Background

Large bowel obstruction is commonly suspected and encountered in nearly all medical and surgical specialities, making knowledge regarding its potential causes and subsequent management essential. In the Western population, volvulus of the colon accounts for 1–5% of all patients presenting with large bowel obstruction.1 A volvulus has been described as an axial twist of a portion of the gastrointestinal tract along its mesentery, potentially causing luminal obstruction with associated venous and arterial occlusion.2 If allowed to progress, this will lead to ischaemia, gangrene, visceral perforation and eventually peritonitis.

Case presentation

A 54-year-old woman was admitted with a 4 day history of severe acute colicky abdominal pain radiating from the left upper quadrant down to the left iliac fossa. This was preceded by absolute constipation for 3 days with associated progressive abdominal distension. She had no other medical or surgical problems but had experienced a similar episode of colicky abdominal pain and constipation some 14 months previously. A plain abdominal radiograph performed during this admission revealed numerous dilated loops of bowel; however, the patient responded to conservative treatment and no follow-up was required. She reported intermittent self limiting mild abdominal pains since her last admission but denied feeling unwell over this period of time.

Investigations

Haematological investigations were normal with a haemoglobin of 13.4 g/dl and a white cell count of 7.7×10³/mm³. All biochemical tests were also normal including urea and electrolytes (U&Es), liver function tests, amylase, C reactive protein, and arterial blood gases. On examination the patient had a distended virgin abdomen and was diffusely tender in the left upper quadrant with associated guarding. Bowel sounds were tinkling and hyperactive and per rectum examination revealed an empty rectum. All bedside observations were normal. Plain abdominal and erect chest films revealed a distended large bowel (fig 1). A subsequent abdominal computed tomography (CT) scan (performed later that day) showed massive distension of the distal transverse colon, splenic flexure and proximal descending colon, highly suspicious of a splenic flexure volvulus (fig 2). No pneumoperitoneum was demonstrated.

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Figure 1

Abdominal x-ray on admission.

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Figure 2

Abdominal computed tomography scan: splenic flexure volvulus.

Differential diagnosis

Plain abdominal film was consistent with large bowel obstruction which has numerous causes including malignancies, benign strictures, a colonic volvulus, and pseudo-obstruction.

Treatment

Following resuscitation, the patient was taken for an urgent laparotomy. The radiological findings were confirmed with the splenic flexure of the colon having rotated 360° along its mesentery (fig 3). All three splenic flexure ligaments were congenitally absent. Even though the bowel remained viable, a 45cm segment was resected and a primary anastomosis between the transverse and descending colon was performed. Postoperatively she was taken to the ward.

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Figure 3

(1) Pathological specimen (upper panel) and perioperative photograph (lower panel) showing volvulus with associated dilated large bowel.

Outcome and follow-up

The patient made a good initial postoperative recovery but later leaked from her anastomosis, necessitating a second laparotomy with formation of an end colostomy. Further laparotomies were required, firstly due to multiple interloop abscesses, and later due to generalised bleeding secondary to heparin induced thrombocytopenia. Following the latter, a laparostomy was fashioned to permit regular changing of the abdominal packs and inspection of abdominal organs. Unfortunately the patient never recovered from her extensive surgery and died of multiple organ failure secondary to septicaemia 2 months following her admission.

Histological examination of the resected specimen from her initial surgery reported a section of large bowel dilated to 15 cm. Focal infarction of the wall was displayed with no evidence of malignancy.

Discussion

Ballantyne et al3 describes a series of 137 patients with a colonic volvulus over a 20 year period attending a US centre. They describe 52% of these as caecal in origin, 43% sigmoid, 3% transverse colon, and only 2% as splenic flexure. Volvulus of the splenic flexure is rare due to its relative immobility, having been held in position by a series of ligaments (phrenicocolic, gastrocolic, and splenocolic).

Approximately 40 cases have been reported in the literature since the condition was first described in 1954.4 A large proportion of these cases involve patients having had previous surgery resulting in a mobile splenic flexure. Several other causative factors have been described by other authors, including congenital absence of these ligaments5 such as in our case, chronic constipation (resulting in elongation of the mesentery), malrotation6 and band adhesions.7