What is the appropriate management for Splenic flexure syndrome?

Management of Splenic Flexure Syndrome

Splenic flexure syndrome should be managed with a combination of dietary modifications, pharmacotherapy, and in severe cases, surgical intervention when conservative measures fail.

Understanding Splenic Flexure Syndrome

Splenic flexure syndrome is a functional disorder characterized by gas trapping at the splenic flexure of the colon, causing abdominal pain, distension, and discomfort in the left upper quadrant. It is distinct from splenic flexure volvulus, which is a rare but more serious condition involving twisting of the colon around its mesentery at the splenic flexure.

Diagnostic Approach

• Imaging studies: CT scan of the abdomen is the gold standard for diagnosis, with a reported accuracy of >90% 1
• Radiographic findings: Characteristic findings include:
  • Markedly dilated, air-filled colon with abrupt termination at the anatomic splenic flexure
  • Two widely separated air-fluid levels (transverse colon and cecum)
  • Empty descending and sigmoid colon 2
• Water-soluble contrast challenge: Can help differentiate partial from complete obstruction 1

Management Algorithm

1. Conservative Management (First-Line)

• Dietary modifications:

  • Low-fermentable diet to reduce gas production
  • Small, frequent meals
  • Adequate hydration

• Pharmacotherapy:

  • Antispasmodics: To relieve colonic spasm
  • Proton pump inhibitors or H2-receptor antagonists: Especially in patients with high output (>2L/day) to reduce gastric secretions and improve absorption 1
  • Loperamide: To reduce intestinal motility and improve transit time 1
  • Avoid medications that may worsen constipation: Particularly anticholinergics which can impair normal peristalsis 3

2. Endoscopic Management (For Acute Presentations)

• Endoscopic decompression: Consider in acute presentations without signs of ischemia or perforation 3
• Water-soluble contrast challenge: Can be both diagnostic and therapeutic in partial obstructions 1

3. Surgical Management (For Refractory Cases)

• Indications for surgery:

  • Failure of conservative management
  • Signs of ischemia or perforation
  • Recurrent episodes despite maximal medical therapy
  • Complete obstruction

• Surgical options:

  • Left hemicolectomy with primary anastomosis: Standard approach for splenic flexure volvulus 3, 4
  • Laparoscopic approach: Consider in hemodynamically stable patients without signs of peritonitis 1

Special Considerations

• Patients with predisposing factors:

  • Mental retardation
  • Chronic constipation
  • Congenital absence of normal colonic attachments
  • Previous abdominal surgery 2, 5

• Monitoring for complications:

  • Signs of bowel ischemia (increasing pain, fever, leukocytosis)
  • Perforation (peritoneal signs, free air on imaging)
  • Recurrence after conservative management

Prevention Strategies

• Regular bowel regimen to prevent chronic constipation
• Adequate fiber and fluid intake
• Physical activity to promote normal bowel motility
• Avoidance of medications that slow intestinal transit

Pitfalls to Avoid

• Misdiagnosis as irritable bowel syndrome or functional dyspepsia
• Delayed surgical intervention in cases with signs of ischemia
• Failure to recognize congenital anatomic abnormalities that may predispose to recurrence
• Overlooking synchronous volvulus at other colonic segments 6

Remember that splenic flexure syndrome is distinct from splenic flexure volvulus, which is a surgical emergency requiring prompt intervention to prevent bowel ischemia and perforation.