The Lethal Twist A Story of Unspoken Pain: Small Intestinal Volvulus in Cerebral Palsy.

Abstract

Small intestinal volvulus (SBV) is the abnormal twisting of bowel around the axis of its mesentery, leading to obstruction and vascular compromise, resulting in bowel ischemia and necrosis which are life-threatening. Risk factors include malformation, malrotation, and adhesions. Its rare incidence and vague clinical presentation make it a difficult diagnosis, more so in a nonverbal patient who cannot express his pain, which is the first and most prominent symptom. Studies suggest an increased frequency of intestinal obstruction in cerebral palsy patients. There are no reported cases of small intestinal volvulus in association with cerebral palsy.We present a case of a 21-year-old man with severe cerebral palsy and kyphoscoliosis. The patient presented to the emergency room with respiratory distress and abdominal distension. An acute abdomen was noted. Abdominal X-rays revealed gas patterns suggestive of small intestinal obstruction. The patient rapidly deteriorated, and resuscitation attempts were unsuccessful.Autopsy revealed peritoneal cavity filled with extensively dilated and thin-walled loops of small intestine. Twisting of the small intestine, showing 360° rotation around the mesenteric root in a clockwise manner at two separate sites, was noted. On bowel dissection, mucosal folds were absent, and mucosa was green with patchy areas of hemorrhage consistent with ischemic necrosis. There was no evidence of any malformation, malrotation or adhesions.Small intestinal volvulus is a rare entity with a nonspecific clinical presentation that poses a diagnostic challenge. This autopsy highlights the need to maintain a high index of suspicion for small intestinal volvulus in cases of bowel obstruction in cerebral palsy patients to expedite surgery and prevent mortality. The primary caregivers of non-verbal cerebral palsy patients living outside of healthcare facilities need to be trained in recognition of life-threatening medical emergencies such as gastrointestinal obstruction and seek emergent attention at the earliest to prevent treatment delays.

Jejunal Volvulus Around Gastrostomy Tube: An Exceptional Complication in Cerebral Palsy

“…Patients with cerebral palsy seem to have an increased risk of volvulus [ 4 ], which might be related to immobility and gastrointestinal dysmotility. However, there have been a few reported cases of small bowel volvulus in patients with a PEG tube ( Table 1 ) [ 4 – 8 ].…”

“…Patients with cerebral palsy seem to have an increased risk of volvulus [ 4 ], which might be related to immobility and gastrointestinal dysmotility. However, there have been a few reported cases of small bowel volvulus in patients with a PEG tube ( Table 1 ) [ 4 – 8 ]. The first case of intestinal volvulus with a PEG tube was reported by Senac and Lee in 1983 in a girl with a previous abdominal surgery [ 5 ].…”

“…Second, patients with cerebral palsy often have associated anatomic deformities such as kyphoscoliosis, as in the present case, which may contribute to the difficulty in recognizing the volvulus through imaging. Hence, intestinal volvulus can be life threatening and fatal in these patients [ 4 , 15 ].…”

Tuberculous peritonitis in a cerebral palsy patient: A challenge in diagnosis and management

“…However, patients with CP often experience a delayed diagnosis due to nonspecific complaints and inability to clearly communicate their symptoms. This leads to increase morbidity and mortality in CP patients with acute abdomen conditions [[4], [5], [6]]. Although most patients with intraabdominal TB well respond to standard anti-TB medication [3], a situation of scarce information as described and the misdiagnosis of an acute abdomen condition had let the patient undergo an unnecessary exploration.…”

“…Although it is possible to diagnose TBP in a normal person, it is often difficult because of the disease’s non-specific symptoms and signs, which can include abdominal pain, ascites, weight loss, fever, and presence of history of TB infection earlier [3]. In a patient with cerebral palsy (CP), a condition comprising of delay of mental development, communication problems, and spastic muscular tone, the diagnosis of TBP does not seem to be possible, and may led to a delayed diagnosis, the misdiagnosis as surgical abdomen condition, or increased morbidity and mortality [[4], [5], [6]].…”