lschemic Colitis Associated with Sigmoid Volvulus: New Observations

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1 lschemic Colitis Associated with Sigmoid Volvulus: New Observations MORTON A. MEYERS, GARY G. GHAHREMANI,2 AND ANTONIO F. GOVONI Ischemic colitis following conservative management of sigmoid volvulus is documented in four cases. Repeat barium enema studies in these patients showed characteristic thumbprinting transverse ridging, and mucosal ulcerations within a segment or the entire length of the sigmoid, lasting up to 7 days after nonoperative decompression. The development, extent, and severity of the ischemic changes seem to correlate with the degree of volvulus. blockage of venous and arterial circulations in the sigmoid mesocolon, and increased intraluminal pressure. Volvulus of the sigmoid colon commonly presents as an abdominal emergency among the adult population. The significance of prompt nadiologic diagnosis and surgical treatment has been well documented. However, the ultimate value of conservative management by proctosigmoidoscopy and placement of a rectal tube has remained controversial, mainly because of an associated high incidence of recurrence and mortality [1]. This report documents the development of severe ischemic colitis complicating nonoperative detorsion of the sigmoid volvulus in four patients. The clinical significance of this new observation in the management of the volvulus of sigmoid is discussed. Case 1 Case Reports An 81-year-old black male, transferred from a mental institution, had a 1 week history of increasing abdominal pain and distention. Chronic constipation had required frequent administration of laxatives. Two previous episodes of acute sigmoid volvulus were successfully treated by rectal tube placement; the last occurred 5 months before admission. Physical examination revealed a distended and diffusely tympanitic abdomen. Abdominal radiographs showed massive gaseous dilatation of the small and large intestine, but no gas in the rectosigmoid. Sigmoidoscopy confirmed obstruction at 25 cm due to sigmoid volvulus. Initially one and later two rectal tubes were inserted. After explosive deflation, radiographs documented decompression and reduction of the volvulus. Because of the persistent abdominal pain and the passage of blood-stained stools, the patient underwent barium enema examination 2 days later. This study showed a redundant sigmoid with rigidity of its wall and irregular narrowing of the lumen due to the projection of many submucosal masses resembling thumbprints (fig. 1). The flow of barium proximal to the splenic flexure was not possible because of fecal impaction. On the following day, a repeat sigmoidoscopy revealed markedly erythematous and irregularly elevated rectosigmoid mucosa due to edematous folds, with areas of petechial hemorrhage and superficial erosions. The findings indicated ischemic changes and intramural hemorrhage. The patient was treated conservatively and returned to the state hospital for follow-up care. Case 2 A 45-year-old mentally retarded male was in relatively good health until 4 days prior to admission when obstipation and progressive abdominal distention associated with left lower quadrant pain were noted. On physical examination, the abdomen was massively distended and tympanitic with a few high-pitched bowel sounds. Sigmoidoscopy showed narrowing of the sigmoid lumen at 25 cm. Abdominal radiographs demonstrated marked gaseous dilatation of the sigmoid. Barium enema study revealed a narrowing in the middle third of the sigmoid colon with a typical beaklike appearance, indicating sigmoid volvulus. The patient was treated conservatively with deflation by long rectal tube. Follow-up abdominal films 3 days later showed persistent distention of the proximal portion of the sigmoid colon. A second barium enema study 1 week after tube insertion demonstrated submucosal edematous changes within the dilated paretic proximal sigmoid colon and rectum (fig. 2). A sigmoid colectomy was performed 3 days later. At surgery. the sigmoid colon appeared markedly distended, with a thick wall and a long mesentery. Microscopically. there was evidence of mural and mucosal edema. Case 3 A 79-year-old female with a long history of syringomyelia was admitted because of respiratory distress and marked abdominal distention. Abdominal radiographs showed findings of sigmoid colon obstruction with marked dilatation of the remaining segments of large bowel. A water-soluble contrast enema confirmed retrograde obstruction at the rectosigmoid junction. with a configuration indicating volvulus. The volvulus was reduced by proctoscopy and insertion of a long rectal tube. A barium enema study 2 days later revealed ischemic changes throughout the length of a redundant sigmoid colon, most marked in its distal limb (fig. 3). The patient was discharged without signs or symptoms 8 days later. Case 4 A 76-year-old man with dementia was seen in the emergency room because of severe lower abdominal pain for 2 days. Abdominal radiographs demonstrated large bowel distention, and a barium enema study confirmed obstruction of the middle third of the sigmoid. Colonoscopy was performed and the sigmoid volvulus was reduced. Follow-up barium enema examination 4 Received August , accepted after revision December 14, Department of Radiology. New York Hospital-Cornell University Medical Center, 525 East 68th Street, New York, New York Department of Radiology. Evanston Hospital-Northwestern University Ridge Avenue, Evanston, Illinois Address reprint requests to G. G Ghahremani. Am J Roentgenol 128: April

2 592 MEYERS ET AL. days later disclosed ischemic changes localized to a segment of the distal limb of a redundant sigmoid colon (fig. 4). Sigmoidectomy with end-to-end anastomosis was performed 9 days after admission. The specimen disclosed a markedly edematous and congested colon with focal areas of mucosal ulceration. Discussion Sigmoid volvulus, which accounts for 3%-5% of colonic obstructions, is the most common type of intestinal volvulus [1-3]. The actual mechanism of volvulus involves both a torsion of the sigmoid along its mesentenic axis and an axial torsion around the axis of the bowel. It is the axial Fig 1.-Case 1. Barium enema study 2 days after detorsion of sigmoid volvulus showing diffuse mucosal ulceration and submucosal hemorrhage manifested as thumbprints in redundant sigmoid colon. Note marked thickening and rigidity of colon due to intramural hemorrhage Ischemic changes also involve adjacent segments of descending colon and rectum. torsion that contributes to the classical peaked configuration at the site of stenosis on barium enema study [4, 51. The onset of associated circulatory impairment varies with the duration and degree of the mesentenic twist. Even though closed loop obstruction is present, the blood supply may remain adequate unless firm torsion of the loop strangulates the mesentery and its vessels. First the venous flow is inhibited and then the arterial blood supply. Edema and necrosis most frequently occur first at the site of the torsion in the mesentery, but may involve the entire loop. It has been thought that circulatory changes at the site of stenosis can usually be evaluated by sigmoidoscopy. If no ischemia is noted, conservative treatment is indicated (i.e., passing a soft rubber tube through the twisted area),

3 ISCHEMIC COLITIS WITH SIGMOID VOLVULUS 593 Fig. 2.-Case 2. Barium enema study 7 days after detorsion of volvulus showing ischemic changes in rectum and sigmoid colon thus allowing for decompression of the loop by the release of gas and fluid [2 1.This may then be followed by a delayed resection of the redundant sigmoid as the ultimate method of treatment [ After a diagnosis of sigmoid volvulus by plain films and/or barium enema and successful decompression by a rectal tube, further radiologic study is generally not pursued. This is probably the reason why findings like those noted in our patients have not been fully recognized previously. In fact, we found only two reported cases in which ischemic changes were detected on barium enema following reduction of sigmoid volvulus [ However, recent experimental and clinical studies clearly document the occurrence and pathogenesis of ischemic colitis secondary to obstructing lesions of the colon such as carcinoma, diverticulitis, and stricture [ This report establishes the persistence of ischemic changes up to 7 days after successful detorsion of a sigmoid volvulus, even when not particularly suspected clinically or endoscopically during the acute episode. The characteristic changes include transverse ridging. mural thumbpnints and mucosal ulcerations [81. The stenosis at the site of axial torsion, most consistently at the rectosigmoid junction. is usually of a degree to prevent passage of a sigmoidoscope or contrast medium on a retrograde study. Therefore, the observations highlight the fact that, even if no edema or discoloration is evident at the point of obstruction by either method, some circulatory impairment may have already occurred. These observations have several practical applications in the period immediately following decompression. The contribution of the ischemic changes to persistent rectal bleeding can be evaluated by serial barium enema studies. The development of a stricture in the ischemic segment is a potential, although rare, complication [ Since many cases of sigmoid volvulus are recurrent and resolve spontaneously, contrast study after an acute episode may first identify these ischemic changes as the residual of the previously undiagnosed condition. Furthermore, detorsion of sigmoid volvulus by passage of a long rectal tube through the sigmoidoscope is an emergency measure; most patients will subsequently undergo operative treatment [1 1. In such cases the described barium enema findings of ischemia can be crucial, because it may otherwise be difficult to recognize an ischemic bowel at surgery once the color of the coon has returned to normal [101. Failure to utilize this radiologic information in the planning of the resection may result in anastomosis of the ischemic colon and subsequent stenosis [101. The severity and extent of the vascular changes noted in our patients seem to be related to factors such as the degree and duration of the volvulus. As the sigmoid mesocolon becomes twisted, drainage through the thin-walled veins at the two points of fixation becomes impeded, followed in time by arterial insufficiency. Gerwig [31 noted at surgery that thrombosis of the superior hemornhoidal veins may develop. Furthermore, the increased intraluminal pressure secondary to obstruction results in a decreased intestinal blood flow, thus contributing to the ischemic changes within the distended sigmoid loop [ This mechanism also seems to explain the extension of ischemic colitis to the descending colon proximal to the site of obstruction (fig. 1 ). Involvement of the rectum (figs. 1-3) is difficult to fully understand on an anatomic basis, as in any instance of ischemic proctitis [121, but it may be an indication of severe stasis or thrombosis within the hemorrhoidal venous system [31. REFERENCES 1. Kerry RL, Ransom HK: Vo(vulus of the colon: etiology. diagnosis and treatment. Arch Surg 99: , Bruusgaard C: Volvulus of the sigmoid colon and its treatment. Surgery 22:

4 594 MEYERS ET AL. Fig. 3.-Case 3 A, Barium enema examination showing mucosal ulceration and edema involving distal limb of sigmoid colon B. Close-up of rectosigmoid junction showing abnormal mucosal pattern associated with extensive intramural hemorrhage 3. Gerwig WH Jr: Volvulus of the colon, in Diseases of the Co/on and Anorectum. edited by Turell R, Philadelphia, Saunders, 1969, pp Frimann-Dahl J; Roentgen Examinations In Acute Abdominal Disease, 3d ed. Springfield. Ill., Thomas, Laurell H: Volvulus der Flexura Sigmoidea: eine klinischer#{246}ntgenologische Studie. Acta Radiol 7: , Avnet NL, Elkin M: Unusual appearance of the colon following sigmoid volvulus. Radiology 77: , Seaman WB: Disease of the colon: new concepts, old problems. Radiology 100: , Boley SJ. Schwartz SS. Lash J, Sternhill V: Reversible vascular occlusion of colon. Surg Gynecol Obstet 116: Boley SJ. Agrawal GP, Warren AR, Veith FJ. Levowitz BS. Treiber W. Dougherty J. Schwartz SS. Gliedman ML: Pathophysiologic effects of bowel distention on intestinal blood flow. Am J Surg 117: , Schwartz SS. Boley SJ: Ischemic origin of ulcerative colitis associated with potentially obstructing lesions of the colon. Radiology 102: , Hannan JR. Jackson BE, Pipik P: Fibrosis and stenosis of the descending colon and sigmoid following occlusion of the inferior mesenteric artery. Am J Roentgenol 91: , Kilpatrick ZM, Farman J, Yesner R, Spiro HM: lschemic proctitis. JAMA 205:

5 ISCHEMIC COLITIS WITH SIGMOID VOLVULUS 595. j Fig Case 4. Barium enema study showing schemic colitis localized to 10 cm segment (arrows) at rectosigmoid junction. corresponding to distal point of fixation and torsion in sigmoid volvulus 4*

6 This article has been cited by: 1. Moaziz Sarfaraz, Syeda Rana Hasan, Shahid Lateef Sigmoid volvulus in young patients: Ą new twist on an old diagnosis. Intractable & Rare Diseases Research 6:3, [Crossref] 2. Kuniyuki GOMI, Yoshiya FUJIMOTO, Tsuyoshi KONISHI, Satoshi NAGAYAMA, Yosuke FUKUNAGA, Masashi UENO A case of stricturing type of ischemic colitis following repeat occurrences of sigmoid volvulus that was successfully treated using laparoscopic colectomy. Nihon Rinsho Geka Gakkai Zasshi (Journal of Japan Surgical Association) 73:5, [Crossref]