sigmoid volvulus
Introduction
Introduction to sigmoid torsion The colonic hernia is partially or completely occluded by the rotation of the mesentery as a fixed point along the long axis of the mesentery, called volvulus. The torsion is generally clockwise, and the torsion can occur when the torsion is above 180°. The mild torsion can be less than 1 week (360°), and the heavy one can reach 2 to 3 weeks. On the one hand, intestinal stenosis and obstruction may occur on the one hand, and may be narrowed due to compression of the mesangial blood vessels. The sigmoid torsion is a closed intestinal obstruction. The twisted intestinal fistula often has a high degree of dilatation and expansion. When the intestinal wall expands excessively, spotted tonic necrosis or perforation may also occur. basic knowledge Sickness ratio: 0.0001% Susceptible people: no special people Mode of infection: non-infectious Complications: shock, colonic torsion
Cause
Cause of sigmoid torsion
Disease factors (25%):
On the basis of the above anatomical factors, such as pelvic inflammation, adhesion, scar formation, shortening of the sigmoid mesenteric root, swollen lymph nodes in the intestinal wall or mesentery, tumors, cysts, etc., may be the cause of the formation of torsion.
Colonic motility changes (30%):
Full meal, excessive fiber residue in the food, constipation, intestinal mites, congenital megacolon, etc., can increase the weight of the intestinal tract itself. Due to gravity, the posture posture suddenly changes, it is easy to reverse, and the laxative is abused. In patients with mental illness, abdominal trauma can cause peristalsis, long-term bedridden elderly, hypokalemia and other intestinal paralysis. Practice has proved that abnormal changes in intestinal motility are closely related to intestinal torsion.
Anatomical factors (35%):
The sigmoid colon is too long, and the sigmoid mesenteric attachment is short and narrow. The proximal and distal sides of the intestine are close to each other, and the intestinal fistula is highly active. This is an anatomical basis for easy torsion.
Pathogenesis
The sigmoid torsion can be clockwise or counterclockwise. The degree of influence of torsion on the blood circulation of the intestine depends mainly on the degree of torsion and the degree of tightness. For example, when the angle is 180°, the mesenteric circulation can be not narrowed, and only the rectum behind the sigmoid wall is affected. Compression and simple intestinal obstruction, when twisted more than 360 °, will cause strangulated closed intestinal obstruction, intestinal gas, fluid volume increased, sigmoid colon over-expansion due to torsion, initially venous blood flow stop, congestion The thrombosis further aggravates the circulatory disorder, and the arterial blood flow will also stop. The twisting of the intestinal tract becomes an ideal anaerobic environment. Within a few hours, the anaerobic bacteria and the aerobic bacteria can multiply at the same time, and the intestinal mucosal barrier function is destroyed. Increased permeability, bacteria in the intestine and some of its toxic substances, on the one hand can leak into the abdominal cavity and absorbed into the blood, on the other hand can directly invade the portal system, bacteremia and toxemia, and eventually die from infection Sexual and hypovolemic mixed shock.
Chronic torsion has a recurrent episode, which can be naturally recovered without obvious blood circulation.
Prevention
Sigmoid colon torsion prevention 1. Adjust daily life and workload, and regularly carry out activities and exercise to avoid fatigue. 2. Maintain emotional stability and avoid emotional excitement and tension. 3. Keep the stool smooth, avoid using stools, eat more fruits and high-fiber foods. 4. Avoid cold irritation and keep warm.
Complication
Sigmoid torsion complications Complications, shock, colonic torsion
Acute sigmoid torsion often accompanied by intestinal necrosis or perforation, clinical manifestations of acute abdomen symptoms.
Symptom
Sigmoid torsion symptoms Common symptoms Defecation disorder Abdominal pain with nausea, vomiting, bloating, fecal impaction, fecal vomit, intussusception shock
Sigmoid colon torsion has a history of chronic constipation, with abdominal pain and progressive bloating as the main clinical manifestations, according to the urgency of the disease can be divided into subacute and acute fulminant.
1. Subacute type: common, accounting for 75% to 85% of sigmoid torsion, mostly elderly patients, slow onset, past history of irregular abdominal pain and disappearance of abdominal pain after defecation and exhaustion, the main symptoms are middle and lower Persistent abdominal pain, paroxysmal aggravation, no defecation and exhaust; nausea, vomiting, but less vomiting, late vomiting with fecal odor, progressive abdominal distension.
Physical examination: the patient is generally in good condition, the abdomen is obviously inflated, and the abdominal distension is asymmetry. The left side is even worse. Except for intestinal necrosis, the abdomen has only mild tenderness, no obvious peritoneal irritation, and sometimes can be touched with tenderness. Sexual mass, auscultation with high-pitched bowel sounds or gas over water.
Older patients or those with weak constitution may have shock performance when the course of disease is long.
2. Acute type: rare, more common in young people, acute onset, rapid development of the disease, typical low intestinal obstruction, severe abdominal pain, diffuse pain in the whole abdomen; vomiting occurs early and frequent, due to massive fluid loss, patients Prone to shock.
Physical examination: bloating is lighter than subacute, and the peritoneal irritation sign is obvious. There are tenderness and rebound tenderness in the whole abdomen, abdominal muscle tension is obvious, and bowel sounds disappear, suggesting that intestinal necrosis may occur.
Examine
Sigmoid colon torsion examination
X-ray inspection
(1) Abdominal X-ray film: It can be seen that the large abdomen of the abdomen is obviously inflated by the left abdomen, and the pelvic cavity reaches the middle and upper abdomen, and even reaches the armpit, occupying most of the abdominal cavity, forming a so-called "bending tube" sign in the huge sigmoid colon. In the intestinal fistula, two liquid-vapor surfaces in different planes are often seen, and the left and right colons and the small intestine have different degrees of flatulence.
(2) barium enema: the barium is blocked at the junction of the rectosigmoid colon, the tip of the mast is conical or bird's beak, and the capacity of the enema is often less than 500ml (normally can be filled above 2000), and it flows out, ie It can be proved that there is obstruction in the sigmoid colon. This test is only suitable for cases of early torsion with better general condition. When there is obvious peritoneal irritation or abdominal tenderness, the barium enema examination is contraindicated, otherwise there is a risk of intestinal perforation.
2. Sigmoidoscopy.
3. The hypobaric saline enema experiment was filled with physiological saline <500ml, which can prove the torsion obstruction in the sigmoid colon.
Diagnosis
Sigmoid colon torsion diagnosis
diagnosis
Chronic constipation, there have been multiple abdominal pains in the past, the onset of rapid onset, typical low intestinal obstruction, such as left lower abdominal cramps, abdominal distension, vomiting, etc., suspected sigmoid torsion, physical examination showed obvious abdominal distension, left lower abdomen To the twisted bowel, etc.; X-ray plain film sees a large flatulent torsion sigmoid colon, sputum enema shows that the tincture is blocked at the torsion, or a "bird's beak"-like deformity, or a constricted stenosis can be clearly diagnosed.
Differential diagnosis
Acute sigmoid torsion combined with intestinal necrosis or perforation, need to be differentiated from peptic ulcer perforation, acute pancreatitis, etc., often need emergency surgery.
