel function. Hasty eating is unhealthy. Several smaller portions spread throughout the day are recommended. Do not forget daily physical exercise. During surgery, part of the intestine had to be removed. An artificial intestinal outlet became necessary. This enterostoma will be removed after some time. Regeneration after the first part of the operation takes longer. The medical aftercare includes the handling of the stoma. The medical staff cleans the access daily. After a few days, the patient takes over these actions. The bowel has regenerated and the artificial outlet is removed. After the wound has healed, no further medical measures are necessary. Dietary changes are also necessary here. Already in the “stoma phase”, the necessary steps are explained by the nursing staff.
What you can do yourself
Acute volvulus must be treated immediately by a doctor. If there is stomach pain, malaise, or other signs of intestinal engorgement, alert emergency medical services. The body should be kept immobilized until the physician arrives. Acute volvulus must be treated surgically to prevent death of the affected section of intestine. After the operation, rest and sparing are the first and foremost requirements. If necessary, the diet must be changed. In the case of chronic volvulus, a surgical procedure is also necessary. The patient must then adhere to the doctor’s instructions and, for example, avoid sporting activity. In the case of a volvulus of the sigmoid, medical intervention is indicated. Afterwards, rest and a change of lifestyle are again required. In addition to regular physiotherapy, which can be performed by the patient at home, sufficient fruit and vegetables should be consumed. The diet should also consist of high-fiber foods that are also easy to digest. A nutritionist can prepare a suitable plan. It is important to consume sufficient fluids. Water and isotonic drinks have proved particularly effective. Furthermore, physical activity is important for the health of the gastrointestinal tract.
