Primary Small Bowel Volvulus

Abstract

A t laparotomy, 2 L of ascites was suctioned out and the entire intraperitoneal small bowel was found to be ischemic. Volvulus of the smallbowel mesentery was the etiologic factor (the 71-yearold patient had a congenital malrotation). The smallbowel mesentery was detorsed in a counterclockwise fashion, resulting in an immediate change from ischemic (purple) bowel to a normal appearance with almost immediate restoration of peristalsis. Adhesiolysis was performed on a band connecting a proximal loop of jejunum, restoring its blood supply. Lysis of bands lateral to the cecum and ascending colon was undertaken. The retrocecal appendix and base of the cecum were above the level of the umbilicus; appendectomy and cecopexy were performed.Small-bowel mesenteric volvulus in patients with congenital malrotation is a rare cause of intestinal ischemia in adults. Midgut volvulus is most commonly seen in neonates, and it is a surgical emergency. Embryologically, malrotation occurs when the fetal midgut returns to the abdominal cavity at about 10 to 12 weeks; normally, there is a 270°counterclockwise rotation, but this is arrested at varying degrees in malrotation. Ladd bands can occur across the duodenum, sometimes resulting in obstruction. 1 On computed tomographic scan, a swirl pattern is often seen. In Figure 1, tissue is seen rotating around the superior mesenteric artery. In Figure 2, a twisting of the small bowel mesentery is demonstrated. Because the location of the appendix is abnormal, appendectomy is performed to prevent future diagnostic uncertainty.In this patient, there is a possibility that her diet contributed to her condition. Duke and Yar 2 reported that there was a "striking increase in the frequency" of primary small-bowel volvulus in Afghani Muslim men during Ramadan. This was hypothesized to be secondary to high fiber intake following fasting.

Abrupt Vomiting and Pain With Abdominal Mass

“…Cases of SBV involving a jejunal diverticulum have been reported more often in Asia than in the West. [5][6][7] The incidence of diverticulum of the jejunum may be high in Asia. It is reported that small-bowel diverticulum in older people is an independent risk factor for SBV, 8 and large diverticulum of the small bowel, in particular, might play a contributing role in the occurrence of SBV in adults.…”

Novel Operative Management of Primary Mesenteric Volvulus

“…World-wide the prevalence has ranged from 5% in the United States to 51% in India [2, 3]. It is uncommon in most affluent countries but is one of the most common acute surgical problems encountered among certain African, Asian and Middle Eastern nations [4]where in some series the majority of cases present as idiopathic ones [5]and where it can reach 13% of all patients with small bowel obstruction [6]. …”

Primary volvulus of the small intestine in an adult, and review of 15 other cases from the Japanese literature

“…1 Reports of primary volvulus of the small intestine are rare in Western Europe and the United States, but this condition is one of the more common surgical emergencies in Central Africa, India, and the Middle East. 1-3 Duke and Yar 1 suggested that the high incidence in Afghanistan was related to abrupt changes in dietary intake at Ramadan (the yearly festival when Muslims fast from sunrise to sunset for 1 month).…”

“…1-3 Duke and Yar 1 suggested that the high incidence in Afghanistan was related to abrupt changes in dietary intake at Ramadan (the yearly festival when Muslims fast from sunrise to sunset for 1 month). 1 They suggested that the absence of food during daylight hours and the consumption of a single, large, high-fiber meal at night was related to the high incidence of this disease during the festival. In Japan, reports of primary volvulus of the small intestine are very rare; in our search of the Japanese literature, we found only 15 reported cases.…”

“…1 Primary volvulus of the small intestine is one of the more 360° clockwise mesenteroaxic torsion. Reduction of the torsion demonstrated strangulation of the intestine from 200 cm anal to the Treitz ligament to 5 cm oral to the terminal ileum, but there was no anatomical abnormality in the entire intestine nor was there any fibrous adhesion caused by the previous operation.…”