American Journal of Emergency Medicine 32 (2014) 491.e1–491.e2
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Sigmoid volvulus in pregnancy: early diagnosis and intervention are important☆,☆☆ Abstract Bowel obstruction is rare in pregnancy, and delay in recognition can lead to serious maternal and fetal complications. Most reported causes of bowel obstruction in pregnancy (adhesions, intussusception, hernia, and carcinoma) require surgical intervention. Sigmoid volvulus is an acute surgical cause that can now be managed successfully without surgery. We report the case of 33-year-old lady who presented with a sigmoid volvulus that was successfully managed with urgent endoscopic decompression. Gastrointestinal symptoms are common during pregnancy, but bowel obstruction is considered rare. The reported incidence of bowel obstruction occurring during pregnancy ranges from 1 in 1500 to 1 in 66 431 deliveries [1,2]. Delay in the diagnosis and treatment of bowel obstruction in pregnancy can lead to serious maternal and fetal complications [3]. Most reported causes of bowel obstruction in pregnancy (adhesions, intussusception, hernia, and carcinoma) require surgical intervention. Sigmoid volvulus, a less common cause of bowel obstruction, can be managed successfully without surgery. Early diagnosis and decompression are important to avoid progression to bowel ischemia. A 33-year-old (G7 P5+1) lady of 26th week gestation presented with a 1-day history of increasing abdominal pain and distension. On the day of presentation, she complained of nausea and vomiting and not passing flatus. She had experienced a similar episode a few weeks previously but with milder symptoms that had spontaneously resolved. She had a long history of constipation and typically opened her bowels only once to twice a week. She had no previous surgery history. On examination, she was of low body mass index. She was afebrile, moderately dehydrated, and mildly hypotensive (blood pressure 96/69 mm Hg) but with a normal pulse rate. Her abdomen was distended, tympanic, and mildly tender to palpation, but without guarding. There were visible peristalsis, and bowel sounds were sluggish. In view of her pregnancy, abdominal radiography was not performed. At this point, a clinical diagnosis of bowel obstruction was inferred, and she was referred to the on-call surgeon and gynecologist. Rectal examination was empty with no palpable mass. Per vagina examination was unremarkable, with a long cervix and the os closed. Pelvic ultrasound by the attending gynecologist showed a viable fetus. Routine laboratory investigations revealed elevated white blood cell of 18.7 × 10 9/L and elevated urea and creatinine. Serum potassium was normal. Other investigations including liver profile, serum amylase, and blood
☆ Conflict of interest: None for all authors. ☆☆ Financial declaration: None for all authors. 0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
glucose were all normal. Without any further imaging, the level of bowel obstruction remained uncertain. After discussion between the surgeon, gynecologist, and gastroenterologist, the decision was to proceed with an abdominal radiograph. This was discussed with the on-call radiologist, which revealed dilated large bowel with abnormal gas pattern with a coffee bean appearance, pathognomic of a sigmoid volvulus (Fig. A). The patient underwent an urgent flexible sigmoid decompression without sedation using a gastroscope (diameter, 9.2 mm). The sigmoid was grossly dilated with liquid stool, and on retroflexion of the scope (Fig. B), a twist was evident. The colon was decompressed, and the sigmoid volvulus was devolved with immediate relief of symptoms. She remained well and was discharged several days later. Unfortunately, her volvulus reoccurred, and she represented at 35-week gestation and was immediately decompressed endoscopically. She was maintained on a stool softener, remained well on follow-up, and delivered without any complication. She was later planned for a sigmoid colectomy. Although considered rare, sigmoid volvulus is the second most common cause of intestinal obstruction in pregnancy after adhesions, accounting for between 25% and 44% of the cases [2,4,5]. To date, there have been less than 90 cases reported in the literature. The mechanism of sigmoid volvulus in pregnancy is postulated to be due to displacement of an abnormally mobile sigmoid colon by the enlarging uterus. Being pushed out of the pelvis, the mobile sigmoid can easily twist around its mesocolon fixation point, which is usually long in patients with constipation [2]. Volvulus of the other parts of the colon and the small bowel have also been reported but are less common [6-8]. The diagnosis of sigmoid volvulus should be suspected when a pregnant patient presents with a clinical triad of abdominal pain, distension, and absolute constipation. However, these classical signs are often diminished or absent. This often leads to a delay in diagnosis. This is further compounded by delay in presentation and reluctance of clinicians to do any radiologic investigations for fear of radiation exposure to the fetus. The radiation dose to the fetus from a plain abdominal radiograph only averages 0.1 to 0.3 rads (should give dose in mSv—its 0.7 mSv), and this is below the radiation dose associated with adverse effects. Early diagnosis is paramount as delay will lead to bowel complications, such as ischemia, necrosis, perforation, and potentially fatal outcomes for both fetus and mother. The mainstay of treatment in reported cases has been surgery [2,9]. However, these cases were complicated either due to delayed presentations or diagnosis. Endoscopy is both a diagnostic and a therapeutic modality, not just in sigmoid volvulus, but also for volvulus affecting the other parts of the bowel [8]. However, endoscopy during the third trimester is associated with a risk of premature labor. Use of a smaller caliber endoscope as in our case a
491.e2
A. Ahmad et al. / American Journal of Emergency Medicine 32 (2014) 491.e1–491.e2
Fig. A, Abdominal radiograph showing dilated large bowel with a “coffee bean” sign, sigmoid consistent with a sigmoid volvulus. B, A retroflexed endoscopic image showing the twist in the sigmoid.
gastroscope, which is also more flexible, is safe and was well tolerated without sedation. As the risk of volvulus recurrence is high even in the nonpregnant state, the patient should undergo definitive treatment typically sigmoid colectomy. In conclusion, sigmoid volvulus complicating pregnancy is rare. Diagnosis requires a high index of suspicion, and hesitancy in obtaining radiologic investigation often contributes to delay. Delay in diagnosis and treatment can results in increased fetal and maternal morbidity and mortality. Anis Ahmad, MBBS Department of General Surgery RIPAS Hospital Bandar Seri Begawan BA 1710 Brunei Darussalam Koh Kai Shing, MBBS Department of Accident and Emergency Bandar Seri Begawan BA 1710 Brunei Darussalam Khim Khee Tan, MBChB, FRCS Department of General Surgery RIPAS Hospital Bandar Seri Begawan BA 1710 Brunei Darussalam Mary Krasu, FRCOG Department of Obstetrics and Gynaecology RIPAS Hospital Bandar Seri Begawan BA 1710 Brunei Darussalam
Ian Bickle, FRCR Department of Radiology RIPAS Hospital Bandar Seri Begawan BA 1710 Brunei Darussalam Vui Heng Chong, FRCP Department of Medicine RIPAS Hospital Bandar Seri Begawan BA 1710 Brunei Darussalam http://dx.doi.org/10.1016/j.ajem.2013.11.024 References [1] Perdue PW, Johnson Jr HW, Stafford PW. Intestinal obstruction complicating pregnancy. Am J Surg 1992;164:384–8. [2] Kolusari A, Kurdoglu M, Adali E, Yildizhan R, Sahin HG, Kotan C. Sigmoid volvulus in pregnancy and puerperium: a case series. Cases J 2009;2:9275. [3] Redlich A, Rickes S, Costa SD, Wolff S. Small bowel obstruction in pregnancy. Arch Gynecol Obstet 2007;275:381–3. [4] Kalu E, Sherriff E, Alsibai MA, Haidar M. Gestational intestinal obstruction: a case report and review of literature. Arch Gynecol Obstet 2006;274:60–2. [5] De U, De KK. Sigmoid volvulus complicating pregnancy. Indian J Med Sci 2005;59: 317–9. [6] Draçini X, Dibra A, Celiku E. Cecal volvulus during pregnancy. Case report. G Chir 2012;33:129–31. [7] Vassiliou I, Tympa A, Derpapas M, Kottis G, Vlahos N. Small bowel ischemia due to jejunum volvulus in pregnancy: a case report. Case Rep Obstet Gynecol 2012;2012: 485863. [8] Siwatch S, Noor MT, Dutta U, Kochhar R, Behera A, Singh K. Endoscopic management of a pregnant lady with duodenal obstruction due to malrotation with midgut volvulus. Trop Gastroenterol 2011;32:339–41. [9] Ribeiro Nascimento EF, Chechter M, Fonte FP, Puls N, Valenciano JS, Fernandes Filho CL, et al. Volvulus of the sigmoid colon during pregnancy: a case report. Case Rep Obstet Gynecol 2012;2012:641093.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Sigmoid volvulus in pregnancy: early diagnosis and intervention are important☆,☆☆ Abstract Bowel obstruction is rare in pregnancy, and delay in recognition can lead to serious maternal and fetal complications. Most reported causes of bowel obstruction in pregnancy (adhesions, intussusception, hernia, and carcinoma) require surgical intervention. Sigmoid volvulus is an acute surgical cause that can now be managed successfully without surgery. We report the case of 33-year-old lady who presented with a sigmoid volvulus that was successfully managed with urgent endoscopic decompression. Gastrointestinal symptoms are common during pregnancy, but bowel obstruction is considered rare. The reported incidence of bowel obstruction occurring during pregnancy ranges from 1 in 1500 to 1 in 66 431 deliveries [1,2]. Delay in the diagnosis and treatment of bowel obstruction in pregnancy can lead to serious maternal and fetal complications [3]. Most reported causes of bowel obstruction in pregnancy (adhesions, intussusception, hernia, and carcinoma) require surgical intervention. Sigmoid volvulus, a less common cause of bowel obstruction, can be managed successfully without surgery. Early diagnosis and decompression are important to avoid progression to bowel ischemia. A 33-year-old (G7 P5+1) lady of 26th week gestation presented with a 1-day history of increasing abdominal pain and distension. On the day of presentation, she complained of nausea and vomiting and not passing flatus. She had experienced a similar episode a few weeks previously but with milder symptoms that had spontaneously resolved. She had a long history of constipation and typically opened her bowels only once to twice a week. She had no previous surgery history. On examination, she was of low body mass index. She was afebrile, moderately dehydrated, and mildly hypotensive (blood pressure 96/69 mm Hg) but with a normal pulse rate. Her abdomen was distended, tympanic, and mildly tender to palpation, but without guarding. There were visible peristalsis, and bowel sounds were sluggish. In view of her pregnancy, abdominal radiography was not performed. At this point, a clinical diagnosis of bowel obstruction was inferred, and she was referred to the on-call surgeon and gynecologist. Rectal examination was empty with no palpable mass. Per vagina examination was unremarkable, with a long cervix and the os closed. Pelvic ultrasound by the attending gynecologist showed a viable fetus. Routine laboratory investigations revealed elevated white blood cell of 18.7 × 10 9/L and elevated urea and creatinine. Serum potassium was normal. Other investigations including liver profile, serum amylase, and blood
☆ Conflict of interest: None for all authors. ☆☆ Financial declaration: None for all authors. 0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
glucose were all normal. Without any further imaging, the level of bowel obstruction remained uncertain. After discussion between the surgeon, gynecologist, and gastroenterologist, the decision was to proceed with an abdominal radiograph. This was discussed with the on-call radiologist, which revealed dilated large bowel with abnormal gas pattern with a coffee bean appearance, pathognomic of a sigmoid volvulus (Fig. A). The patient underwent an urgent flexible sigmoid decompression without sedation using a gastroscope (diameter, 9.2 mm). The sigmoid was grossly dilated with liquid stool, and on retroflexion of the scope (Fig. B), a twist was evident. The colon was decompressed, and the sigmoid volvulus was devolved with immediate relief of symptoms. She remained well and was discharged several days later. Unfortunately, her volvulus reoccurred, and she represented at 35-week gestation and was immediately decompressed endoscopically. She was maintained on a stool softener, remained well on follow-up, and delivered without any complication. She was later planned for a sigmoid colectomy. Although considered rare, sigmoid volvulus is the second most common cause of intestinal obstruction in pregnancy after adhesions, accounting for between 25% and 44% of the cases [2,4,5]. To date, there have been less than 90 cases reported in the literature. The mechanism of sigmoid volvulus in pregnancy is postulated to be due to displacement of an abnormally mobile sigmoid colon by the enlarging uterus. Being pushed out of the pelvis, the mobile sigmoid can easily twist around its mesocolon fixation point, which is usually long in patients with constipation [2]. Volvulus of the other parts of the colon and the small bowel have also been reported but are less common [6-8]. The diagnosis of sigmoid volvulus should be suspected when a pregnant patient presents with a clinical triad of abdominal pain, distension, and absolute constipation. However, these classical signs are often diminished or absent. This often leads to a delay in diagnosis. This is further compounded by delay in presentation and reluctance of clinicians to do any radiologic investigations for fear of radiation exposure to the fetus. The radiation dose to the fetus from a plain abdominal radiograph only averages 0.1 to 0.3 rads (should give dose in mSv—its 0.7 mSv), and this is below the radiation dose associated with adverse effects. Early diagnosis is paramount as delay will lead to bowel complications, such as ischemia, necrosis, perforation, and potentially fatal outcomes for both fetus and mother. The mainstay of treatment in reported cases has been surgery [2,9]. However, these cases were complicated either due to delayed presentations or diagnosis. Endoscopy is both a diagnostic and a therapeutic modality, not just in sigmoid volvulus, but also for volvulus affecting the other parts of the bowel [8]. However, endoscopy during the third trimester is associated with a risk of premature labor. Use of a smaller caliber endoscope as in our case a
491.e2
A. Ahmad et al. / American Journal of Emergency Medicine 32 (2014) 491.e1–491.e2
Fig. A, Abdominal radiograph showing dilated large bowel with a “coffee bean” sign, sigmoid consistent with a sigmoid volvulus. B, A retroflexed endoscopic image showing the twist in the sigmoid.
gastroscope, which is also more flexible, is safe and was well tolerated without sedation. As the risk of volvulus recurrence is high even in the nonpregnant state, the patient should undergo definitive treatment typically sigmoid colectomy. In conclusion, sigmoid volvulus complicating pregnancy is rare. Diagnosis requires a high index of suspicion, and hesitancy in obtaining radiologic investigation often contributes to delay. Delay in diagnosis and treatment can results in increased fetal and maternal morbidity and mortality. Anis Ahmad, MBBS Department of General Surgery RIPAS Hospital Bandar Seri Begawan BA 1710 Brunei Darussalam Koh Kai Shing, MBBS Department of Accident and Emergency Bandar Seri Begawan BA 1710 Brunei Darussalam Khim Khee Tan, MBChB, FRCS Department of General Surgery RIPAS Hospital Bandar Seri Begawan BA 1710 Brunei Darussalam Mary Krasu, FRCOG Department of Obstetrics and Gynaecology RIPAS Hospital Bandar Seri Begawan BA 1710 Brunei Darussalam
Ian Bickle, FRCR Department of Radiology RIPAS Hospital Bandar Seri Begawan BA 1710 Brunei Darussalam Vui Heng Chong, FRCP Department of Medicine RIPAS Hospital Bandar Seri Begawan BA 1710 Brunei Darussalam http://dx.doi.org/10.1016/j.ajem.2013.11.024 References [1] Perdue PW, Johnson Jr HW, Stafford PW. Intestinal obstruction complicating pregnancy. Am J Surg 1992;164:384–8. [2] Kolusari A, Kurdoglu M, Adali E, Yildizhan R, Sahin HG, Kotan C. Sigmoid volvulus in pregnancy and puerperium: a case series. Cases J 2009;2:9275. [3] Redlich A, Rickes S, Costa SD, Wolff S. Small bowel obstruction in pregnancy. Arch Gynecol Obstet 2007;275:381–3. [4] Kalu E, Sherriff E, Alsibai MA, Haidar M. Gestational intestinal obstruction: a case report and review of literature. Arch Gynecol Obstet 2006;274:60–2. [5] De U, De KK. Sigmoid volvulus complicating pregnancy. Indian J Med Sci 2005;59: 317–9. [6] Draçini X, Dibra A, Celiku E. Cecal volvulus during pregnancy. Case report. G Chir 2012;33:129–31. [7] Vassiliou I, Tympa A, Derpapas M, Kottis G, Vlahos N. Small bowel ischemia due to jejunum volvulus in pregnancy: a case report. Case Rep Obstet Gynecol 2012;2012: 485863. [8] Siwatch S, Noor MT, Dutta U, Kochhar R, Behera A, Singh K. Endoscopic management of a pregnant lady with duodenal obstruction due to malrotation with midgut volvulus. Trop Gastroenterol 2011;32:339–41. [9] Ribeiro Nascimento EF, Chechter M, Fonte FP, Puls N, Valenciano JS, Fernandes Filho CL, et al. Volvulus of the sigmoid colon during pregnancy: a case report. Case Rep Obstet Gynecol 2012;2012:641093.
