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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 55-56

Splenic flexure volvulus: Rarest type of colonic volvulus, report of a case


1 Department of General and Laparoscopic Surgery, Columbia Asia Hospital, Bengaluru, Karnataka, India
2 Department of GI and Oncosurger, Columbia Asia Hospital, Bengaluru, Karnataka, India
3 Department of Radiology, Columbia Asia Hospital, Bengaluru, Karnataka, India

Date of Web Publication26-Nov-2019

Correspondence Address:
C R Praveen
Department of General and Laparoscopic Surgery, Columbia Asia Hospital, Whitefield, Bengaluru - 560 066, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCS.IJCS_1_19

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  Abstract 


Only in 15% of cases, colonic volvulus is one of the causes of large-bowel obstruction. Splenic flexure volvulus is the rarest subtype of colonic volvulus (<1% of cases). We report one such case in a 50-year-old female, who was subjected to extended left hemicolectomy after stabilization. The histopathology report showed no evidence of malignancy.

Keywords: Colonic volvulus, large-bowel obstruction, splenic flexure volvulus


How to cite this article:
Praveen C R, Prakash M, Nandakumar G, Palleti A. Splenic flexure volvulus: Rarest type of colonic volvulus, report of a case. Indian J Colo-Rectal Surg 2018;1:55-6

How to cite this URL:
Praveen C R, Prakash M, Nandakumar G, Palleti A. Splenic flexure volvulus: Rarest type of colonic volvulus, report of a case. Indian J Colo-Rectal Surg [serial online] 2018 [cited 2019 Dec 12];1:55-6. Available from: http://www.ijcrsonweb.org/text.asp?2018/1/2/55/271745




  Introduction Top


The most common benign cause of colorectal obstruction is volvulus, with sigmoid volvulus being the most common bowel involved. Splenic flexure volvulus can occur in patients who have a mobile splenic flexure following a congenital or acquired loss of colonic attachments.


  Case Report Top


A 50-year-old female presented with an increasing abdominal distension associated with pain and obstipation for 3 days. She had no fever. There was no previous history of similar symptoms or constipation. There was no previous surgery. Generalized abdominal distension more toward the upper abdomen was noted on examination. There were no features suggestive of local peritonitis. X-ray abdomen showed features of large-bowel obstruction [Figure 1]a. Contrast computed tomography scan of the abdomen was done, which showed features of large-bowel obstruction with features suggestive of splenic flexure volvulus. The splenic flexure and proximal descending colon showed abrupt short segment narrowing with twist in its mesentery (swirl sign positive) with streaks of enema contrast passing through the narrowed segment [Figure 1]b. Beak sign was noted at distal aspect of the narrowing. Colon was dilated up to the distal end of transverse colon (5.6 cm at its maximum extent) and showed intraluminal contrast from enema [Figure 1]c. The distal segments of descending colon, sigmoid colon, and rectum showed normal contrast filling. Colonoscopic decompression of the dilated loop of the colon in the splenic flexure region was done. No obvious intraluminal cause responsible for volvulus was found. However, the scope could not be negotiated into the proximal colon. Her total leukocyte counts were not elevated. All other biochemical investigations were normal.
Figure 1: X-ray with classical splenic flexure volvulus appearance (a), contrast-enhanced computed tomography abdomen showing swirl sign-twist in mesentery, shown by arrow (b), dilated splenic flexure on computed tomography scan with partial intraluminal contrast (c), and intraoperative photograph showing the dilated splenic flexure (d)

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After adequate optimization, the patient was subjected to exploratory laparotomy. Volvulus of the splenic flexure was seen [Figure 1]d. Congenital splenic flexure attachments were absent. There was a swollen and ischemic epiploic appendage with adhesions to the pericolonic tissues at the distal end of the volvulus. This was probably the cause for the partial obstruction followed by the twist due to lack of congenital attachments.

Left extended hemicolectomy with stapled side-to-side colonic anastomosis was done. Postoperatively, she had an uneventful recovery. She passed stools on the 3rd postoperative day and was discharged on the 5th postoperative day.

Histopathology revealed mucosal edema and focal ischemic changes with no evidence of malignancy.


  Discussion Top


Splenic flexure volvulus is a rare type of colonic volvulus (1%–2% of the colonic volvulus cases).[1] Its rarity is due to its relative immobility and the fact that is held in position by various ligaments (phrenicocolic, gastrocolic, and splenocolic). Congenital or acquired absence of attachments of splenic flexure and chronic constipation are the proposed predisposing factors.[2]

A radiological diagnosis is warranted, in an appropriate clinical setting, when the following are seen: markedly dilated, air-filled colon with an abrupt termination at the anatomic splenic flexure; widely separated air-fluid levels, one in the transverse colon and the other in the cecum; an empty descending and sigmoid colon; and a characteristic beak at the anatomic splenic flexure at a barium enema examination.[3]

In the present case, there was no previous surgery. However, there was absence of the phrenicocolic and splenocolic ligaments.

Endoscopic decompression is best considered a temporizing measure as it is ineffective to overcome detorsion, and there is a recurrence of splenic flexure volvulus.[4] In our case, colonoscopic decompression helped us in ruling out any intraluminal cause of obstruction as well as in optimizing her condition for surgery.

Although bowel resection is indicated in patients with gangrenous bowel, even in patients with viable colon given the high chance of recurrence, resection (extended left hemicolectomy) is preferred.[4]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ballantyne GH, Brandner MD, Beart RW Jr., Ilstrup DM. Volvulus of the colon. Incidence and mortality. Ann Surg 1985;202:83-92.  Back to cited text no. 1
    
2.
Jones IT, Fazio VW. Colonic volvulus. Etiology and management. Dig Dis 1989;7:203-9.  Back to cited text no. 2
    
3.
Mindelzun RE, Stone JM. Volvulus of the splenic flexure: Radiographic features. Radiology 1991;181:221-3.  Back to cited text no. 3
    
4.
Gingold D, Murrell Z. Management of colonic volvulus. Clin Colon Rectal Surg 2012;25:236-44.  Back to cited text no. 4
    


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