Primary Segmental Volvulus of Small Intestine: Surgical Perspectives According to Age at Diagnosis

Abstract

Background: Small intestinal volvulus often occurs with malrotation. However, in some cases, it could develop without any other clinical conditions, and this is called primary segmental volvulus (PSV) of the small intestine. Two types of PSV (early and late neonatal) have been described previously, especially in preterms. Moreover, there were other cases occurring beyond the neonatal period. Methods: The medical records of 14 cases definitively identified as PSV were retrospectively reviewed. The patients were divided into 2 groups according to postnatal age at diagnosis: neonatal group and beyond neonatal group. Then, the 2 groups were compared in terms of clinical features. Results: There were 11 patients in the neonatal group (78.6%) and 3 patients in the beyond neonatal group (21.4%). There were no differences in gestational age, birth weight, and ratio of prematurity. In the neonatal group, the antenatal abnormal sonographic findings were found more frequently and the perforation of the involved segment were relatively common. Meanwhile, the involved segment was confined to the ileum and more commonly associated with mesentery change in the beyond neonatal group. There was no mortality. Conclusion: The 2 clinical types of PSV according to postnatal age at diagnosis show some differences in clinical features. Moreover, PSV should be considered a possible cause of surgical problems beyond the neonatal period.

Primary Segmental Small Bowel Volvulus in an Adolescent Female

“…3 Information about segmental SBV in schoolage children and adolescents is especially scarce and derived mostly from single case reports and small case series, which have usually featured children younger than 5 and older than 15 years. 3,[6][7][8][9][10] Clinical diagnosis of segmental SBV is challenging due to its nonspecific presentation. 2 Whereas in neonates, abdominal distension, and bilious vomiting are common signs of midgut volvulus as well as segmental volvulus, signs of intestinal obstruction may be present but are not obligatory in older children and adults.…”

“…The diagnostic "whirlpool sign" in color Doppler ultrasound (wrapping of the superior mesenteric vein and the mesentery around the SMA) offers a high specificity for midgut volvulus, but as in our case, it is not usually present in segmental SBV. 6,12 In adult patients, abdominal computed tomography (CT) is the preferred imaging modality for small bowel obstruction (with sensitivities over 96% and specificities up to 100%) and suspected SBV, as it may show specific signs of volvulus (the "whirlpool" spiral appearance of the mesenteric vessels) as well as signs of obstruction and intestinal ischemia. MRI can provide conclusive evidence of volvulus without the risks of ionizing radiation and is an alternative to CT in children.…”

“…The decision to perform a primary anastomosis versus a staged operation of segmental resection with ileostomy is not only an individual one but also depends on the patient ̀s age at presentation. 6 Initial assessments of bowel viability based on clinical signs like discoloration of bowel and motility have shown to be imprecise. 16 In the presence of longer bowel segments of questionable viability, temporary closure and reevaluation in a second-look operation after 24 to 48 hours may allow for the preservation of as much bowel as possible.…”

“… 3 Information about segmental SBV in school-age children and adolescents is especially scarce and derived mostly from single case reports and small case series, which have usually featured children younger than 5 and older than 15 years. 3 6 7 8 9 10 …”

“… 2 Whereas in neonates, abdominal distension, and bilious vomiting are common signs of midgut volvulus as well as segmental volvulus, signs of intestinal obstruction may be present but are not obligatory in older children and adults. 6 7 Abdominal pain is the earliest and most common symptom and may be colicky or steady. The onset of acute symptoms may be preceded by colicky epigastric pain several days before, as seen in this case.…”