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Jejunal volvulus: a rare complication after open appendicectomy

Mahmood Abbas, Saeed Al-Hindi, Anoop Kumar, Eizat Abrar, Aziz Hasan
Division of Pediatric Surgery, Department of Surgery, Salmaniya Medical Complex, Manama, Kingdom of Bahrain

 

Correspondence 

Mahmood Abbas MD
Consultant pediatric surgeon
Department of Surgery, Salmaniya Medical Complex
Tel: 0097339652551 / E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

 

Abstract

Small bowel volvulus after abdominal surgery is a rare complication. Early detection and urgent exploration is necessary to avoid bowel infarction. Post operative adhesions and bands are considered as predisposing factors in the etiology of postoperative volvulus. We present a case of jejunal volvulus that occurred early after open appendicectomy and was predisposed by severe bowel distension.

key words: appendicectomy, bowel distention, jejunal volvulus

 

 

Introduction

Postoperative intestinal obstruction due to segmental volvulus of the small bowel is a rare clinical entity [1, 2]. The mechanics of this pathology has been described by Perry in 1983 [3]. Although many cases have been reported in the literature, the exact incidence of this condition has still not been established. The most important aspect of management is early detection and timely intervention to salvage the compromised bowel.

Case report

A 3 year old boy presented with abdominal pain and recurrent non-bilious vomiting of 4 days duration. Clinical evaluation was suggestive of complicated appendicitis. Laparotomy revealed perforated appendix and severe dilatation of the small bowel loops. There was no evidence of malrotation. Appendicectomy was done. The postoperative course was marked by prolonged ileus without signs of peritonitis. On eighth postoperative day, abdominal distention increased significantly with generalized mild tenderness. Plain abdominal X-ray was suggestive of mechanical obstruction of the small bowel ( fig. 1). Upper GIT contrast study followed by abdominal CT scan was done and the findings revealed complete high small bowel obstruction with a strong possibility of jejunal volvulus ( fig 2, 3). Exploratory laparotomy confirmed the findings of a segmental jejunal volvulus of 360º without any evidence of local adhesions or bands ( fig 4). Detorsion of the viable jejunal volvulus was performed. and the postoperative course was unremarkable.

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Figure.1: Plain abdominal X-ray showing dilated small bowel segment in upper abdomen and absent gas distally without free air

 

10 JPSS 8 1 2010-10-2 10 JPSS 8 1 2010-10-3
Figure 2: Upper GIT contrast study showing complete stoppage of contrast in proximal jejunum Figure 3: CT scan illustrating severe proximal small bowel dilatation, collapsed distal small bowel loops, and whirl-like pattern of jejunal loops encircling segmental branches of superior mesenteric artery (main artery is not involved). There was no free air.

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Figure 4: Volvulus of a segment of jejunum and its mesentry 

Discussion

Small bowel obstruction is a well known complication after appendicectomy in children. The presentation may be early or can be delayed up to years after operation. The overall risk is low (0.7%) and is significantly related to perforated appendicitis. The most common causes of post op- erative intestinal obstruction are inflammatory adhesions or bands [4]. Postoperative volvulus of a segment or entire small bowel is unusual cause of postoperative intestinal obstruction among children and adults [1, 2, 5].

Most of the reported cases of postoperative volvulus occurred in bowel without malrotation and with normal mesentery [1]. The suggested mechanism involves obstruction of a small bowel loop at two fixed points by adhesions or bands. As the loop fills with liquid, peristalsis causes that segment to twist around its mesentery [2, 6]. The diagnosis of post operative volvulus can be delayed because of the rare occurrence of this complication and the vague clinical manifestation. The clinical presentation is usually that of an intestinal obstruction. Diagnostic workup of this surgical emergency should not delay an exploratory laparotomy. CT scan findings of volvulus include C- or U-shaped bowel loops radiating from two close points of obstruction, beak sign or whirl sign [7].

In this case, persistent ileus and abdominal distention beyond 7th postoperative day along with the findings on plain abdominal x-ray raised the suspension of mechanical obstruction. An upper gastrointestinal contrast study and abdominal CT scan confirmed the diagnosis and revealed the cause of obstruction which was jejunal volvulus. The occurrence of volvulus in this case can be explained by severe ileus causing significant bowel distention after initial surgery. This distention was probably aggravated by nitrous oxide administered during general anesthesia. Nitrous oxide is known to diffuse into the gut and cause bowel distension [8, 9].

In 1983, Perry presented a concept of the etiology of intestinal volvulus based on the fact that bowel when distended becomes elongated [3]. The antimesenteric border of the bowel elongates more than the mesenteric border which compels the bowel to adopt a position of increased curvature and this provides the driving force which initiates curling of bowel and sustains the volvulus. Conversely, he showed that deflating the bowel, which is a well recognized therapeutic maneuver, allows a reversal of the process [3].

Conclusion

Small bowel volvulus, though rare, should be considered in any child with intestinal obstruction after abdominal surgery. Prolonged ileus and bowel distention are possible predisposing factors.

 

 

References 

  1. Huang JC, Shin JS, Huang YT, Chao CJ, Ho SC, Wu MJ, Huang TJ, Chang FJ, Ying KS, Chang LP. Small bowel volvulus among adults. J Gastroenterol Hepatol. 2005 Dec;20(12):1906-12
  2. Iwuagwu O, Deans GT. Small bowel volvulus: a review. J R Coll Surg Edinb. 1999;44:150–5
  3. E. G. Perry. Intestinal volvulus: A new concept. Aust. N.Z. J . Surg. 1983, 53, 483-486
  4. Tsao KJ, St Peter SD, Valusek PA, Keckler SJ, Sharp S, Holcomb GW , Snyder CL, Ostlie DJ. Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach. J Pediatr Surg. 2007 Jun;42(6):939-42
  5. Mohamed AY, al-Ghaithi A, Langevin JM, Nassar AH. Causes and management of intestinal obstruction in a Saudi Arabian hospital. J R Coll Surg Edinb. 1997 Feb;42(1):21-3
  6. Rubio PA, Galloway RE. Complete jejunoileal necrosis due to torsion of the superior mesenteric artery. South Med J. 1990;83:1482–1483
  7. Mariano Scaglione, Stefania Romano, Fabio Pinto, Ferdinando Flagiello, Roberto Farina, Ciro Acampora, Luigia Romano. Helical CT diagnosis of small bowel obstruction in the acute clinical setting. European Journal of Radiology.2004(50): 15–22
  8. Akca O, Lenhardt R, Fleischmann E, Treschan T, Greif R, Fleischhackl R, Kimberger O, Kurz A, Sessler DI. Nitrous oxide increases the incidence of bowel distension in patients undergoing elective colon resection. Acta Anaesthesiol Scand. 2004 Aug;48(7):894-8
  9. Orhan-Sungur M, Apfel C, Akça O. Effects of nitrous oxide on intraoperative bowel distension. Curr Opin Anaesthesiol. 2005 Dec;18(6):620-4