Disease Overview
Intestinal torsion refers to a segment of intestinal collaterals twisted more than 180 degrees along its mesenteric longitudinal axis, either clockwise or counterclockwise, resulting in complete or partial occlusion of the intestinal canal at both ends of the torsion, thus producing closed collaterals intestinal obstruction and mesenteric vascular compression. Intestinal torsion is a kind of strangulated intestinal obstruction, in which necrosis and peritonitis occur rapidly in the twisted intestinal canal, and it is a type of intestinal obstruction with dangerous condition and rapid development.
Intestinal torsion is a common cause of acute intestinal obstruction, accounting for the third most common cause of intestinal obstruction in China, accounting for about 14% of intestinal obstruction, and the onset of intestinal torsion is regionally related. In Western Europe and the United States, intestinal torsion is relatively rare, less than 10% of intestinal obstruction, and in China, there are more small intestinal torsions than colonic torsions.
Etiology
Intestinal torsion can be divided into two categories: primary and secondary.
The cause of primary intestinal torsion is unclear, and there is no anatomical abnormality, it may be caused by a large amount of undigested contents in the intestinal cavity after a full meal, and the small intestine cannot rotate synchronously with the weight sagging when there is an obvious movement of body position change.
Secondary intestinal torsion is caused by congenital or acquired anatomical changes that appear as a fixed point forming the axis of the torsion of intestinal collaterals. However, intestinal torsion is often produced by the simultaneous presence of the following three factors.
1, anatomical factors The mesentery of the twisted intestinal collaterals is too long, and due to congenital development or adhesion contraction makes the root of the mesentery attached to the retroperitoneum too narrow. Therefore, the preferred sites are mostly the small intestine, transverse colon, sigmoid colon and the cecum with high mobility. Post-operative adhesions, Meckel’s diverticulum, redundant sigmoid colon, congenital incomplete rotation of the middle colon, free cecum, etc. are all anatomical factors for intestinal torsion.
2, physical factors On the basis of the above anatomical factors intestinal tube weight volume increase and intestinal tube peristalsis enhance, such as after a full meal, especially more indigestible food into the intestinal cavity; or intestinal cavity has more roundworm mass; intestinal cavity has a large tumor, in the sigmoid colon village rush a large number of dried stool, etc., are potential factors causing intestinal torsion.
3.Dynamic factors Strong peristalsis or sudden change of body position produces asynchronous movement of intestinal collaterals, so that the intestinal collaterals which already have a fixed axial position and a certain weight are twisted.
Pathophysiology
Intestinal torsion is a type of closed-collar intestinal obstruction, a type of strangulated intestinal obstruction. The direction of intestinal torsion varies, with the small intestine, cecum, and transverse colon often twisting in a clockwise direction and the sigmoid colon often twisting in a counterclockwise direction. The greater the degree of torsion, the greater the degree of intestinal obstruction and intestinal strangulation, and the more likely to occur intestinal necrosis.
At the early stage of intestinal torsion, the gas and liquid in the proximal intestinal collaterals of torsional obstruction enter the closed collaterals due to hyperactive intestinal peristalsis, which aggravates the gas and liquid accumulation in the closed collaterals and aggravates the torsion.
In addition to the closed collaterals of the twisted intestine, another closed collaterals are formed between the proximal end of the twisted intestine and the ileocecal valve, which makes the condition more serious. If an overly long intestinal collar of the transverse colon slips into the gap between the liver and the diaphragm and torsion occurs, it is called Chilaiditi syndrome, a special type of intestinal torsion.
Severe intestinal torsion occurs with impaired blood flow in the intestinal canal. On the one hand, mesenteric torsion causes poor torsion of the mesenteric vessels, and on the other hand, intestinal collaterals swell and increase pressure, affecting the blood circulation in the intestinal wall, affecting capillaries, then veins, and finally arteries, causing bleeding in the intestinal cavity and abdominal cavity, embolism, necrosis and perforation of the intestinal wall vessels.
Clinical manifestations and diagnosis
Intestinal torsion is a closed-collar intestinal obstruction plus strangulated intestinal obstruction, with rapid onset and development and mortality rate up to 10% or more, which should be paid special attention to technician diagnosis and treatment. At the onset of the disease, abdominal pain is severe, abdominal distension is obvious, shock can appear at the early stage, and the symptoms continue to develop gradually aggravated, and there is no interval. The clinical manifestations vary depending on the site of torsion.
Small bowel torsion: the most common, often occurs in young and strong male manual laborers, before the onset of the disease, there is often a history of overeating and strenuous activity, the onset of sudden, persistent abdominal pain, with paroxysmal aggravation, the pain around the umbilicus first, can be launched to the lumbar back, only due to pulling the mesenteric root. Vomiting is frequent, abdominal distension is evident, pressure pain is present from early onset, but there is no muscle tension, bowel sounds are diminished, and air over water sounds can be heard. The abdominal radiographs may show different parts of small bowel torsion. In total small bowel torsion, only the gastroduodenum is inflated and dilated, but also the small bowel is generally inflated and has multiple fluid surfaces. In partial small bowel torsion, a large distended, enlarged intestinal collaterals with a fluid-air surface may be present in one part of the abdomen. As a result of intestinal and intra-abdominal leakage and bleeding, together with intestinal displacement of pathogenic bacteria, the patient quickly develops hypovolemic shock and infectious shock. Generally, the diagnosis of strangulated intestinal obstruction can only be made preoperatively, and intestinal torsion can only be determined during surgery.
Sigmoid torsion: Mostly seen in elderly males, with a history of redundant sigmoid colon or constipation. Patients have persistent abdominal distension with gradual bulging, a sensation of lower abdominal cramping but no defecation. The left abdomen is markedly distended, with a bowel pattern and a bulging sound on percussion, and pressure pain and muscle tension are not obvious. x-rays show huge double-lumen inflated intestinal collaterals with fluid planes. Other patients have acute attacks, severe pain and vomiting in the abdomen, pressure pain and muscle tension on palpation, showing heavy torsion, intestinal congestion and ischemia, and intestinal necrosis can occur if not treated in time.
Cecum torsion: rare, mostly occurs in patients with a mobile cecum, and can be divided into two types: acute and subacute. Acute cecum torsion is uncommon, with acute onset, severe pain and vomiting, palpable mass in the right lower abdomen, and pressure pain, which can produce necrotic perforation of the cecum. In the subacute form, the patient complains of right lower abdominal cramps, a rapid and asymmetrical abdominal bulge, and an elastic mass palpable in the upper abdomen; a large inflated intestinal collaterals with multiple intestinal aerated fluid surfaces are seen on X-ray.
If the sigmoid colon or cecum is twisted and there are no symptoms of peritonitis, a low-pressure barium enema can be considered to clarify the diagnosis. In the case of cecum torsion, it shows that the barium is obstructed at the transverse colon or liver area.
Abdominal CT is valuable for the diagnosis of intestinal torsion.
Treatment
After the diagnosis of intestinal torsion is clear, although there are no symptoms of peritoneal irritation yet, surgical treatment should also be actively performed. Active pre-surgical preparation includes correction of imbalance of water, electrolytes and acid-base balance, effective intestinal tube aspiration, prophylactic antibiotics and other measures.
Non-surgical treatment For patients with sigmoid torsion only, sigmoidoscopic decompression treatment or saline barium enema can be used at the early stage of the disease, and the operation should be gentle and meticulous, and changes in the condition should be observed at all times, and once intestinal necrosis is detected, immediate surgical treatment should be performed. For patients who are relieved by non-surgical treatment, because the etiology of intestinal torsion still exists and the recurrence rate is high, scholars at home and abroad now advocate performing intestinal preparation within 10~14 days after reset by non-surgical therapy and doing radical surgery to eliminate the cause of torsion.
Surgical treatment For non-surgical treatment failure or suspected intestinal necrosis, immediate surgical treatment should be performed. Surgery should not only reset the intestinal canal, but also eliminate the cause of intestinal torsion, and if intestinal necrosis occurs, the necrotic intestinal canal needs to be removed. According to the specific situation of intestinal torsion, there are several common surgical procedures: 1. 2. intestinal fixation. 3. intestinal resection and intestinal anastomosis. 4. enterostomy.
Expert opinion
1, intestinal torsion is a kind of strangulated intestinal obstruction, the twisted intestine can quickly occur necrosis perforation and peritonitis, is a type of intestinal obstruction in a dangerous condition, rapid development, such as failure to timely treatment, the mortality rate is high. Therefore, once diagnosed, it should be dealt with promptly and treated with early surgery. This can not only reduce intestinal resection or even avoid intestinal necrosis, which is of great significance to save the life of patients.
2, should strictly grasp the indications for non-surgical treatment, to avoid delaying the timing of surgery, resulting in adverse consequences.