2. Case 1
• A 77-year-old man presented with vomiting, abdominal
pain, persistent and increasing abdominal distension,
and absence of bowel sounds.
3. Volvulus
• Volvulus occurs when an air-filled segment of the colon twists
about its mesentery.
• The sigmoid colon is involved in up to 90% of cases, but
volvulus can involve the cecum (<20%) or transverse colon.
• may reduce or progress to strangulation, gangrene, and
perforation.
• Chronic constipation may produce a large, redundant colon
(chronic megacolon) that predisposes to volvulus, especially if
the mesenteric base is narrow.
6. Sigmoid Volvulus
• Differentiated by the
appearance of plain X-rays of
the abdomen.
• bent inner tube or coffee bean
• Gastrografin enema : bird’s
beak
8. No signs of gangrene or peritonitis
• Resuscitation and endoscopic detorsion
• Rigid sigmoidoscope
• Rectal tube
• decompression
• elective sigmoid colectomy
• risk of recurrence is high
• after the patient has been stabilized
9. Complicated situation
• Strangulation
• Necrotic mucosa, ulceration, or dark blood
• gangrene or perforation
• immediate surgical exploration without an attempt at endoscopic
decompression
• sigmoid colectomy with end colostomy (Hartmann’s procedure)
10. Ceceal Volvulus
• results from nonfixation of the right colon.
• rotation occurs around the ileocolic blood vessels (early
vascular impairment).
• kidney-shaped in X-ray
• almost never be detorsed
• Surgical exploration
• Right hemicolectomy with a primary ileocolic anastomosis
• high rate of recurrence: Simple detorsion or detorsion and
cecopexy
11.
12. Transverse Colon Volvulus
• extremely rare
• Nonfixation of the colon
• chronic constipation with megacolon
• X-ray: like sigmoid volvulus
• Gastrografin enema: reveal a more proximal obstruction
• colonoscopic detorsion → emergent exploration and resection
13. Colonic Pseudo-obstruction
(Ogilvie’s Syndrome)
• is a functional disorder in which the colon becomes massively
dilated in the absence of mechanical obstruction.
• result from autonomic dysfunction and severe adynamic ileus.
• Pseudo-obstruction most commonly occurs in:
• hospitalized patients
• Narcotics
• bed rest
• Old age
• Hypothyroidism
14. Diagnosis and treatment
• massive dilatation of the colon in the absence of a mechanical
obstruction.
• cessation of narcotics,anticholinergics or other
• bowel rest and intravenous hydration
16. Case 1
• A 77-year-old man presented with vomiting, abdominal pain,
persistent and increasing abdominal distension, and absence of
bowel sounds.
• Approach:
1. X_ray
2. Gastrografin enema
17.
18. DIVERTICULAR DISEASE
• The majority of colonic diverticula are false diverticula in which
the mucosa and muscularis mucosa have herniated through the
colonic wall.
• These diverticula occur between the teniae coli, at points where
the main blood vessels penetrate the colonic wall.
• They are thought to be pulsion diverticula resulting from high
intraluminal pressure.
• Diverticular bleeding can be massive but usually is self-limited.
19. Diverticulosis
• sigmoid colon is the most common site
• It is estimated that half of the population older than age 50
years has colonic diverticula.
• high-fiber diet does appear to decrease the incidence of
diverticulosis
Etiology
• lack of dietary fiber
• high intraluminal pressure and high colonic wall tension
• Loss of tensile strength and a decrease in elasticity of the bowel
wall
20. Inflammatory Complications
(Diverticulitis)
• 10% to 25%
• Perforation :contamination, inflammation, and infection.
• Left sided abdominal pain
• Tenderness
• with or without fever, and leukocytosis
• A mass may be present
21. Imaging and DDX
• X-ray
• free intra-abdominal air
• CT_scan
• pericolic inflammation, phlegmon, or abscess.
• Contrast enemas and/or endoscopy
• DDX:
• malignancy, ischemic colitis, infectious colitis, and inflammatory
bowel disease.
22. Approach
• Diverticulosis
• Mild Diverticulitis (Uncomplicated Diverticulitis)
• low-residue diet
• broad-spectrum oral antibiotics: 7 to 10 days
• Sever Diverticulitis (complicated )
• IV antibiotic
• Bowel rest
• Hemodynamic
23. diverticulitis
• Failure to improve may suggest abscess formation.(24_72h)
• CT scan
• many pericolic abscesses can be drained percutaneously
• Deterioration in a patient’s clinical condition and the
development of peritonitis are indications for laparotomy.
• Recurrent diverticulitis:
• Elective sigmoid colectomy
24. Surgery after the first episode of diverticulitis
1. in very young patients
2. Immunosuppressed patients
3. colon carcinoma
4. Complicated Diverticulitis
• all patients must be evaluated for malignancy after resolution of
the acute episode. Colonoscopy is recommended 4 to 6 weeks
after recovery.
26. Complicated Diverticulitis
• Abscess
• Small abscesses (<2 cm in diameter) may be treated with parenteral
antibiotics.
• Larger abscesses are best treated with CT-guided percutaneous
drainage.
• diffuse peritonitis
• resect the affected segment of bowel
• sigmoid colectomy with a primary anastomosis
28. hemorrhage
• Bleeding from a diverticulum results from erosion of the
peridiverticular arteriole and may result in massive hemorrhage.
• Fortunately, in 80% of patients, bleeding stops spontaneously.
• Clinical management should focus on resuscitation and
localization of the bleeding site as described for lower
gastrointestinal hemorrhage.
29. Giant Colonic Diverticulum
• Most occur on the antimesenteric side of the sigmoid colon.
• Complications of a giant diverticulum include perforation,
obstruction, and volvulus.
• Resection of the involved colon and diverticulum is
recommended.
