A RARE METACHRONOUS COLONIC VOLVULUS

---

P.A. Ekhaiyeme¹, N.A. Olagunju¹, O.A. Ajagbe¹, O.J. Bello¹, P.H. Yatu¹, O. Afuwape^1,2, D.O. Irabor^1,2

1. Department of Surgery, University College Hospital, Ibadan, Oyo State, Nigeria.
2. College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria.

Abstract

Introduction: Colonic volvulus is a common cause of large bowel obstruction with the sigmoid colon most commonly affected. Volvulus of the transverse colon is an uncommon occurrence. Rarer still is a transverse colon volvulus developing after surgery for a sigmoid colon volvulus. Early diagnosis is critical as delay in detection and intervention is associated with the risk of complications – perforation, peritonitis, and death.

Case presentation: We report the case of an 86-year-old man who presented with features of large bowel obstruction 14 months following a sigmoid colectomy for a sigmoid colon volvulus.

Conclusion: A metachronous transverse colonic volvulus is uncommon. Preoperative diagnosis is challenging as there are no defining radiographic features compared to the volvulus of the sigmoid colon with the classical omega sign. Most cases are diagnosed intra-operatively. Bowel resection and anastomosis in a single stage is a safe option.

Keywords: Metachronous, Sigmoid colon, Transverse colon, Volvulus.

Introduction

Colonic volvulus is the torsion of the colon on its mesentery, with the sigmoid colon the most affected (75%)^.1,2 There are a few cases of volvulus reoccurring in the same patient after treatment for an initial one.³ We share our experience in the management of a patient with metachronous colonic volvulus.

CASE PRESENTATION
A 86-year-old man, with no known comorbidity, presented with a five-day history of colicky abdominal pain, worsening abdominal distension, and associated constipation which progressed to obstipation. The pain worsened significantly but with no associated vomiting. His last bowel movement was 4 days before presenting to the hospital. There was no history of fever, jaundice, early satiety, spurious diarrhea, the passage of pelletlike stools, or weight loss.

Past medical history revealed a similar presentation fourteen months prior to the onset of present problem with clinical and radiological features revealing a sigmoid volvulus, and a one-stage sigmoidectomy with end-to-end anastomosis was performed. (Figure 1 & 2)

Examination findings included palor, tachycardia (pulse rate of 120 per minute) and an elevated blood pressure even though he has never been diagnosed as hypertensive. He has severe abdominal distension with a midline longitudinal scar and hypoactive bowel sounds. There was no rebound tenderness. A digital rectal examination revealed scanty hard feces.

On this current admission, a provisional diagnosis of adhesive bowel obstruction was made and he was resuscitated with intravenous fluids and antibiotics while a nasogastric tube passed for immediate decompression of the abdomen and a trial of enema done with minimal improvement. Further evaluation of the patient was done to rule out the possibility of a second volvulus or Ogilvie syndrome as a second alternative.

Laboratory investigations revealed a normal white cell count with a neutrophil predominance of 80.6%, hematocrit of 39.3% and hypokalaemia of 3.0mmol/L which was corrected before surgery. Viral markers were all negative and the clotting profile was not deranged. Urinalysis showed proteinuria, ketonuria, and haematuria. Erect plain abdominal radiograph revealed multiple air-fluid levels and a gasless pelvis while a supine view revealed massively dilated (>10cm) bowel loops peripherally located, with haustra markings
(Fig. 3).

He underwent an exploratory laparotomy and findings included a massively dilated transverse colon that was twisted 540^o in the anticlockwise direction, A perforation was noted in the descending colon at the distal point of the torsion with spillage of intestinal contents (Fig. 4). The transverse and descending colon were viable and a left hemicolectomy was performed with one-layered end-to-end anastomosis. The postoperative recovery was uneventful and he was discharged home 8 days after surgery.