Sigmoid volvulus is a rare clinical condition in young individuals. It should be accurately diagnosed and treated in a rapid manner. Surgical and nonsurgical conservative methods are used for the treatment of sigmoid volvulus. Patients having no signs of perforation or peritonitis should be primarily treated by colonoscopic detorsion. A delay in the diagnosis and treatment of this condition may cause significant morbidity and mortality in an immunosuppressed patient with newly performed renal transplant and diffuse abdominal pain. This paper reports a young patient who was diagnosed with sigmoid volvulus during admission with sudden-onset abdominal pain and distension after having undergone renal transplant from a living donor 3 days previously. The patient avoided the burden of a second surgical intervention by a bedside endoscopic detorsion procedure.
Key words : Colonoscopy, Detorsion, Immunosuppression
Sigmoid volvulus, one of the causes of intestinal obstruction, should be diagnosed and treated at an early stage. It may lead to intestinal ischemia, necrosis, perforation, and diffuse peritonitis when a delay occurs in its diagnosis.1 Gastrointestinal symptoms or complications after renal transplant result in significantly increased morbidity and mortality.2,3 Here, we report a young patient who was diagnosed with sigmoid volvulus and treated with a colonoscopic detorsion procedure after being admitted with sudden-onset abdominal pain and distension 3 days after renal transplant from a living donor.
A 28-year-old woman with familial Mediterranean fever for 15 years and who had been receiving dialysis due to amyloidosis for 2 years underwent renal transplant from a living donor. The graft was taken from her sister and had 3 HLA mismatches. The recipient was given basiliximab before the operation. Postoperative immunosuppression was maintained with tacrolimus, mycophenolate mofetil, and corticosteroids. The recipient kidney, which had been retrieved by a laparoscopic technique, had a single renal artery, a single renal vein, and a ureter. Anastomoses were duly performed after the placement of the graft to the right iliac fossa. No surgical complications occurred during the early postoperative period. The patient's urine output and vital signs also had a stable course. Oral food intake was gradually started after the patient was able to pass stool and gas.
However, the patient developed sudden-onset abdominal pain and distension 3 days after the transplant procedure. On physical examination, she had diffuse abdominal tenderness and voluntary guarding. On auscultation, intestinal sounds were diminished and metallic sounds were heard. Rectal digital examination showed feces of a normal color. The results of hemogram and biochemical studies performed after the onset of her symptoms were as follows: white blood cell count of 4.8/μL, urea level of 20 mg/dL, creatinine level of 0.6 mg/dL, potassium concentration of 4.2 mmol/L, and C-reactive protein level of 45 mg/L. She had no history of another abdominal surgery. An upright plain abdominal radiogram revealed dilated colonic segments and omega loop and coffee bean appearances, particularly in the segment corresponding to the sigmoid colon, making the diagnosis of sigmoid volvulus prominent (Figure 1a). An abdominal ultrasonography showed free fluid in the abdominal cavity, but the patient had abdominal free fluid at the preoperative and intraoperative periods previously.
With the onset of symptoms, the patient’s urine output dropped to 10 cm3 per hour. The patient’s treatment included stopping oral intake. Despite the possibility that physical examination findings may have been masked, nonoperative techniques were primarily considered for the treatment of the condition. Rectum and colon were entered with a flexible colonoscope. No ischemia or necrosis was present on colonic mucosa. An endoscopic detorsion procedure was attempted with successful results. A plain abdominal radiograph taken after the procedure showed sigmoid colon with detorsion (Figure 1b). The patient’s physical examination findings and symptoms improved, and passage of gas and stool returned to normal.
No signs of recurrent obstruction were observed during early follow-up, and thus no surgical intervention was planned. During the patient’s treatment, despite the reduced urine output, no perfusion abnormality was detected in renal parenchymal and by Doppler ultrasonography examination. The patient was discharged with urea and creatinine levels within normal ranges.
Sigmoid volvulus is one of the most common causes of large intestinal obstruction in developing countries. It results from a closed obstruction brought about by a colonic segment rotating around its own mesentery.1 It is more common in older men with comorbidities and occurs quite rarely in younger people. Affected individuals mostly seek medical attention because of abdominal pain, bloating, nausea, vomiting, and inability to pass stool and gas.4
A long and mobile colonic segment with a narrow mesenteric base is considered the most important predisposing condition for volvulus. In addition, chronic constipation, colonic motility disorders, anatomic variations, megacolon, prolonged bed rest, aging, neuropsychiatric disorders, previous abdominal surgery, pregnancy, Chagas disease, Hirschsprung disease, and scleroderma have also been held responsible as causative factors.5 Sigmoid volvulus early after renal transplant is not a common complication, and no clear mechanisms to explain this occurrence or to describe it are available in the literature. Considering the young age of our patient, her clinical condition may be related to her primary disease, namely familial Mediterranean fever, although volvulus is a rare complication in younger patients. A more thorough anamnesis taken from our patient indicated that she previously had intermittent attacks of abdominal pain, none of which were associated with volvulus or a similar condition, and her symptoms abated with routine familial Mediterranean fever therapy at every episode.
The most important diagnostic tools used for volvulus include physical examination, plain abdominal radiographs, endoscopic examinations, computerized tomography, magnetic resonance imaging, and barium enema. Plain radiographs show air-fluid levels in dilated small intestinal loops; the “omega” and “coffee bean” signs of the overdistended colonic segments are present in about 30% of all volvulus cases and may suffice for the diagnosis. The treatment of volvulus consists of nonsurgical and surgical methods. The former methods include rectal tube placement, enema, and rigid or flexible endoscopic decompression. These techniques should be applied when there are no signs of necrosis or perforation. It is known that endoscopic decompression is the most efficient nonsurgical method.6
Surgical treatment methods performed in emergency situations are associated with higher rates of mortality and morbidity due to the presence of comorbid conditions, poor general status, and the inability to perform preoperative intestinal cleaning. For this reason, attempting nonsurgical methods first is more beneficial. In cases when nonsurgical methods fail, an urgent surgical intervention becomes inevitable.7 Although it has been reported that 76% to 89% of sigmoid volvulus cases are successfully detorsioned by endoscopic methods, recurrence rates can be as high as 21% to 57%. Therefore, it is recommended that sigmoid colon resection is performed under elective conditions after endoscopic detorsion.8
After renal transplant, patients become more prone to infections as a result of immunosuppressive therapy. It is also well known that the risk of infection can be high with colonic surgery. Impaired hemodynamic status due to a new operation and the underlying causes unfavorably affect the functions of a grafted kidney. Patients using immunosuppressants are more susceptible to intraperitoneal sepsis than individuals not on these agents.9 In this sense, we aimed to avoid a second surgical procedure as much as possible at an early stage after renal transplant. Although intensive immunosuppressive therapy would have masked any physical examination findings suggesting that perforation or peritonitis had developed, we opted for a colonoscopic detorsion procedure.
In conclusion, it is risky for a patient early after renal transplant to be exposed to a second surgical intervention. A bedside colonoscopic detorsion procedure can be successfully applied initially for the treatment of a young renal transplant patient with sigmoid volvulus when signs of necrosis or perforation are absent.
Volume : 16
Issue : 5
Pages : 611 - 613
DOI : 10.6002/ect.2015.0287
From the 1Health Sciences University, Mehmet Akif
İnan Training and Research Hospital, Clinic of General Surgery, Şanlıurfa,
Turkey; the 2Lokman Hekim Sincan Hospital, Clinic of General Surgery,
Ankara, Turkey; the 3Clinic of Gastroenterology and the 4Clinic
of Nephrology, Medical Park Ankara Hospital, Ankara, Turkey; the 5Koru
Ankara Hospital Clinic of Nephrology, Ankara, Turkey; and the 6Gazi
University Faculty of Medicine Department of General Surgery, Ankara, Turkey
Acknowledgements: The authors declare that they have no sources of funding for this study, and they have no conflicts of interest to declare.
Corresponding author: Mehmet Tolga Kafadar, Health Sciences University, Mehmet Akif İnan Training and Research Hospital, Clinic of General Surgery, 63300 Şanlıurfa, Turkey
Phone: +90 414 318 6000
Figure 1. Abdominal Radiograph Images Before and After Detorsion Procedure