An Overview of Volvulus

Volvulus occurs when part of the intestine loops around and folds over itself. It often happens in the cecal and sigmoid colon sections of the intestines. The twisting can cut off the tissue's blood supply, leading to symptoms such as extreme pain, bloody stool, and bowel obstruction.

Volvulus can lead to bowel perforation and necrosis, or tissue death, which can be life-threatening. Older people between the ages of 50 and 80 are more at risk for volvulus, as are people with chronic health conditions. It's also common in newborns diagnosed with intestinal malrotation.

This article explains volvulus symptoms and the causes of volvulus. It discusses how the condition is diagnosed and treated, including surgeries that may be necessary due to bowel tissue death.

Volvulus Symptoms

Volvulus symptoms usually occur over time and gradually get worse. These symptoms may begin with cramping, but the pain eventually becomes unbearable.

Common symptoms of volvulus that may signal bowel obstruction include:

• Abdominal distention
• Abdominal tenderness
• Vomiting
• Blood in stools
• Constipation

Both children and adults with volvulus may develop hemodynamic instability from not having enough fluid intake or because of septic shock.

Along with the cecal and sigmoid colons, the stomach may be affected. In children, the small intestine is usually where volvulus occurs.

For children, a main symptom is vomiting with what looks like bile, a yellow-green fluid produced by the liver. This is a strong sign of something going wrong in the bowel and requires an immediate workup. However, vomiting may not look like bile.

Causes of Volvulus

The causes of volvulus are not entirely known. It primarily occurs in older adults between the ages of 60 and 80. It often affects people living with underlying neurologic or psychiatric conditions.

It's also more common in people who live in care homes, or who spend a lot of time in bed.

Some factors that may increase the risk of volvulus include:

• Chronic constipation
• A high-fiber diet
• Past abdominal surgery

Volvulus also may be more likely in people with specific anatomical features. That's the case if you have a long and twisty sigmoid colon with more length to wrap around itself, and a narrow mesenteric attachment. The mesentery is a fold in the peritoneum (your abdominal cavity) that helps to attach the intestines to the wall of the abdomen.

If the colon is not moving as it normally does, it may make it easier for the sigmoid colon to twist. The retained fecal matter in the colon of people with chronic constipation may lead to elongation of the sigmoid colon. It also may become dilated, or widen.

Causes in Children

Volvulus in children is often first diagnosed as a disorder in newborns, or even before birth.

For example, connections have been made between sigmoid volvulus and people born with a congenital disorder called Hirschsprung's disease. This condition arises when parts of the bowel, usually the rectum and sigmoid colon, do not have the nerve cells needed to create the regular movement of the colon.

Volvulus often affects children because of an abnormality in the rotation of the gut as the fetus is developing in utero, something that happens in about one in 6,000 live births. About 80% of these cases of intestinal malrotation are diagnosed in newborns.

Intestinal Detorsion

Volvulus is caused by intestinal twisting, but it's also possible for intestinal detorsion to happen. In this case, the intestines spontaneously unwrap themselves, sometimes over and over again such that the blood supply is not completely cut off.

This is more likely to occur in younger people, who experience symptoms that come and go multiple times. They may have painful bouts that spontaneously resolve with time. This does not mean the issue goes away. It may just take more time to diagnose and treat.

Diagnosing Volvulus

Volvulus is diagnosed on the basis of its symptoms, which include abdominal pain, nausea, abdominal distention, constipation, and inability to pass gas.

A healthcare provider may suspect volvulus based on this history and begin looking for a possible cause, which may include additional tests beyond a physical exam.

Labs and Tests

Lab tests are usually done to check electrolytes or other markers for infection and necrosis. A urine test may be needed to rule out any urinary tract or bladder involvement. If you're of childbearing age, you also may need a pregnancy test.

People who are already quite sick when they see a healthcare provider may need a more detailed lab workup. This may include blood tests for liver function and pancreatic function.

CT Scan

In adults, an abdominal computed tomography (CT scan) may be performed. The results of a CT scan with a contrast dye may show:

• A "whirl pattern" caused by sigmoid colon dilation, wrapped around the mesentery and vessels
• A "bird-beak" appearance, where a contrast dye is blocked and cannot pass through
• Absence of rectal gas
• Bubbles in the bowel wall (pneumatosis intestinalis) if there is bowel necrosis

These findings are not always seen, however, and the diagnosis can be made without them.

X-Rays

Abdominal X-rays can help to make the diagnosis of sigmoid volvulus but usually need to be accompanied by other forms of imaging. (For children, an ultrasound can be performed initially to prevent radiation exposure.)

Findings consistent with volvulus include a distended large bowel. But these findings also are seen with other types of bowel obstruction or disease, so it is difficult to pinpoint the diagnosis of volvulus with just these X-rays alone.

Contrast Enema

A contrast enema demonstrates the pattern of a twisted taper or again, the appearance of a "bird's beak." This procedure relies on fluoroscopy.

There's a risk of perforation with this procedure, so it shouldn't be done if your healthcare provider suspects you may have peritonitis, an inflammation of tissues in the abdominal cavity.

Volvulus Treatment

Volvulus treatment focuses on two goals: Fixing the currently twisted intestine and preventing future episodes.

The process of untwisting the intestines is called "reducing" the volvulus. It first requires a flexible sigmoidoscopy procedure, which relies on a flexible, tube-like instrument equipped with a light and camera.

Inserting and advancing the instrument can help to untwist a sigmoid volvulus and restore blood supply while allowing the gastroenterologist (GI specialist) to see and assess any tissue damage.

This may help to determine if surgery is necessary although some experts suggest surgery is still needed to prevent further episodes. If volvulus happens twice, the risk of even more volvulus episodes is even higher.

Surgery for a sigmoid volvulus includes removing part of the bowel and then either reconnecting it or creating a colostomy, a hole in the abdominal wall through which fecal matter then passes.

Surgery is necessary for most cases of cecal volvulus because of the location of the cecum. In some cases, a cecoplexy to reattach the cecum to the abdominal wall may be successful. If too much tissue damage has occurred, a colostomy may be necessary.

A Word From Verywell

Volvulus symptoms may not be severe at first, but over time, they can lead to serious and potentially life-threatening complications. If you have symptoms, contact your healthcare provider. An early diagnosis and treatment may improve the outcome.