Volvulus

Volvulus
Obstruksi yang disebabkanb
oleh terpelintirnya usus lebig
dari 180 derajat dari axis
mesenterium.
1-5% obstruksi usus besar

Sigmoid ~ 65%
Cecum ~25%
ColonTransverse ~4%
Splenic Flexure

Sigmoid Volvulus
Worldwide - up to 50% of obstruction

India, Africa, E. Europe

Sering terjadi pada pasien yang tua.

Redundant colon, mesocolon menyempit,
mesenterium terpelintir
Faktor resiko

Chronic constipation
Masalah psikiatri
Non-western societies
high residue diet

Presentation
Hx: Nyeri perut,
distension, tidak ada
flatus atau gerakan
usus
Pemeriksaan :
tympanitic abdomen,
distension,
tenderness ringan,
Teraba massa

Sigmoid volvulus
Jeratan dibagian
dalam lumen
appearance
Dilated sigmoid loop
with limbs pointing
towards the RLQ

Sigmoid volvulus
Coffee bean
appearance with the 2
pelintiran loops
dengan double
komponen dinding
central

Barium Enema
Kontraindikasi
pada pasien
dengan free air on
AXR, Gejala klinis
peritonitis, atau
suspect nekrotik
usus
Birds beak
Bisa dekompresi

Pilihan Penanganan
Dekompresi Endoskopik

Rigid or flexible
proctosigmoidoscope
dimasukkan ke rektum
Gush of air/feces --> successful
decompression
Rectal tube
Successful in 85-90% of cases
Kambuh >60%
Penurunan resiko nekrotik usus
bila diobati dengan cepat
Colon ischemia, perforation

Elective resection

Management Operatif
sigmoid volvulus
Reseksi Elective

Same admission

Emergency laparotomy

Operasi tergantung viability

usus
Resection and
anastomosis
Hartmann resection
Exteriorization resection
Detorsion
Detorsion with colopexy
Percutaneous colostomy
Percutaneous sigmoidpexy

Reseksi yang terlambat dengan primer

anastomosis

Mortality rate 8%

Operative mortality berhubungan dengan

viabilitas usus

Viable 12% vs nonviable 53% mortality

Volvulus Ceacum
Lebih jarang dibandingkan sigmoid volvulus
Parietal peritoneum tidak berhubungan
dengan cecum dan colon kanan

Ada sekitar10% of population

Peningkatan mobilisasi usus, sehingga hal itu

terpelintir pada porosnya atau ke atas
Peluntiran proximal ke cecum
Faktor resiko:

Distal obstruction,Hamil, adhesions, jeratan

congenital, constipation lama, meteorism dengan
tanpa tekanan udara

Hx: abdominal pain,

kolik

Distention

Type puntiran axial

Puntiran 180-360 derajat

pada longitudinal axis of
colon assending (distal
ileum and ascending
colon)
Berhubungan dengan
bowel compromise,
ischemia, and perforation

Cecal bascule

Cecum folds anteriorly on

ascending colon
May result in intermittent
obstructive symptoms

X-rays
comma shaped
Convexity toward
right and downward
BE - risk of
perforation with
getting air/contrast to
right colon

Management
Decompression
dengan colonoscope

Kurang sukses
dibandingkan dengan
sigmoid volvulus

Emergent operation
bila ada tanda
masalah pembuluh
darah

Operative management for

cecal volvulus
Detorsi appendectomy
Cecopexy/Laparoscopic
cecopexy

jahitan colon kanan ke lateral

paracolic or use lateral
peritoneal flap

Cecostomy
Resection

Right colectomy with primary

anastomosis

Results
Detorsion appendectomy

High rate of recurrence (not commonly done

anymore)

Cecopexy

Do not need to have prepped bowel

Recurrence 25%

Cecostomy cecopexy

Combined procedure more effective in preventing

recurrence

Resection

Primary anastomosis unless peritoneal

contamination is present

Transverse colon volvulus

Less common area for volvulus(4%)
Associated with mobile right colon, distal
obstruction, chronic constipation, congenital
malrotation of the midgut
Usually not diagnosed preoperatively
No characteristic radiological findings except
colonic dilatation
Resection of transverse colon

High rate of recurrence if treated with detorsion alone