Volvulus of the splenic flexure of the colon ... Colonic volvulus represent an infrequent cause of intestinal ... tial resection of redundant colon was done. He had ...
1130-0108/2008/100/8/515-522 REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS Copyright © 2008 ARÁN EDICIONES, S. L.
REV ESP ENFERM DIG (Madrid) Vol. 100, N.° 8, pp. 515-522, 2008
Letters to the Editor
Volvulus of the splenic flexure of the colon Key words: Volvulus. Splenic flexure. Colon. Dear Editor,
Colonic volvulus represent an infrequent cause of intestinal obstruction. Splenic colonic flexure volvulus could be considered exceptional, with less than 30 cases reported in scientific literature.
Recently, we attended a 46-year-old man, with Down’s syndrome and severe mental retardation, was admitted to our hospital with a 24-hours-evolution of diffuse abdominal pain and progressive abdominal distension. There was a history of constipation and absence of stool passage in the preceding 2 days. Thirteen years ago, he presented a gastric volvulus and was submitted to urgent surgical gastropexia. Then, a dolichocolon with an absence of colon fixation ligaments was noted, but no procedure was performed over the colon. Present physical examination revealed a distended and tympanic abdomen and diffuse abdominal pain. During the rectal digital exam no faeces were present. The complete blood count and biochemical analysis did not show any alterations. Abdominal radiography showed a proximal massively-dilated colon. The gas distension of the intestine was also noted on the abdominal computed tomography (CT). Subsequent barium enema revealed a “bird beak sign” (Fig. 1A). The barium passed difficulty into the markedly dilated splenic flexure (Fig. 1B). A colonoscopia was then successfully performed in order to devolvulate the colon. A large amount of flatus and faeces were evacuated and the pa-
Fig. 1. A: Barium enema shows the characteristic “bird beak” configuration at the splenic flexure. B: Although difficulty, the barium passed to the distended segment through the stenosis.
tient became asymptomatic in 24-48 hours. He was discharged and then referred to the surgery department. Two days later, the symptoms reappeared and a recurrence of the splenic flexure volvulation was diagnosed. Newly performed colonoscopia resolved the urgent process. The patient was submitted to programmed surgical intervention, where a partial resection of redundant colon was done. He had an uneventful postoperative recovery.
Splenic flexure of the colon is usually immobilized by ligamentous attachments and the retroperitoneal location of descending colon. Primary described by Buenger (1), splenic flexure volvuluses have been reported as a rare cause of mechanical obstruction, producing 0-2% of colonic volvuluses (2) and less than 30 cases are described in scientific literature (3). Previous abdominal surgery, anomalies of fixation, and constipation played
LETTERS TO THE EDITOR
important roles in pathogenesis. In our case, a history of upper abdominal operation, absence of phrenocolic ligaments and a redundant colon were present, justifying the volvulation process. Four radiographic features have been pointed out as characteristics of a volvulus of the splenic flexure (4): a) a markedly dilated, air-filled colon with an abrupt termination at the anatomic splenic flexure; b) two widely separated air-fluid levels, one in the transverse colon and the other in the cecum; c) an empty descending and sigmoid colon; and d) a characteristic beak at the anatomic splenic flexure at a barium enema examination. In this context, the diagnosis and treatment of patients with splenic flexure volvulus requires a narrow collaboration between several specialists, such as radiologists, endoscopists and surgeons. As it happens in volvulus of the sigmoid colon, the initial and urgent treatment of splenic colonic flexure volvulus, if there are no signs of ischemia or perforation, may be conservative, with endoscopic devolvulation. Nevertheless, due to the high rate of recurrence, the definitive treatment must be, as in the presented case, surgery. Surgery is needed soon after the di-
REV ESP ENFERM DIG (Madrid)
agnosis and it is performed from detorsion and fixation to resection of the colon. D. Martínez-Ramos, J. Gibert-Gerez, A. E. R. Herfarth and J. L. Salvador-Sanchís
Service of General Surgery and Digestive Diseases. Hospital General de Castellón. Spain
Buenger RE. Volvulus of the splenic flexure of the colon. AJR 1954; 71: 81-3. 2. Ballantyne GH, Bradner MD, Beart RW, et al. Volvulus of the colon: incidence and mortality. Ann Surg 1985; 202: 83-92. 3. Mittal R, Samarasam I, Chandran S, et al. Primary splenic flexure volvulus. Singapore Med J 2007; 48: 87-9. 4. Mindelzun RE, Stone JM. Volvulus of the splenic flexure: radiographic features. Radiology 1991; 181: 221-3.
REV ESP ENFERM DIG 2008; 100 (8): 515-522