Secondary Logo

Journal Logo

Case Report

Transverse Colon Volvulus Around the Gastrostomy Tube Site

Al-Homaidhi, Hossam S.; Tolia, Vasundhara

Author Information
Journal of Pediatric Gastroenterology and Nutrition: November 2001 - Volume 33 - Issue 5 - p 623-625
  • Free

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.

FIG. 1.
FIG. 1.:
Upright film of abdomen shows arrow on hugely dilated loop of colon.
FIG. 2.
FIG. 2.:
Decubitus film of the abdomen shows the dilated loop of bowel by arrow.

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.


1. Zinkin LD, Katz LD, Rosin JD. Volvulus of the transverse colon: report of a case and review of the literature. Dis Colon Rectum 1979; 22: 492–6.
2. Black RE, Cox JA. Volvulus of the transverse colon in children: report of a case and review of the literature. Z Kinderchir 1984; 39: 69–71.
3. Smith SD, Golladay ES, Wagner C, et al. Sigmoid volvulus in childhood. South Med J 1990; 83: 1347–50.
4. Ballantyne GH. Review of sigmoid volvulus, clinical patterns and pathogenesis. Dis Colon Rectum 1982; 25: 823–30.
5. Weir DC, Wong JC. Volvulus of the transverse colon due to congenital bands. Miss Med 1959; 56: 908–9.
6. Parrish RA, Crook JA, Moretz WH. Coexistent volvulus of the transverse, sigmoid and right colon. Am Surg 1964; 30: 311–6.
7. Cuderman BS, Roback SA, Weintraub WH, et al. Volvulus of the transverse colon. Surgery 1971; 69: 797–9.
8. Howell HS, Freeark RJ, Bartizal JF. Transverse colon volvulus in pediatric patients. Arch Surg 1976; 111: 90.
9. Eisenstat TE, Raneri AJ, Mason GR. Volvulus of the transverse colon. Am J Surg 1977; 134: 396–9.
10. Dadoo RC, Keswani RK. Volvulus of the transverse colon in a child. Clin Pediatr 1977; 16: 751–2.
11. Anderson JR, Lee D, Taylor TV, et al. Volvulus of the transverse colon. Br J Surg 1981; 68: 179–81.
12. Asano S, Konwna K, Rikimaru S, et al. Volvulus of the transverse colon in four year old boy. Z Kinderchir 1982; 35: 21–3.
13. Trillis F, Gauderer MWL, Ponsky JL, et al. Transverse colon volvulus in a child with pathologic aerophagia. J Pediatr Surg 1986; 21: 966–8.
14. Neilson IR, Youssef S. Delayed presentation of Hirschsprung's disease: acute obstruction secondary to megacolon with transverse colon volvulus. J Pediatr Surg 1990; 25: 1177–9.
15. Mercado-Deane MG, Burton EM, Howell CG. Transverse colon volvulus in pediatric patients. Pediatr Radiol 1995; 25: 111–2.
16. Houshian S, Sorensen JS, Jensen KEJ. Volvulus of the transverse colon in children. J Pediatr Surg 1998;33:1399–1401.
17. Ballantyne GH, Brandner MD, Beart RW, et al. Volvulus of the colon: incidence and mortality. Ann Surg 1985; 202: 83–92.
18. Boley SJ. Volvulus of the transverse colon. Am J Surg 1958; 96: 122–5.
19. Lapin R, Kane AA, Lee CS, et al. Volvulus of the transverse colon associated with submucosal hamartoma. Am J Gastroenterol 1973; 59: 170–3.
20. MelIor MFA, Drake DG. Colonic volvulus in children: value of barium enema for diagnosis and treatment in 14 children. AJR 1994; 162: 1157–9.
21. Fishman EK, Goldman SM, Patt PG, et al. Transverse colon volvulus: diagnosis and treatment. South Med J 1983; 76: 185–9.
22. Brothers TE, Strodel WE, Eckhauser FE. Endoscopy in colonic volvulus. Ann Surg 1987; 206: 1–4.
23. Loke KL, Chan CS. Case report: Transverse colon volvulus: unusual appearance on barium enema and review of the literature. Clin Radiol 1995; 50: 342–4.
© 2001 Lippincott Williams & Wilkins, Inc.