INFORMATION FOR CANDIDATE:

as surgical resident you have been called to the

emergency department to assess a 22-year-old Miss
Debbie Winter who presented with colicky severe
abdominal pain, nausea and vomiting. One week ago
she underwent a laparoscopic appendicectomy (only
mildly inflamed appendix, ?retrograde menstruation)
with uncomplicated post-operative recovery. Over the
last 2 days the abdominal pains have reoccurred, now
becoming quite severe and colicky. She has not
opened her bowels for 3 days.
YOUR TASK IS TO:
Take a focused history
Examine the patient
Arrange appropriate investigations
Discuss your diagnosis and management with the
patient

HOPC: Debbie Winter presented a week ago with colicky severe abdominal pain, nausea
and vomiting. The pain was sharp and tight over the upper abdomen and the RIF, worse
on eating and when lying flat. The physical examination was equivolcal. She underwent a
diagnostic laparoscopy and appendicectomy ( some blood in the pelvis, normal appearing
appendix with only mildly inflamed appendix on pathology report, ?retrograde
menstruation) with uncomplicated post-operative recovery and she was discharged on day
3. Over the last 2 days the nausea, vomiting and abdominal pains have reoccurred, now
becoming quite severe and colicky. She has not opened her bowels for 3 days.
O+G Hx: unremarkable, LMP 9 days ago, no intercourse.
PHx. + FHx: unremarkable
SHx: single shop assistant, shares a house with 2 friends, non smoker, little alcohol,
NKA, no medication.
EXAMINATION: HR 110, BP 105/75, RR 20, SaO2 95% on RA, T 36.8.
Distended abdomen, lower abdomen and right flank tenderness, bowel sounds high
pitched, and they occur in frequent runs at the same time as her colicky pains.
INVESTIGATIONS:
Hb 115/WCC 6.7/CRP 370/Creatinine 59/Lipase 13
AXRAbdominal X ray revealed Marked gaseous distension of numerous loops
of small bowel and large bowel

CT abdomen appearances are compatible with small bowel obstruction with

no transition point apparent (transition point is a focal area where the calibre of
the bowel abruptly changes from dilated proximal bowel to decompressed distal
bowel.)
DIAGNOSIS: SMALL BOWEL VOLVULUS!
Small bowel volvulus (SBV, an abnormal twisting of a loop of bowel around the axis of
its own mesentery) is an uncommon but important cause of small intestinal obstruction. It
often results in ischemia or even infarction. Delay in diagnosis and surgical intervention
increases morbidity and mortality rates. Goals for treatment of small bowel volvulus
should include physician awareness of this uncommon diagnosis, accurate workup, and
advanced surgical intervention.
SBV is uncommon in Western countries, but is more common in Africa and Asia.
In Western societies its annual occurrence varies from 1.7 to 5.7/100 000 of the
population, compared with 24 to 60/100 000 per population in Africa or Asia.
The prevalence of SBV varies considerably and accounts for 3.5% to 6.2% of small bowel
obstruction in the Western world, compared with 18.5% to 51.5% of small bowel
obstruction in Africa and Asia.
Based on cause, small bowel volvulus can be divided into primary and secondary type:
Primary Small Bowel Volvulus
This occurs in an otherwise normal abdomen. Although the aetiology is still
poorly understood, several aetiological factors have been proposed:

1. Diet may be a factor as their patients had eaten large quantities of fibre
after prolonged fasting.
2. Gut motility: there must be a combination of a long small bowel ,very
firm abdominal muscles (restricting bowel movement to the coronal
plane) and a diet with an exceptionally high bulk, eaten rapidly on an
empty stomach.

Secondary Small Bowel Volvulus

It is relatively more common in Western countries where it accounts for 70-90%
of cases in SBV. The most frequently related conditions are bands, adhesions,
Meckel's diverticulum, internal hernia, Ascariasis and pregnancy.
Other associations that have been reported include ileal atresia, meconium ileus,
enteroenterostomy, leiomyoma of the mesentery, and following operations,
particularly gastrostomy, gastrectomy and total hip replacement.

SBV presents with the classical features of intestinal obstruction. Typical symptoms are
sudden abdominal pain followed by nausea, vomiting and abdominal distension. The
vomitus begins with gastric content, bile stained fluid and later even faeculent smelling
material!
A white blood cell count over 18 has been associated with the presence of necrotic bowel
loops, hyperamylasaemia and abnormal serum lactate levels in 86% of patients with
gangrenous small bowel, in contrast with 5% and 4%, respectively, in those with other
causes of small bowel obstruction.
Metabolic acidosis can be present in three-quarters of those with strangulated bowel.
Plain films usually show nonspecific features, ultrasonography is also a low-accuracy test
in bowel obstruction cases as a result of bowel distension and gas interposition.
The imaging test of choice for the diagnosis of small bowel volvulus is the CT scan;
characteristic findings include the "whirl" sign of the rotated mesentery and "peacock's
tail" sign resulting from torsion of the bowel around the mesenteric axis.
Small bowel ischemia is suggested on CT scan by the presence of bowel wall thickening,
intramucosal air, and intraperitoneal fluid.
The outcome of SBV is dependent on the speed of diagnosis leading to surgical
intervention
MANAGEMENT:
NBM
IV Abx
Analgesia PRN
The surgical options for SBV consist of de-rotation, with or without fixation, and
resection with anastomosis.