Transverse Colon Volvulus: Case Reports and Review

NEIL A. NEWTON’ AND HOWARD D. REINES’

Volvulus of the transverse colon is an uncommon event verse colon with undertaken with end-to-end anastomosis
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but results in mortality or significant morbidity relatively and proximal right lower quadrant cecostomy. Postoperative
more often than cecal or sigmoid volvulus. Two cases are course and subsequent follow-up were uneventful.
presented with emphasis on incidence, predisposing fac- Comment. Partial malnotation and lack of hepatic flexure
tors, clinical presentation, and radiologic examination. fixation enabled the transverse colon to fold on itself.
The need for early diagnosis and surgical intervention is
stressed.
Case 2

M. D., a severely retarded 26-year-old woman, had a his-

Volvulus of the transverse colon continues to be a rela-
tory of several episodes of abdominal distention. A barium
tively rare medical problem and is infrequently included enema 4 months prior to admission was reported as nega-
in the differential diagnosis of the acute abdomen. Since tive. She had increasing abdominal distention for 3 days and
Kallio [1] presented the first case of transverse colon one episode of vomiting on the day of admission. Rectal
volvulus in 1 932, fewer than 30 cases have been re- tubes and enemas had been attempted without success at
ported in the literature [2-7]. This disorder constitutes an outside hospital.
less than 1 % of all large bowel obstructions and 4%- Physical examination in the emergency room revealed a
1 1 % of reported cases of colonic torsions in the United young woman in mild distress with normal vital signs. Her
States [8]. However, mortality in transverse colon vol- abdomen was distended with occasional bowel sounds and
was nontender. All laboratory data were within normal limits.
vulus is three times that of cecal volvulus and half
Supine and upright abdominal films were obtained (figs.
again as a great as that of sigmoid volvulus [8]. The
2A and 28) showing a huge amount of colonic gas with a
following cases illustrate the radiologic findings in this very long air-fluid level in the colon. A barium enema was
condition and stress the importance of early surgical immediately performed (fig. 2C), demonstrating volvulus of
intervention as definitive treatment. the transverse colon immediately proximal to the splenic
flexure.
At surgery a 2700 twist in a massively dilated colon was
Case Reports discovered. The hepatic flexure was not attached; the trans-
Case 1 verse colon was extremely long and had a long mesocolon
which was thickened at its base. The distal transverse colon
S. M., a healthy 25-year-old woman, had sudden onset of
appeared bound down to this band. The bowel was untwisted,
diffuse, crampy abdominal pain associated with tenesmus
and no evidence of vascular compromise was noted. The
and bilious vomiting. Past history was notable only in that
fibrous band was divided, releasing the bowel and giving the
the patient had had a Meckel’s diverticulectomy in infancy.
transverse colon a broader base to prevent future torsion.
Physical examination revealed a thin woman in acute distress
The patient tolerated the procedure well and was discharged
with a distended, tympanitic, diffusely tender abdomen with-
following a benign postoperative course.
out rebound or rigidity. Auscultation elicited decreased
Comment. It is postulated that the thickened area in the
bowel sounds with an occasional high-pitched tinkle. No
mesocolon may have been the result of recurrent torsions.
blood was present in the stool, and rectal examination was
In the absence of a hepatic flexune, the colon had rotated
normal. Vital signs and routine laboratory tests were unre-
around this area paralleling the middle colic artery, eventually
mankable.
becoming adherent to the fibrous band.
Plain films showed evidence of large bowel obstruction
with a left-sided cecum (fig. IA) and two air-fluid levels in
the upright position (fig. 18). Subsequent barium examination
Discussion
revealed a transverse colon volvulus with a typical beak sign
(fig. 1C). Etiology
A laparotomy was performed 4 hr after onset of symp-
The necessary factors for colonic torsion include
toms. The ascending colon and cecum possessed no lateral
closely approximated points of fixation about which a
attachments, permitting the cecum to lie in the left lower
relatively redundant mobile bowel may twist [9]. Well
quadrant. The transverse colon was extremely ptotic and
had twisted almost 360#{176}on its elongated mesentery. The separated points of fixation of the transverse colon at
transverse colon was gangrenous and never regained arterial the hepatic and splenic flexures make torsion, even in
pulsation following detorsion. Since the right colon and the presence of enteroptosis, practically impossible.
cecum appeared viable, a primary resection of the mid trans- Three types of underlying pathology have been incrimi-

Received February 2. 1 976; accepted after revision September 30. 1976.

I Department of Radiology, Medical Center Hospital of Vermont and the University of Vermont College of Medicine. Burlington, Vermont 05401.
Present address: Presbyterian University Hospital. University of Pittsburgh School of Medicine, Pittsburgh. Pennsylvania 1 5213. Address reprint requests
to N. A. Newton.
2 Department of Surgery. Medical Center Hospital of Vermont and the University of Vermont College of Medicine, Burlington, Vermont 05401.

Am J Ro.ntg.nol 128:69-72, January 1977 69

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70
NEWTON
AND
REINES
 TRANSVERSE COLON VOLVULUS 71

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Classical symptoms include crampy abdominal pain,

distention, constipation or obstipation, and vomiting.
Findings are often minimal at the onset, and symptoms
 72 NEWTON AND REINES

lasting for more than 24 hr are not uncommon. Physical REFERENCES

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amination. of 205 .cases. Sung Gynecol Obstet 96:677-682, 1953
3. Boley SJ: Volvulus of the transverse colon. Am J Sung
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Radiologic Diagnosis
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