Case Report
Eurasian J Med 2015; 47: 75-6
Sigmoid Volvulus Complicating Pregnancy: A Case Report Gebelik ile Komplike Sigmoid Volvulus: Olgu Sunumu Sabri Selcuk Atamanalp1, Abdullah Kisaoglu1, Bunyami Ozogul1, Mecit Kantarci2, Esra Disci1, O. Hakan Bulut1, Nurhak Aksungur1, Refik Selim Atamanalp3 Department of General Surgery, Ataturk University Faculty of Medicine, Erzurum, Turkey Department of Radiology, Ataturk University Faculty of Medicine, Erzurum, Turkey 3 Ataturk University Faculty of Medicine, Erzurum, Turkey 1 2
Abstract
Özet
Sigmoid volvulus during pregnancy is a rare complication, and as of 2012, fewer than 100 cases had been reported. In this report, we present a 30 year-old pregnant woman with sigmoid volvulus, and we discuss this rare entity.
Gebelikte sigmoid volvulus nadir bir komplikasyondur ve 2012’ye kadar 100’den az bildirilmiştir. Bu yazıda, 30 yaşında sigmoid volvuluslu bir gebe bayanı sunmakta ve nadir durumu tartışmaktayız.
Keywords: Sigmoid colon, volvulus, pregnancy
Introduction Sigmoid volvulus (SV) during pregnancy is a rare complication, and as of 2012, fewer than 100 cases had been reported in the literature [1]. The disease is generally presented as a bowel obstruction, and the physiologic symptoms of pregnancy may cloud the clinical picture [1, 2]. Laboratory findings are not pathogonomic, X-ray is generally avoided, and ultrasonography is helpful providing information about foetus [1, 3]. The treatment requires a multidisciplinary approach, and surgical intervention is frequently needed [1, 4]. The prognosis of SV is relatively poor [1]. In this report, we present a 30 year-old pregnant woman with SV, who is the tenth pregnant SV case of our 974-total and 175-female patient series over a 48-year period between June 1966 and June 2014.
Case Report A 30 year-old female patient with a two-day history of abdominal pain, distension, obstipation, nausea, and vomiting was admitted to the hospital. She had a 16 weekpregnancy, and she was multiparous. Clinical examination demonstrated a distended tender abdomen with hypokinetic bowel sounds. Laboratory tests revealed an increased leucocyte count. Abdominal ultrasonography showed a 16 weekhealthy foetus. Abdominal MRI demonstrated whirl sign in Received: October 14, 2014 / Accepted: October 18, 2014
Anahtar Kelimeler: Sigmoid kolon, volvulus, gebelik
sigmoid mesentery with enlarged sigmoid segments as well as small intestines (Figure 1). Flexible sigmoidoscopy showed bowel ischemia and necrosis in torsioned sigmoid colon. An urgent laparotomy was performed after resuscitation. Operative findings demonstrated a volvulus in sigmoid colon with gangrene. After the resection of sigmoid colon, an endto-end anastomosis was performed. The patient revealed an uneventful recovery. Histopathologic examination reported acute gangrenous colitis.
Discussion Although intestinal obstruction during pregnancy is a rare complication with an incidence ranging from 1 in 1500 to 1 in 66431 deliveries, sigmoid volvulus (SV) is the first or second most common cause of intestinal obstruction complicating pregnancy [1, 5]. Affected women are generally 15 to 35 years of age, nearly 75% of them are multiparous, and approximately 66% are in the third trimester [1, 2, 4, 5]. Typical symptoms of SV in pregnancy are intermittent and severe abdominal pain, distention, and obstipation, which are known as SV triad, and additionally nausea and vomiting, while the common signs are abdominal tenderness, distention, hyperkinetic or hypo/akinetic bowel sounds, and empty rectum [1, 2, 4, 6]. Although abdominal pain, nausea, and vomiting, which are the physiologic findings of pregnancy, are generally thought to cloud the clinical picture [1, 6], in
Correspondence to: Sabri Selcuk Atamanalp, Department of General Surgery, Ataturk University Faculty of Medicine, 25040, Erzurum, Turkey Phone: +90 532 655 50 00 e-mail: [email protected] ©Copyright 2015 by the Atatürk University School of Medicine - Available online at www.eajm.org DOI:10.5152/eajm.2014.0105
76
Atamanalp et al. Sigmoid Volvulus Complicating Pregnancy
Eurasian J Med 2015; 47: 75-6
patients with peritonitis, bowel gangrene, or unsuccessful nonoperative detorsion. In gangrenous cases, the nonviable sigmoid colon is resected and a diverting colostomy, or preferably a primary anastomosis is added, while detorsion is preferred as a sole procedure in non-gangrenous patients [1, 2, 7, 10]. The prognosis is poor with a 6% to 12% of maternal mortality and a 20% to 26% of foetal mortality [1, 5, 6]. Ethics Committee Approval: Ethics committee approval was received for this study from the local ethics committee of Atatürk University Faculty of Medicine Informed Consent: Written informed consent was obtained from the patient who participated in this case. Peer-review: Externally peer-reviewed. Author Contributions: Concept - S.S.A.; Design - S.S.A., M.K.; Supervision - S.S.A., A.K., B.O., M.K., R.S.A.; Funding - S.S.A., E.D., O.H.B., N.A.; Materials - S.S.A., M.K.; E.D., O.H.B., N.A.; Data Collection and/or Processing - S.S.A., M.K.; E.D., O.H.B., N.A.; Analysis and/or Interpretation - S.S.A., A.K., B.O., M.K.; Literature Review - S.S.A., A.K., B.O., R.S.A.; Writing - S.S.A., A.K., B.O., R.S.A.; Critical Review - S.S.A., A.K., B.O., M. K.; Other - S.S.A., E.D., O.H.B., N.A. Conflict of Interest: No conflict of interest decleared by the authors.
Figure 1. Coronal T2 Weighted MRI image shows dilated intestinal loops (stars) and foetus (F).
our experience, abdominal pain in SV is severe, and nausea and vomiting are not prominent symptoms in the second and third trimesters of pregnancy. The laboratory findings are not pathognomonic in pregnant SV cases [1, 4]. Although a single plain abdominal X-ray may be used in necessary cases [1, 3], it is generally avoided because of the radiation risk of foetus [1]. Abdominal and obstetric ultrasonography may provide information about the foetus, in addition to eliminating other pathologies [7]. Nevertheless, a nonspecific clinical diagnosis of intestinal obstruction is generally made, unless MRI or flexible endoscopy is used [1, 8, 9], as was in our case. The management of SV in pregnancy requires a collaboration of general surgeons, obstetricians, and neonatologists in addition to a proper resuscitation [1, 7]. The usage of the tocolytics for uterine stability or steroids for foetal lung maturity, as well as the pursuance of the delivery or caesarean procedure in mature cases, or abortion in patients with a dead foetus are dependent on maternal and foetal conditions [1]. Although flexible endoscopic detorsion is occasionally unsuccessful because of the enlarged uterus acts as a mechanical impediment [3, 4, 7], it seems reasonable to attempt the non-operative detorsion as the initial treatment [1]. Emergency surgery is required for the
Financial Disclosure: The authors decleared that this study has received no financial support.
References 1. 2.
3. 4. 5. 6.
7.
8. 9.
10.
Atamanalp SS, Ozturk G. Sigmoid volvulus in pregnancy. Turk J Med Sci 2012; 42: 9-15. Narjis Y, El Mansouri MN, Jgounni R, Louzi A, Abassi H, Soumani A, et al. Sigmoid volvulus, a rare complication of pregnancy. Gynecol Obstet Fert 2008; 36: 776-8. [CrossRef] Hofmeyr GJ, Sonnendecker EWW. Sigmoid volvulus in advanced pregnancy. Report of 2 cases. S Afr Med J 1985; 67: 63-4. De U, De KK. Sigmoid volvulus complicating pregnancy. Indian J Med Sci 2005; 59: 317-9. [CrossRef] Perdue PW, Johnson HW Jr, Stafford PW. Intestinal obstruction during pregnancy. Am J Surg 1992; 164: 384-8. [CrossRef] Alshawi JS. Recurrent sigmoid volvulus in pregnancy: report of a case and review of the literature. Dis Colon Rectum 2005; 48: 1811-3. [CrossRef] Vo TM, Gyaneshwar R, Mayer C. Concurrent sigmoid volvulus and herniation through broad ligament defect during pregnancy: case report and literature review. J Obstet Gynaecol 2008; 34: 658-62. Atamanalp SS. Sigmoid volvulus: diagnosis in 938 patients over 45.5 years. Tech Coloproctol 2013; 17: 419-24. [CrossRef] Atamanalp SS, Kantarcı M, Aydınlı B, et al. The diagnostic efficiency of CT and MRI in ileosigmoid knotting. Turk J Med Sci 2014; 44: 1134-5. [CrossRef] Atamanalp SS. Treatment of sigmoid volvulus: a single-center experience of 952 patients over 46.5 years. Tech Coloproctol 2013; 17: 561-9. [CrossRef]
Copyright of Eurasian Journal of Medicine is the property of Aves Yayincilik Ltd. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Eurasian J Med 2015; 47: 75-6
Sigmoid Volvulus Complicating Pregnancy: A Case Report Gebelik ile Komplike Sigmoid Volvulus: Olgu Sunumu Sabri Selcuk Atamanalp1, Abdullah Kisaoglu1, Bunyami Ozogul1, Mecit Kantarci2, Esra Disci1, O. Hakan Bulut1, Nurhak Aksungur1, Refik Selim Atamanalp3 Department of General Surgery, Ataturk University Faculty of Medicine, Erzurum, Turkey Department of Radiology, Ataturk University Faculty of Medicine, Erzurum, Turkey 3 Ataturk University Faculty of Medicine, Erzurum, Turkey 1 2
Abstract
Özet
Sigmoid volvulus during pregnancy is a rare complication, and as of 2012, fewer than 100 cases had been reported. In this report, we present a 30 year-old pregnant woman with sigmoid volvulus, and we discuss this rare entity.
Gebelikte sigmoid volvulus nadir bir komplikasyondur ve 2012’ye kadar 100’den az bildirilmiştir. Bu yazıda, 30 yaşında sigmoid volvuluslu bir gebe bayanı sunmakta ve nadir durumu tartışmaktayız.
Keywords: Sigmoid colon, volvulus, pregnancy
Introduction Sigmoid volvulus (SV) during pregnancy is a rare complication, and as of 2012, fewer than 100 cases had been reported in the literature [1]. The disease is generally presented as a bowel obstruction, and the physiologic symptoms of pregnancy may cloud the clinical picture [1, 2]. Laboratory findings are not pathogonomic, X-ray is generally avoided, and ultrasonography is helpful providing information about foetus [1, 3]. The treatment requires a multidisciplinary approach, and surgical intervention is frequently needed [1, 4]. The prognosis of SV is relatively poor [1]. In this report, we present a 30 year-old pregnant woman with SV, who is the tenth pregnant SV case of our 974-total and 175-female patient series over a 48-year period between June 1966 and June 2014.
Case Report A 30 year-old female patient with a two-day history of abdominal pain, distension, obstipation, nausea, and vomiting was admitted to the hospital. She had a 16 weekpregnancy, and she was multiparous. Clinical examination demonstrated a distended tender abdomen with hypokinetic bowel sounds. Laboratory tests revealed an increased leucocyte count. Abdominal ultrasonography showed a 16 weekhealthy foetus. Abdominal MRI demonstrated whirl sign in Received: October 14, 2014 / Accepted: October 18, 2014
Anahtar Kelimeler: Sigmoid kolon, volvulus, gebelik
sigmoid mesentery with enlarged sigmoid segments as well as small intestines (Figure 1). Flexible sigmoidoscopy showed bowel ischemia and necrosis in torsioned sigmoid colon. An urgent laparotomy was performed after resuscitation. Operative findings demonstrated a volvulus in sigmoid colon with gangrene. After the resection of sigmoid colon, an endto-end anastomosis was performed. The patient revealed an uneventful recovery. Histopathologic examination reported acute gangrenous colitis.
Discussion Although intestinal obstruction during pregnancy is a rare complication with an incidence ranging from 1 in 1500 to 1 in 66431 deliveries, sigmoid volvulus (SV) is the first or second most common cause of intestinal obstruction complicating pregnancy [1, 5]. Affected women are generally 15 to 35 years of age, nearly 75% of them are multiparous, and approximately 66% are in the third trimester [1, 2, 4, 5]. Typical symptoms of SV in pregnancy are intermittent and severe abdominal pain, distention, and obstipation, which are known as SV triad, and additionally nausea and vomiting, while the common signs are abdominal tenderness, distention, hyperkinetic or hypo/akinetic bowel sounds, and empty rectum [1, 2, 4, 6]. Although abdominal pain, nausea, and vomiting, which are the physiologic findings of pregnancy, are generally thought to cloud the clinical picture [1, 6], in
Correspondence to: Sabri Selcuk Atamanalp, Department of General Surgery, Ataturk University Faculty of Medicine, 25040, Erzurum, Turkey Phone: +90 532 655 50 00 e-mail: [email protected] ©Copyright 2015 by the Atatürk University School of Medicine - Available online at www.eajm.org DOI:10.5152/eajm.2014.0105
76
Atamanalp et al. Sigmoid Volvulus Complicating Pregnancy
Eurasian J Med 2015; 47: 75-6
patients with peritonitis, bowel gangrene, or unsuccessful nonoperative detorsion. In gangrenous cases, the nonviable sigmoid colon is resected and a diverting colostomy, or preferably a primary anastomosis is added, while detorsion is preferred as a sole procedure in non-gangrenous patients [1, 2, 7, 10]. The prognosis is poor with a 6% to 12% of maternal mortality and a 20% to 26% of foetal mortality [1, 5, 6]. Ethics Committee Approval: Ethics committee approval was received for this study from the local ethics committee of Atatürk University Faculty of Medicine Informed Consent: Written informed consent was obtained from the patient who participated in this case. Peer-review: Externally peer-reviewed. Author Contributions: Concept - S.S.A.; Design - S.S.A., M.K.; Supervision - S.S.A., A.K., B.O., M.K., R.S.A.; Funding - S.S.A., E.D., O.H.B., N.A.; Materials - S.S.A., M.K.; E.D., O.H.B., N.A.; Data Collection and/or Processing - S.S.A., M.K.; E.D., O.H.B., N.A.; Analysis and/or Interpretation - S.S.A., A.K., B.O., M.K.; Literature Review - S.S.A., A.K., B.O., R.S.A.; Writing - S.S.A., A.K., B.O., R.S.A.; Critical Review - S.S.A., A.K., B.O., M. K.; Other - S.S.A., E.D., O.H.B., N.A. Conflict of Interest: No conflict of interest decleared by the authors.
Figure 1. Coronal T2 Weighted MRI image shows dilated intestinal loops (stars) and foetus (F).
our experience, abdominal pain in SV is severe, and nausea and vomiting are not prominent symptoms in the second and third trimesters of pregnancy. The laboratory findings are not pathognomonic in pregnant SV cases [1, 4]. Although a single plain abdominal X-ray may be used in necessary cases [1, 3], it is generally avoided because of the radiation risk of foetus [1]. Abdominal and obstetric ultrasonography may provide information about the foetus, in addition to eliminating other pathologies [7]. Nevertheless, a nonspecific clinical diagnosis of intestinal obstruction is generally made, unless MRI or flexible endoscopy is used [1, 8, 9], as was in our case. The management of SV in pregnancy requires a collaboration of general surgeons, obstetricians, and neonatologists in addition to a proper resuscitation [1, 7]. The usage of the tocolytics for uterine stability or steroids for foetal lung maturity, as well as the pursuance of the delivery or caesarean procedure in mature cases, or abortion in patients with a dead foetus are dependent on maternal and foetal conditions [1]. Although flexible endoscopic detorsion is occasionally unsuccessful because of the enlarged uterus acts as a mechanical impediment [3, 4, 7], it seems reasonable to attempt the non-operative detorsion as the initial treatment [1]. Emergency surgery is required for the
Financial Disclosure: The authors decleared that this study has received no financial support.
References 1. 2.
3. 4. 5. 6.
7.
8. 9.
10.
Atamanalp SS, Ozturk G. Sigmoid volvulus in pregnancy. Turk J Med Sci 2012; 42: 9-15. Narjis Y, El Mansouri MN, Jgounni R, Louzi A, Abassi H, Soumani A, et al. Sigmoid volvulus, a rare complication of pregnancy. Gynecol Obstet Fert 2008; 36: 776-8. [CrossRef] Hofmeyr GJ, Sonnendecker EWW. Sigmoid volvulus in advanced pregnancy. Report of 2 cases. S Afr Med J 1985; 67: 63-4. De U, De KK. Sigmoid volvulus complicating pregnancy. Indian J Med Sci 2005; 59: 317-9. [CrossRef] Perdue PW, Johnson HW Jr, Stafford PW. Intestinal obstruction during pregnancy. Am J Surg 1992; 164: 384-8. [CrossRef] Alshawi JS. Recurrent sigmoid volvulus in pregnancy: report of a case and review of the literature. Dis Colon Rectum 2005; 48: 1811-3. [CrossRef] Vo TM, Gyaneshwar R, Mayer C. Concurrent sigmoid volvulus and herniation through broad ligament defect during pregnancy: case report and literature review. J Obstet Gynaecol 2008; 34: 658-62. Atamanalp SS. Sigmoid volvulus: diagnosis in 938 patients over 45.5 years. Tech Coloproctol 2013; 17: 419-24. [CrossRef] Atamanalp SS, Kantarcı M, Aydınlı B, et al. The diagnostic efficiency of CT and MRI in ileosigmoid knotting. Turk J Med Sci 2014; 44: 1134-5. [CrossRef] Atamanalp SS. Treatment of sigmoid volvulus: a single-center experience of 952 patients over 46.5 years. Tech Coloproctol 2013; 17: 561-9. [CrossRef]
Copyright of Eurasian Journal of Medicine is the property of Aves Yayincilik Ltd. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
