Intestinal Obstruction by Blind Vove Iess Riobamba Hospital 2014

Intestinal volvulus is produced by the twisting of a mobile segment of the colon around its mesenteric axis. The location, in order of frequency, is: 80% in sigma, 15% in blind and 5% in transverse colon [1]. The volvulus of the right colon is rarer. They do not present a defined geographical distribution, as in the sigmoid volvulus, which would indicate that the external factors that produce intestinal diseases do not have a higher incidence [23]. The colon, from the embryological, anatomical, functional and surgical point of view, is divided into a right sector (right colon) and another left (left colon) whose limit is a line that passes over the transverse colon to the left of the artery medium colic [4-5].


Introduction
Intestinal volvulus is produced by the twisting of a mobile segment of the colon around its mesenteric axis. The location, in order of frequency, is: 80% in sigma, 15% in blind and 5% in transverse colon [1]. The volvulus of the right colon is rarer. They do not present a defined geographical distribution, as in the sigmoid volvulus, which would indicate that the external factors that produce intestinal diseases do not have a higher incidence [2][3]. The colon, from the embryological, anatomical, functional and surgical point of view, is divided into a right sector (right colon) and another left (left colon) whose limit is a line that passes over the transverse colon to the left of the artery medium colic [4][5].
The volvules located in the right sector are mainly due to a congenital malformation. Those located in the left colon, always correspond to the sigmoid and recognize as an etiological cause an abnormally mobile loop added to diseases that dilate and lengthen the sigma (dolicomegasigma) [6]. The volvules located in the transverse are due to the exaggeration of a normal situation (garland colon) and are exceptional. Various causes have been implicated in etiopathogenesis: anatomical (long and redundant), alimentary (diet rich in residues), pathological (chronic constipation, laxative abuse, psychiatric and central nervous system diseases in 40% of cases: dystrophies) , Parkinson's disease, Alzheimer's disease, cerebrovascular accidents, etc.) [7,8], sex (more common in women) and age (over 70 years). Cecal volvulus is more common in women with a mean age of 50-60 years, with a history of previous episodes and a clinical picture of small bowel obstruction and abdominal pain [9][10].

Clinical Case
A 65-year-old female patient, with no relevant medical history. She went to the emergency department due to distension, abdominal pain and absence of bowel movements, which lasted 5 days. The examination revealed an important abdominal distension, with diffuse pain without signs of peritoneal irritation, percussion tympany and absence of peristalsis on auscultation. In the analytical study, only one leukocytosis of 13,000/μl was highlighted, with a deviation to the left of 84%. On plain abdominal radiography an image of great distension of the colon was identified ( Figure 1).

Figure 1:
Simple Abdominal X-ray: great distention of the colon with doubtful image of "coffee bean" in the cecum Given the suspicion of intestinal occlusion caused by a volvulus, urgent surgery was indicated. A midline laparotomy was performed, observing a cecal volvulus with adherence at the level of the peritoneum in union with the omentum (Figures 2-3). We performed, section and adherence ligature, blind developing, revision of intestinal loops and extraction of appendix ( Figure 4). The pathological anatomy reported an initial acute appendicitis. The postoperative period was uneventful. The patient follows correct controls in external surgeries of surgery and develops a socio-labor activity according to her age up to now.

Discussion
The cecal volvulus supposes the torsion of a segment of the colon on its mesenteric axis, which causes strangulation, with the consequent occlusion of the two ends of the volvulated segment and with a compromise of the vascularization, all of which produces a closed loop obstruction [11][12]. To present a redundant colon is necessary, with excessive mobility of the caecum and the ascending colon caused by a lack of fixation to the lateral retroperitoneum, a narrow and short mesentery at its base, and distension with air [13]; it almost never happens when the colon is full of solid stool. Colonic volvulus usually occurs more frequently in the sigma, followed by the cecum, although it also occurs occasionally in the transverse colon and in the splenic or hepatic angle of the colon [14][15][16].
A series of factors that influence the development of colon volvulus (usually congenital in cecal volvulus and acquired in the sigmoid volvulus) have been described, such as: diet rich in residues, chronic constipation and abuse of laxatives (in patients hospitalized in centers psychiatric), Chagas disease, disabling neurological diseases, mental patients under treatment with psychotropic drugs (which contribute to constipation), pregnant women etc. [17,18]. The clinic is usually more or less acute, with the typical triad of abdominal pain, distension and constipation, followed by nausea and vomiting; there is usually tympany to percussion and absence of peristalsis to auscultation; If gangrene or perforation develops, it manifests as an acute abdomen with signs of peritoneal irritation and shock, and if it is evolved it can cause the patient's death [19][20][21]. In almost half of the subjects there is a history of similar previous episodes, but of lesser intensity.
In the laboratory, there is leukocytosis with or without deviation to the left, in cases of ischemia and / or necrosis of the colonic wall [22]. Abdominal radiography shows a significant distention of the cecum, with the presence of hydro-aerial levels and dilatation of the small intestine; the "coffee bean" image can sometimes be observed. The opaque enema is usually difficult to interpret, but sometimes the sign of the "bird's beak" appears. Abdominal TAC is usually very specific, identifying cecal volvulus and vascular compromise due to meso twisting and signs of ischemic colitis in the colon wall [23]. Diagnostic colonoscopy is sometimes useful and establishes the viability of the colonic mucosa [24].
The treatment can be conservative or with surgical measures. Return by colonoscopy or barium enema can sometimes be successful (endoscopic decompression is the procedure of choice in sigmoid volvulus prior to surgical approach in stable patients, without ischemic involvement of the colon or perforation [25], but colonoscopy is less effective in right and blind colon volvuli [26]). If there is ischemic compromise or intestinal perforation, resection is necessary, after the corresponding exploratory laparotomy, a right hemicolectomy is performed with or without primary anastomosis.
There are other surgical techniques that have been used occasionally, such as detorsion or simple reduction with or without cecopexy of the colon to the right retroperitoneum and cecostomy [27]. In recent years, minimally invasive techniques such as laparoscopic cecopexy28 have been described. Conservative treatment can sometimes overcome the acute period, recover the colonic mucosa and be able to perform a later definitive surgery with a lower morbidity and mortality than in the acute period and with greater success; but taking into account that endoscopic devolvulation has a recurrence rate of 30-50%. The definitive treatment, with better control of long-term symptoms, is right hemicolectomy with primary ileotransverse anastomosis [29].
Mortality of cecal volvulus varies from 10-15%, if the colon is viable, to 30-40%, if there is intestinal gangrene. The mortality of the sigmoid volvulus varies from 13%, if the previous endoscopic devolvulation is achieved and the clinical situation of the patient with delayed surgery is improved, to 30-70%, if urgent surgery is performed without previous attempt of conservative endoscopic management [30]. The high mortality rate in relation to urgent surgery is conditioned by being elderly patients, with important underlying pathology and serious deterioration of their general condition at the time of surgery, first episode of volvulation and more severe symptoms (strangulation, ischemic colitis and perforation).