Overview.
It refers to the twisting of some bowel loops on the axis of the colonic mesentery and the twisting of the bowel itself centered on the longitudinal axis. The incidence of the disease varies in different regions, with a higher incidence in areas such as Shandong and Hebei in China. The disease can occur at any age, with an average age of onset of 40 to 90 years. It is one of the causes of acute low bowel obstruction. The sigmoid colon is the best site of occurrence, followed by the cecum, transverse colon and splenic flexure.
Etiology
Some patients with chronic constipation have more intestinal contents, gas accumulation so that the intestinal loops are dilated, intestinal activity during pregnancy and childbirth enhance the position of intra-abdominal organs change, congenital or acquired factors to distal intestinal obstruction, history of abdominal surgery, etc., which are the common factors of colonic torsion; other diseases that can cause the disease include intestinal luminal ascaris lumbricoides mass, intestinal tumors, intestinal adhesions, scleroderma, intestinal pneumatocystosis, and so on. Torsion of the cecum, ascending colon or transverse colon is more common in young patients, some of which develop after overeating or diarrhea.
Symptoms
Patients are mostly acute onset, the beginning of the manifestation of sudden abdominal pain, followed by abdominal distension, nausea, vomiting and anus without gas, defecation; twisted intestinal loops so that the abdomen is asymmetric manifestation, sometimes visible intestinal shape or peristaltic wave, abdominal pressure pain. To the mid-abdomen or right lower abdominal pain, sometimes can be found in the right lower abdominal expansion of the cecum of the distended mass, can be heard high-pitched intestinal tinnitus and gas over the watery voice, the emergence of peritonitis, abdominal muscle tension and rebound pain, intestinal tinnitus disappeared; when the pulse accelerated, the temperature rises, with signs of peritonitis, and even bloody ascites, it is a common manifestation of intestinal ischemia and necrosis, can quickly occur shock. Transverse colon torsion, on the other hand, manifests as mid-upper abdominal pain and abdominal distension. Sigmoid colon torsion is diversified in its onset, which may be acute, or subacute or chronic, with a history of constipation or recurrent intestinal torsion and obstruction, some of which can be relieved on their own.
Examination
1. Blood leukocyte count
If there are signs of peritoneal irritation and/or intestinal necrosis, the blood leukocyte count will be increased.
2. X-ray findings
The standing abdominal radiograph can see the presence of a large number of gas-liquid flat in the dilated intestinal tube, the horizontal abdominal radiograph can observe the dilated colon, such as cecum torsion can also be seen in the small bowel pneumatization and expansion; however, the non-closed-loop colonic torsion can be manifested as an enlargement of the colonic intestine above the obstruction, in order to clarify the nature of the colonic obstruction, and barium enema can only be clearly diagnosed when the examination is carried out. In this case, the torsional obstruction may show spiral thinning of the bowel or twisted and crossed mucosa (along the longitudinal axis of the bowel) in the thinning of the bowel, and even barium is seen to enter the proximal bowel through the obstruction. Typical X-ray manifestations of closed-loop colonic torsion, i.e., torsion of a segment of bowel loops in the prone abdominal radiographs can show an enlarged closed loop like an inflated ellipsoidal balloon, especially sigmoid colon torsion of the extremely dilated intestinal curvature in the form of a coffee bean, with a double-line striped intestinal wall shadow in the middle, and rounded knotted dense whitening shadows at both edges, and the enlarged intraluminal folds disappeared. A barium enema for closed-loop sigmoid torsion will show a bird’s beak stenosis at the colonic torsion, and this sign is present with multiple barium enemas under pressure, and the barium will not pass through this stenosis. Torsion of the transverse colon is dilated, the bowel curvature is elliptically dilated in the mid-upper abdomen, a double line of striated bowel wall shadows is also seen in the center, and the descending colon is atrophied. Torsion of the cecum is mostly in a clockwise direction, and in addition to the rounded dilatation of the cecum, the small intestine is also dilated significantly.
3.CT
CT is important for the diagnosis of colonic torsion. Cecal torsion can be seen under CT, cecum and small intestine dilatation, there is a whirlpool sign; similarly, sigmoid colon torsion in the dilatation of the sigmoid colon under the closed loop of the sigmoid colon, there is also a venous dilatation of the mesentery and whirlpool sign.
4. Low-pressure enema
If it is not possible to instill 300-500 ml of saline, it indicates the possibility of obstruction in the sigmoid colon.
5. Fiberoptic colonoscopy
Not only can it assist in diagnosis, it is also a method of non-surgical treatment.
Diagnosis
It is not difficult to initially diagnose colonic torsion in the presence of abdominal pain, bloating, and constipation, combined with the etiology and history. Colon torsion is often accompanied by nausea, vomiting, abdominal distension, abdominal pressure and pain, abdominal asymmetry, intestinal gas mass, intestinal tinnitus, elevated temperature, signs of peritonitis, shock, etc., combined with the relevant auxiliary examination, usually can make the diagnosis of colonic torsion.
Differential diagnosis
1. Colon cancer
Cancer of cecum, transverse colon, sigmoid colon or rectum may present with low intestinal obstruction, but the history of the disease is long, and there is no history of sudden abdominal pain. Colon cancer has a firm mass with clear borders. Colonic torsion, on the other hand, is a swollen bowel, softer in texture on palpation, with indistinct borders, and is easier to distinguish. Of course, barium enema can confirm the diagnosis.
2. Colonic intussusception
Ileum into the cecum is common, and can be extended to the sigmoid colon, the onset of acute, low intestinal obstruction manifestations, most often occur in 5 to 6 months of age. Symptoms are paroxysmal crying, nausea, vomiting with jam-like stools. On palpation, the right lower abdomen is empty and there is a saliciform mass in the right upper abdomen. Barium enema is diagnosed by seeing a cupped shadow of barium. Chronic intussusception in adults is more commonly caused by tumors, less commonly, and all are apparently easily differentiated from colonic torsion.
Complications
In severe cases, the abdomen can be seen to be asymmetrically elevated and irregularly distended intestinal loops. If the distended intestinal loops cannot be repositioned in time, necrosis of the intestinal wall, perforation, peritonitis and even death may occur due to intestinal strangulation.
Treatment
1.General treatment
Fasting and water fasting, and gastrointestinal decompression. Infusion of fluids to correct the water-electrolyte balance disorders. Antibiotics to prevent infection.
2. Non-surgical treatment
(1) For the early stage of colonic torsion, fiberoptic colonoscopy can be tried to reset, especially sigmoid colon torsion with a higher success rate.
(2) Early sigmoid torsion, can be inserted into the obstruction under the clear vision of the colonoscope, the anal tube through the obstruction there are often dilute stools and gases flushed out violently, the patient immediately feel unusually relaxed for the reset sign. In order to prevent recurrence, the anal canal can be retained for 2 to 3 days.
3.Surgery
If the non-surgical treatment of cecum torsion is ineffective, or there is suspicion of strangulation, the cecum should be dissected as soon as possible. If the abdominal cavity seepage is more, must perform abdominal irrigation and rubber tube drainage, in order to reduce the symptoms of systemic toxicity; also need a lot of antibiotic treatment after surgery.
The principle of treatment of transverse colon torsion is that if it is simple mechanical torsion, it can be separated from the adhesion and then reset. If there is necrosis, necrotic resection, transverse colon anastomosis and necessary abdominal drainage.
Sigmoid torsion, if suspected intestinal strangulation or sigmoidoscopy found that the intestinal mucosal necrosis and ulceration of torsional obstruction, then timely surgical treatment should be carried out. If there are multiple recurrences of sigmoid torsion, elective surgery should be performed to resect the overgrown bowel for one-stage anastomosis.
Prognosis
The prognosis of most cases of colonic torsion is good if treated promptly, but the prognosis is worse if there is intestinal strangulation or even rupture and perforation.
Prevention
If colonic torsion is not caused by congenital developmental factors, prevention should be directed at the causative factors, such as preventing constipation and eating high-fiber foods.