Colonoscopic decompression of childhood sigmoid and cecal volvulus

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1 CASE REPORT Colonoscopic decompression of childhood sigmoid nd cecl volvulus Irj Shhrmin 1, Ali Bzi 1,2, Dnil Edti 3, Krim Rostmi 3, Mojt Delrmns 1,2 1 Peditric Digestive nd Heptic Reserch Center, Zol University of Medicl Sciences, Zol, Irn 2 Clinicl Reserch Development Unit, Zol University of Medicl Sciences, Amir-Al-Momenin Hospitl, Zol, Irn 3 Student Reserch Committee, Zol University of Medicl Sciences, Zol, Irn Cite this rticle s: Shhrmin I, Bzi A, Edti D, Rostmi K, Delrmns M. Colonoscopic decompression of childhood sigmoid nd cecl volvulus: report of three cses. Turk J Gstroenterol 2018; 29: ABSTRACT Cses of colonic volvulus in children re infrequently descried in the literture. Here we descrie the cse of three ptients with colonic volvulus. The first ptient ws 10-yer-old girl with dominl diltion nd pin nd no owel movement for 48 h. Her dominl X-ry showed the coffee en sign djcent to the diphrgm, which ws comptile with dignosis of cecl volvulus. The second ptient ws 4-yer-old oy with history of chronic constiption during the pst yer nd with no owel movement for 24 h. Clinicl mnifesttions included severe nuse, vomiting, nd dominl distension. His dominl X-ry demonstrted the coffee en sign in the right upper qudrnt with upwrd convexity corresponding to dignosis of sigmoid volvulus. The third ptient ws 10-month-old mle who presented with excessive crying, mlnutrition, nd no owel movement for 36 h. His dominl X-ry demonstrted the coffee en sign in the left upper qudrnt with upwrd convexity. The presence of gs ws not oserved in the distl ostructed region, corresponding to dignosis of sigmoid volvulus. All three ptients successfully underwent colonoscopy for volvulus reduction. Volvulus did not reoccur in ny of the ptients within 6 months of follow-up. It is recommended to perform dominl X-ry imging in ptients who present with dominl pin nd distension, dirrhe, or constiption for possily dignosing volvulus. Keywords: Intestinl volvulus, intestinl ostruction, stomch volvulus INTRODUCTION Volvulus is condition in which the colon twists round itself nd the mesentery. It my resolve spontneously, ut it usully cuses intestinl ostruction, which cn led to strngultion, gngrene, nd perfortion. Chronic constiption my cuse excessive colon enlrgement tht will cuse volvulus, prticulrly if the mesenteric se is nrrow. The symptoms of volvulus re similr to those of cute ostruction. Ptients present with dominl distension, nuse, nd vomiting. The condition rpidly progresses to generlized dominl pin nd tenderness (1,2). Volvulus occurs in the sigmoid colon in more thn 90% of cses, ut it cn lso involve the cecum or trnsverse colon in pproximtely 20%-40% of cses (1,3). Sigmoid volvulus cn often e differentited from trnsverse colon or cecl volvulus y mens of performing dominl X-ry imging. Sigmoid volvulus presents s n inner tue or with coffee en sign with convexity to the right upper qudrnt (RUQ) (opposite side of the ostruction). Gstrogrfin enem revels nrrowing of the ostruction, which cretes pthognomonic ppernce of ird s ek sign (4). Except for ptients with cler signs of gngrene or peritonitis, primry tretment of sigmoid volvulus is resuscittion of ptients nd then colonoscopic volvulus reduction. Although these techniques re successful in terms of reducing sigmoid volvulus in most ptients, the risk of recurrence is high. In cse of gngrene or perfortion, emergency lprotomy should e performed. Cecl volvulus occurs due to motile right colon. Rottion occurs round the ileocolic rtery, impiring lood supply. Simple dominl X-ry imging revels renl-shped ir-filled structure in the left upper qudrnt (LUQ), nd gstrogrfin enem proves the presence of ostruction t the site of volvulus (1,5). Trnsverse colon volvulus is extremely rre in childhood. Colon stgntion nd chronic constiption long with megcolon my cuse trnsverse ORCID IDs of the uthors: I.S ; A.B ; M.D Address for Correspondence: Mojt Delrmns E-mil: delrmns@yhoo.com Received: August 17, 2017 Accepted: Octoer 20, 2017 Copyright 2018 y The Turkish Society of Gstroenterology Aville online t DOI: /tjg

2 Shhrmin et l. Colonic volvulus in childhood Turk J Gstroenterol 2018; 29: colon volvulus. The rdiologic view of trnsverse colon volvulus is similr to tht of sigmoid volvulus; however, gstrogrfin enem hs reveled tht the ostruction site is more proximl thn its ctul loction. Although volvulus cn sometimes e successfully decompressed y colonoscopy, most ptients require emergency lprotomy nd resection. In this cse series, the cses of three ptients with colonic volvulus presenting to the peditric wrd of Amir-Al-Momenin Hospitl of Zol city in the south-est of Irn hve een introduced nd discussed. Ethicl considertions of the Helsinki Declrtion were followed. CASE PRESENTATIONS We hve presented three cses of volvulus in two children ged 10 yers nd 4 yers nd in one 10-month-old neonte. Informed consent ws otined from the prents of ll three ptients. A clinicl exmintion ws performed during rectl exmintion. The ptients vitl signs were norml. Lortory exmintions reveled norml levels of cute-phse rectnts, including C-rective protein levels, erythrocyte sedimenttion rte, nd white lood cell count. Before colonoscopy, the ptients styed in fsting condition (nil per os; NPO, nothing through the mouth). They were dministrted with intrvenous electrolytes nd ntiiotics. They were closely monitored until 24 h fter the procedure. First cse: Cecl volvulus The ptient ws 10-yer-old girl who hd complined of dominl diltion, pin, nd no owel movement for the pst 48 h. The pin ws continuous. During her physicl exmintion, severe dominl distension with mss touchle in domen in the LUQ section, ws detected. An dominl X-rys ws otined, in which the coffee en sign ws oserved with convexity to the diphrgm (Figure 1). The ptient who ws dignosed with cecl volvulus underwent colonoscopy, nd volvulus reduction ws performed. Then, nother dominl X-ry ws otined from the ptient, which showed volvulus correction (Figure 1). The ptient ws monitored for 24 h. Adominl distension ws reduced, nd the ptient ws dischrged in good generl condition. Second cse: Sigmoid volvulus The ptient ws 4-yer-old oy with history of chronic constiption for out 1 yer; he presented with complints of lck of owel movements for the pst 24 h. The Figure 1.,. X-ry of 10-yer-old girl with cecl volvulus: efore colonoscopy, the coffee en sign ws oserved with convexity to the diphrgm (); intestinl rdiogrphy fter correcting the defect through colonoscopy () 222

3 Turk J Gstroenterol 2018; 29: Shhrmin et l. Colonic volvulus in childhood ptient lso presented with severe nuse nd vomiting. The ptient s pin ws continuous; thus, he hd to e sedted. There were no signs of peritonitis or free dominl ir. During his physicl exmintion, we found reltive dominl dilttion long with generlized tenderness. On performing rectl exmintion, the mpull of the rectum ws empty. His dominl X-ry showed the coffee en sign in the RUQ section with upwrd convexity (Figure 2). Then, the ptient who ws dignosed with sigmoid volvulus underwent colonoscopy nd volvulus reduction; lter, nother dominl x-ry ws otined (Figure 2). The ptient ws monitored for 24 h. Adominl distension resolved, nd the ptient ws dischrged in good generl condition. Third cse: Sigmoid volvulus The ptient ws 10-month-old mle who presented with restlessness, excessive crying, severe mlnutrition due to poor nutrition, nd lck of owel movement for the pst 36 h. During his dominl exmintion, we identify mss touchle in the LUQ. An dominl X-ry ws otined from the ptient, in which the coffee en sign ws oserved in the LUQ section with upwrd convexity, indicting sigmoid volvulus. The presence of gs ws not oserved in the distl ostructed region (Figure 3). A second dominl X-ry ws otined from the ptient, which showed tht the ostruction ws removed nd tht the ir ws oserved long the entire length of the colon (Figure 3). The ptient ws monitored for 24 h. Adominl distension ws ovited, nd the ptient ws dischrged in good generl condition. DISCUSSION In this report, we presented the cses of colonic volvulus: two oys (one ws 4 yers old nd the other ws 10 months old) nd one girl (10 yers old). Two ptients hd sigmoid volvulus nd one hd cecl volvulus. The ge t colonic volvulus onset in children vries from 10 weeks to 17 yers old (2,6,7). In previous reports, it hs een stted tht there is higher numer of mle children, mong ptients dignosed with colonic volvulus (6,8). From the three reported cses here, two were mles. While smll intestine rottion is common phenomenon in children, lrge intestine twisting in children is rrely cused y colonic volvulus (6,9). Similr to dults, mlrottion in children is lso most commonly oserved in the sigmoid colon, while in cecl volvulus, it is seen in 20%-40% of cses (3). Figure 2.,. X-ry of 4-yer-old oy with sigmoid volvulus: efore colonoscopy, the coffee en sign ws oserved in the right upper qudrnt with upwrd convexity (); fter colonoscopy () 223

4 Shhrmin et l. Colonic volvulus in childhood Turk J Gstroenterol 2018; 29: Risk fctors ssocited with volvulus re previous surgery, intermittent constiption, neuromusculr disorders, nd congenitl nomlies (1,6,8,10). While rottion in the cecum my e triggered y long-term distention or constiption or surgicl procedures, sigmoid volvulus generlly results from n unstle/motile sigmoid colon. In 18% of children with sigmoid volvulus, the condition my e detected in the context of Hirschsprung disese (9). Colonic volvulus is life-thretening condition in which twisted portion of the colon my result in severe ischemi, perfortion, nd necrosis. Furthermore, gngrenous lesions my occur in s mny s 80% of ptients with sigmoid volvulus (7). Despite eing rre cuse of childhood intestinl ostruction, clinicins should consider colonic volvulus in those with suggestive clinicl signs nd symptoms. Rdiologic studies re mndtory for mking dignosis s clinicl symptoms re non-specific. The most common imging methods re dominl X-ry imging, contrst enem, nd computed tomogrphy (11). In the first cse we presented, the coffee en sign ws convex to the diphrgm, which ws comptile with dignosis of cecl volvulus. In the second cse, the dominl X-ry reveled the coffee en sign in the RUQ region with upwrd curvture, corresponding to dignosis of sigmoid volvulus. In the dominl X-ry in the third cse, the coffee en sign ws detected in the LUQ with n upwrd curvture nd there ws lck of gs in the distl prt of the ostruction. Although rium contrst enem is the most sensitive dignostic procedure for colonic volvulus (12), plin X-ry imging is fst nd ffordle, with low rdition dose. Specific signs tht re highly indictive of cecum, sigmoid, or trnsverse colon volvulus (i.e., kidney een sign, coffee en sign, nd inverted coffee een sign) cn e seen in dominl X-rys (13). Although the clssicl coffee en sign on performing X-ry imging is specific dignostic feture, only 30% of ptients my hve this sign (9). In survey of 19 ptients with colonic volvulus, only two hd the coffee en sign in their dominl X-rys (8). Other dignostic chrcteristics of colonic volvulus in X-rys re n irless rectum nd dilted picl colon (8), which were lso oserved in the third cse descried here. The lst two fetures re prticulrly sensitive mrkers; nevertheless, their specificity is low (11). Bsed on these, Figure 3.,. X-ry of 10-week-old infnt with sigmoid volvulus: efore colonoscopy, the coffee en sign ws oserved in the left upper qudrnt with upwrd convexity, indicting sigmoid volvulus (no gs is oservle in the distl ostructed region) (); fter colonoscopy, no volvulus ws seen () 224

5 Turk J Gstroenterol 2018; 29: Shhrmin et l. Colonic volvulus in childhood dominl X-ry imging is generlly used s the primry screening method in ptients in whom volvulus is suspected. There is no single widely ccepted strtegy for resolving childhood colonic volvulus, lthough endoscopic reduction generlly is mong the first-line pproches. Despite the fct tht surgicl intervention is curtive pproch for colonic volvulus, this procedure is invsive. Surgicl intervention is generlly considered for trnsverse colon volvulus (9). On the other hnd, colonoscopy my e ssocited with high risk of recurrence (11). Becuse of the stle clinicl conditions of our ptients, the defects were corrected through colonoscopy. In 6-month follow-up, none of our ptients experienced volvulus recurrence or ny colonoscopy-relted compliction. Necrosis, mucosl ulcertion, or drk lood reveled y endoscopy suggests strngultion nd necessittes performing surgery. If gngrenous owel is found during lprotomy, sigmoid colectomy with end colostomy (Hrtmnn procedure) is the est surgicl technique for tretment (14). However, it seems tht in uncomplicted cses, colonic volvulus cn e effectively corrected y minimlly invsive colonoscopy. In conclusion, volvulus is n uncommon cute dominl emergency, showing symptoms of owel ostruction. Its dignosis is usully sed on the pst history of ptients nd on the results of simple dominl exmintion. All ptients with dominl pin, colonic or dominl distension, dirrhe, or constiption without dignosis of inflmmtory owel disese re recommended to undergo simple dominl X-ry imging to exmine if volvulus is present. In cses when ptient symptoms re stle nd severe ischemi is not present, resection cn e done through colonoscopy. Timely volvulus reduction nd symptom resolution my prevent the recurrence of volvulus t lest for 6 months. If left untreted, colonic volvulus my led to intestinl ischemi nd perfortion, which re potentilly ftl conditions; therefore, it is dvisle to timely dignose suspicious ptients with longterm dominl pin nd distention. Informed Consent: Informed consent ws otined from the prents. Peer-review: Externlly peer-reviewed. Author Contriutions: Concept - I.S.; Design - A.B.; Supervision - I.S.; Resource - I.S.; Mterils - I.S., D.E., K.R.; Dt Collection nd/or Processing - D.E., K.R., M.D.; Anlysis nd/or Interprettion - A.B., M.D.; Literture Serch - A.B., M.D.; Writing - A.B.; Criticl Reviews - I.S. Acknowledgements: We thnk the fmilies of the ptients for their coopertion. Conflict of Interest: No conflict of interest ws declred y the uthors. Finncil Disclosure: The uthors declred tht this study hs received no finncil support. REFERENCES 1. Tnnouri S, Hendi A, Gilje E, Grissom L, Ktz D. Peditric colonic volvulus: A single-institution experience nd review. J Peditr Surg 2017; 52: Khlyleh H, Koplewitz BZ, Kpuller V, Armon Y, Au-Leil S, Arell D. Neontl sigmoid volvulus. J Peditr Surg 2016; 51: Shh SS, Louie JP, Fein JA. Cecl volvulus in childhood. Peditr Emerg Cre 2002; 18: Sls S, Angel CA, Sls N, Murillo C, Swischuk L. Sigmoid volvulus in children nd dolescents. J Am Coll Surg 2000; 190: Erdogn D, Krmn A, Cvusoglu YH, Krmn I, Ozctl M. Colon Volvulus in Childhood: Cse Report. Turkiye Klinikleri J Med Sci 2012; 32: O Keefe LM, Hu YY, Thker S, Finck C. Sigmoid volvulus: A peditric cse report nd review of mngement. J Peditr Surg Cse Rep 2016; 7: Atmnlp SS, Yildirgn Mİ, Bşoğlu M, Kntrci M, Yılmz İ. Sigmoid colon volvulus in children: review of 19 cses. Peditr Surg Int 2004; 20: Mrine MB, Cooper ML, Delney LR, Jennings SG, Rescorl FJ, Krmzyn B. Dignosis of peditric colonic volvulus with dominl rdiogrphy: how good re we? Peditr Rdiol 2017; 47: Grel C, Blouet M, Belloy F, Petit T, Pelge J-P. Dignosis of peditric gstric, smll-owel nd colonic volvulus. Peditr Rdiol 2016; 46: Tkd K, Hmd Y, Sto M, Fujii Y, Terguchi M, Kneko K, et l. Cecl volvulus in children with mentl disility. Peditr Surg Int 2007; 23: Tnnouri S, Hendi A, Gilje E, Grissom L, Ktz D. Peditric colonic volvulus: A single-institution experience nd review. J Peditr Surg Folrnmi SE, Cho A, Treen F, Morito A, Rkoczy G, Cserni T. Proximl lrge owel volvulus in children: 6 new cses nd review of the literture. J Peditr Surg 2012; 47: Theilen T, Fiegel H, Gfrörer S, Rolle U. The Coffee Ben Sign: Dignosing Sigmoid Volvulus in n 8-Yer-Old Child. Klin Pditr 2015; 227: Rveenthirn V, Mdi TE, Atmnlp SS, De U. Volvulus of the sigmoid colon. Colorectl Dis 2010; 12: