What is the management of small intestine twisting?

Management of Small Intestine Twisting (Volvulus)

Surgery is the treatment of choice for small intestine volvulus, with prompt intervention required to prevent intestinal ischemia, necrosis, and perforation. 1, 2

Clinical Presentation and Diagnosis

• Symptoms and signs:

  • Abdominal pain (often colicky and severe)
  • Nausea and vomiting
  • Abdominal distension
  • Abnormal bowel sounds
  • Signs of peritonitis (in advanced cases)
  • Hemodynamic instability (in cases with bowel ischemia/necrosis)

• Diagnostic workup:

  • CT scan is the diagnostic test of choice to identify intestinal volvulus 3
  • CT findings include:
    • Whirl sign (twisted mesentery and vessels)
    • Closed-loop obstruction
    • Signs of intestinal ischemia (pneumatosis, portal venous gas)
    • Free air (in cases of perforation)
  • Plain radiographs may show signs of small bowel obstruction but cannot exclude the diagnosis 4
  • Laboratory tests should include white blood cell count and C-reactive protein to assess for infection/inflammation 1

Management Algorithm

1. Initial Stabilization

• Fluid resuscitation with intravenous crystalloids
• Nasogastric tube placement for decompression (especially with significant distension and vomiting)
• Broad-spectrum antibiotics if peritonitis or perforation is suspected
• Pain management

2. Surgical Management

• Timing of surgery:

  • Immediate surgery for signs of peritonitis, perforation, or hemodynamic instability 1
  • Early surgery (within 12-24 hours) for stable patients with persistent symptoms 3
  • Delay beyond 48 hours is associated with increased mortality 3

• Surgical approach:

  • Open approach is recommended for hemodynamically unstable patients or those with peritonitis 1
  • Laparoscopic approach may be considered in hemodynamically stable patients if expertise is available 1, 3

• Intraoperative management:

  • Systematic exploration of the entire small bowel, starting from the ileocecal junction and working proximally 3
  • Assessment of bowel viability at the site of volvulus
  • Consider indocyanine green fluorescence angiography to assess perfusion if available 3

• Surgical procedures based on bowel viability:

  1. Viable bowel:

     • Detorsion (untwisting) of the volvulus
     • Resection of the affected segment with primary anastomosis is preferred over simple reduction alone to prevent recurrence 3

  2. Non-viable bowel:

     • Mandatory resection of the necrotic segment 1
     • Primary anastomosis in hemodynamically stable patients 3
     • Consider temporary stoma in cases of severe peritoneal contamination or hemodynamic instability 1

3. Post-Surgical Management

• Close monitoring for signs of anastomotic leak or recurrence
• Early enteral nutrition when bowel function returns
• Monitor for recurrence symptoms, particularly in the first year after surgical management 3

Special Considerations

• Primary vs. Secondary Volvulus:

  • Primary volvulus occurs without predisposing factors
  • Secondary volvulus is more common and associated with adhesions, tumors, Meckel's diverticulum, or other anatomical abnormalities 2

• Compound Volvulus (Ileosigmoid Knot):

  • Rare but severe form where small bowel twists around the sigmoid colon
  • Requires urgent surgical intervention due to rapid progression to gangrene 5

• High-Risk Populations:

  • Patients with cerebral palsy may have increased risk of intestinal obstruction and volvulus with atypical presentations 6
  • Bariatric surgery patients are at risk for internal hernias and intussusception that can lead to volvulus 3

Pitfalls and Caveats

• Delay in diagnosis and treatment can lead to bowel ischemia, necrosis, and perforation
• Simple reduction without resection is associated with higher recurrence rates 3
• Non-verbal or cognitively impaired patients may have delayed diagnosis due to inability to express pain 6
• Volvulus should always be considered in the differential diagnosis of acute small bowel obstruction, especially in patients with risk factors 2