The Case Files
A 17-year-old Caucasian man with no significant past medical history or hospitalization presented to the ED complaining of abdominal pain, bloating, and diarrhea for five days. The patient said his pain was located in his upper abdomen; it was cramping, constant, and worse when he laid down, with a 7/10 intensity.
He reported more than 10 episodes of watery, brown, non-bloody diarrhea daily since the onset of his symptoms. He said he had nausea and had one episode of non-bloody and non-bilious vomiting prior to arrival. He denied fever, chills, headache, sore throat, back pain, genital pain, weight loss, and rash. He recalled similar symptoms that occurred five months earlier that lasted for one week and resolved without intervention. He had no associated trauma, sick contacts, recent travel, or family history of abdominal problems.
The patient's vital signs were stable with a temperature of 98°F, a pulse of 80 bpm, a respiratory rate of 16 bpm, a blood pressure of 130/66 mm Hg, and an oxygen saturation of 100 percent on room air.
The patient appeared uncomfortable during the physical exam. Heart sounds were normal, and lung fields were clear bilaterally. No bowel sounds were heard. He had marked abdominal distention in the epigastric region, and the abdomen was diffusely tender, firm to palpation, and tympanic to percussion, with guarding. A fluid wave was not appreciated. His mucous membranes were moist, and his skin had good turgor.The remainder of the physical exam was normal.
Intravenous fluid was started, labs were drawn, and x-rays of his abdomen with decubitus and erect views were ordered. The patient was given morphine for pain control and ondansetron (Zofran) for nausea. The laboratory results were unremarkable except for a mild elevation in total bilirubin of 1.4 mg/dL. The x-ray showed marked constipation with moderate large bowel predominant air dilation, with the absence of gas in the rectum. (Figure 1.) A CT abdomen and pelvis with oral and IV contrast was ordered. The CT revealed significant distention of the entire colon, with a sigmoid diameter of 10 cm. A transition was seen at the rectosigmoid junction, and no air fluid levels were present. A mesenteric twist was seen at the base of the sigmoid, consistent with a sigmoid volvulus. (Figure 2.)
The patient was admitted to the pediatric in-patient service. IV piperacillin/tazobactam and metronidazole were started. A barium enema was performed, but the volvulus was unable to be reduced. (Figure 3.) A flexible sigmoidoscopy and rectal suction biopsy was performed, which was successful in decompressing the sigmoid colon. The next day, the patient had a large bowel movement, which caused significant improvement in his distention. Rectal biopsies were negative for Hirschsprung's disease. The patient's diet was slowly advanced, and the patient was discharged home after three days on a high-fiber diet to prevent constipation, which was believed to be the precipitating factor. Ultimately, the patient did not require further intervention.
Sigmoid volvulus is a rare diagnosis in the pediatric population, with only 63 reported cases in patients under 18 years of age from 1940 to 2000. The median age of diagnosis in a previous review was found to be 7 years old, with a strong male predominance of 3.5:1. (J Am Coll Surg 2000;190:717.) The etiology of pediatric sigmoid volvulus differs from that seen in the adult population. It is most commonly caused by constipation in adults, and has also been associated with a high-fiber diet in developing countries. It is believed to be caused by a redundancy of the sigmoid colon, a long mesentery with a narrow base, or a lack of fixation of the mesentery to a portion of the colon in children. Children with Hirschsprung's disease are also at risk. (J Pediatr Surg 2004;39:1434.)
Sigmoid volvulus most commonly presents with the symptoms of abdominal pain, bloating, and vomiting. Less common signs and symptoms include abdominal tenderness, diarrhea, nausea, and fever. (J Am Coll Surg 2000;190:717.) A plain film will most commonly show dilated loops of colon, and may demonstrate the coffee bean sign, referring to the two distended sigmoid compartments with the central double walls of the colon. Plain films can make a diagnosis in 35–60 percent of cases. A CT is the preferred modality for diagnosis in the emergency department, nearing 100 percent accuracy, and can exclude other causes of abdominal pain. (J Emerg Med 2013;44:611.)
Managing sigmoid volvulus in children is controversial because of its rarity. Fluid resuscitation and antibiotics should be given because of its association with bowel ischemia, gangrene, and perforation. Early consultation to surgery and gastroenterology is recommended. Nonoperative management should be considered first. Barium enema can be diagnostic and therapeutic, and was successful in reducing the volvulus in 77 percent of patients in a previous study. (J Am Coll Surg 2000;190:717.)
A flexible sigmoidoscopy is also an option, with a success rate of 78 percent, but it has a 2.4 percent risk of traumatic perforation. Nonoperative treatment has a high recurrence rate of 35 percent in children and up to 70 percent in adults. Definitive treatment is sigmoidectomy, and should be considered in most patients to prevent recurrence. (World J Surg 2010;34:1923.)
Sigmoid volvulus, though rare in children, should be considered in any patient presenting with symptoms of bowel obstruction. Early diagnosis and decompression is vital to prevent complications such as bowel ischemia, gangrene, or perforation.© 2014 by Lippincott Williams & Wilkins