Colonic volvulus accounts for 3% to 5% of all intestinal obstructions in adults (1,2) and occurs most commonly in the sigmoid colon followed by the cecum (2–4). Colonic volvulus is rare in childhood and is particularly uncommon in the transverse colon or the splenic flexure (4). Only 14 cases of volvulus of the transverse colon have been reported in the pediatric age group (2,5–16). We present a case of this rare condition in a 15-year-old boy, with a review of reported cases of volvulus of the transverse colon. Our case is unique, because the transverse colon had twisted around a gastrostomy tube site and, on initial x-ray, seemed to be a sigmoid volvulus.
A 15-year-old boy with spastic cerebral palsy, profound developmental delay, and seizure disorder was seen in the emergency department with a 1-day history of abdominal distention, vomiting, and fussiness. He had not had a bowel movement for 2 days and had a long history of chronic constipation. In the past he had been treated with daily senna leaf extract and with bisacodyl suppositories as needed every 3 days. For the 6 years leading up to his presentation, Colyte (Schwartz Pharma, Milwaukee, WI, U.S.A.), 8 oz daily by way of the gastrostomy tube, had been recommended. Compliance with this regimen, which had been effective initially in managing the constipation, had been poor for 2 years before the child's presentation. At 7 years of age, he had had a fundoplication and gastrostomy tube placed for treatment of a hiatus hernia and refractory gastroesophageal reflux.
Physical examination at the time of presentation revealed a developmentally delayed child with spastic quadriplegia. He appeared dehydrated. His blood pressure was not obtainable, his pulse was 150 beats per minute, and the respiratory rate was 36 per minute. He had a markedly distended abdomen with generalized tenderness. The bowel sounds were sluggish. The rectal ampulla was full of stool.
Abdominal roentgenograms demonstrated an extremely dilated colon consistent with sigmoid volvulus and a markedly dilated rectum filled with fecal material (Fig. 1 and 2). The child was acidotic with very poor peripheral perfusion. He received intravenous normal saline and Ringer's lactate boluses; however, he continued to have a thready pulse and tachycardia. Sigmoidoscopy was performed with a rigid sigmoidoscope, and, even on passing the instrument to 27 cm, no obstruction point was encountered. Visualization of mucosa was difficult because of the large amount of feces in the rectum. He was too unstable to attempt a barium enema and was taken directly to the operating room for exploratory laparotomy.
During surgery, a gangrenous, distended transverse colon was found, which had twisted on itself (closed loop obstruction) and around the gastrostomy tube site at the point where the stomach was adherent to the abdominal wall. The gastrostomy tube was removed, and the adhesions at the gastrostomy tract between the wall of the stomach and the anterior abdominal wall were taken down. The transverse colon was de-torsed. Because of the dilation of the right colon proximal to the volvulus, a complete right hemicolectomy was performed with an end-to-end ileocolic anastomosis. The gastrostomy tube insertion was revised. His postsurgical course was uneventful. His bowel program was reinstituted with 8 oz of Miralax (Braintree Laboratories, Braintree, MA, U.S.A.) daily. The patient has done well after his recovery from surgery. The fact that chronic constipation was a possible precipitating factor leading to the transverse colon volvulus was emphasized to the mother of the patient.
In Western countries, colon volvulus is an uncommon condition even among adults (1,2). Most cases are due to sigmoid volvulus, which constitutes 3.4% of all intestinal obstructions in adults (4) and 9.6% of all colonic obstructions (3,4). Transverse colon and splenic flexure volvulus occurs in less than 5% of all cases of colonic volvulus (4,17). Its rarity is believed to be a result of the relatively short mesocolon and fairly wide fixation points of the colon at the hepatic and splenic flexures, which prevent torsion. (2).
Our review of the English language medical literature on transverse colon volvulus in the pediatric age group revealed 14 cases (2,5–16). The ages of these patients ranged from 4 to 18 years (mean, 11.2 years) with 4 boys and 10 girls. Chronic constipation (7 patients) and developmental delay (5 patients) were present in a significant number of reported cases. Details on 12 cases have previously been reviewed (16).
Several factors have been suggested to predispose to the development of volvulus (1,2,5,9,18). These factors include distal colonic obstruction secondary to congenital bands, adhesions, Hirschsprung disease, or hamartomas (5,12,14,19). Redundant transverse colon and mesocolon (6,10) may allow for the complete volvulus of the transverse colon. It seems that chronic constipation predisposes to elongation and redundancy of the transverse colon (1,7–9). Our case is consistent with some of the reported cases in that he had a long-standing history of constipation, severe mental and motor retardation, and a history of previous abdominal surgery. The gastrostomy may have provided the point of fixation around which the bowel twisted. No specific notation was made regarding an excessive elongation of the transverse mesocolon in our patient, so we can only presume its possible presence.
Two types of clinical presentation have been reported in transverse colon volvulus—acute fulminating type with sudden onset of abdominal pain and vomiting occurring over several days, and subacute, progressive type with gradual onset of symptoms and intermittent bouts of crampy pain over a period of weeks or months (9). Our patient seems to have had the acute type.
In cases of transverse colon volvulus, a plain abdominal radiograph typically reveals distended large bowel and moderate to large amounts of feces throughout the colon (2,20,21). Our patient's initial radiograph was believed to be consistent with a sigmoid volvulus, and hence we were misled preoperatively. Because rigid and flexible sigmoidoscopy has been reported to reduce sigmoid volvulus, this procedure was attempted primarily and was unsuccessful (22). If mucosa is visible during the endoscopic procedure, a determination regarding its viability may also be made, and this may assist in determining the timing of surgery (22). If the patient is stable and gangrenous bowel is not suspected, a contrast examination should be performed to define the exact site and type of colonic obstruction. A classic “bird's beak” deformity seen on contrast enema is diagnostic for volvulus (16,23). The contrast enema may be therapeutic, because the reduction of the volvulus may occur either during the procedure or during evacuation of contrast (20). One pediatric case in which successful reduction of a volvulus involving the transverse colon was reported in the series of Mellor and Drake (20). However, this condition was not suspected before surgery in our patient. Furthermore, our patient's moribund condition and the large amount of feces in the colon precluded further endoscopic or radiologic manipulations, and we elected to explore his abdomen after the unsuccessful sigmoidoscopy. Because the bowel was already gangrenous, this in retrospect was the appropriate decision. It should be noted that the reported recurrence rate for colon volvulus in patients with endoscopic reduction as the initial therapy is 57%(22).
In conclusion, although volvulus of the transverse colon is rare in childhood, it should be considered in the differential diagnosis of intestinal obstruction in children with chronic constipation and severe developmental and motor disabilities. Aggressive management of chronic constipation should be emphasized to the caretakers of such children for prevention of this potentially life-threatening complication.
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