eP521 - Transverse Volvulus – an Unusual Cause of Bowel Obstruction in a Patient with Cerebral Palsy

Purpose/Background: Bowel obstruction caused by transverse volvulus is an extremely rare entity with only 100 cases reported in literature. To this day, the diagnosis is challenging for surgeons. Its incidence is low compared to cecum or sigmoid volvulus, however, delay in the diagnosis of this condition leads to a high rate of morbidity and mortality. We present an unusual case of transversus volvulus in a patient with infantile cerebral palsy.Methods/Interventions: A 25-year-old female with history of infantile cerebral palsy who presents with generalized abdominal pain accompanied by anorexia and constipation. The family member refers recurrent episodes of constipation and straining during defecation. Physical examination revealed abdominal distension, tenderness on palpation, generalized tympanism, and audible peristalsis, decreased in frequency at a rate of 1 sound per minute.

Control laboratory studies showed: leukocytes 15.4, neutrophils 80%, Hemoglobin 15.1, platelets 187 and procalcitonin 0.03. An abdominal tomography revealed bowel obstruction, a transition zone is identified in the upper third of the descending colon where a "swirling of the mesenteric vessels" and collapse of the rest of the colon is revealed. Urgent surgical treatment was decided due to the presence of acute abdomen. An emergency exploratory laparotomy showed tumor vs. stricture of the transverse colon, which leads to counterclockwise rotation of the left transverse mesentery with retrograde bowel dilation; ischemic changes in the right colon were also identified as well as reaction fluid of approximately 100 milliliters. An extended right hemicolectomy plus construction of an ileostomy was performed.

The patient had an adequate postoperative evolution and was discharged 7 days later. The specimen was sent to pathology which reported transmural ischemic colitis and atrophy of the colonic mucosa.Results/Outcomes: The majority of volvuluses occur in the sigmoid colon, cecum, and transverse colon. The most common site of a colonic volvulus is the sigmoid, it accounts for approximately 60 – 80% of volvulus of the large intestine. The second most common location would be cecum (20 – 40%); transverse colon accounts for 3 %. There are predisposing factors for this type of volvulus, such as anomalies in the development of fixation, which have been revealed in cases of volvulus and malrotation.

Transverse volvulus presents a clinical presentation compatible with bowel obstruction. This is frequently associated with abdominal pain, vomiting and abdominal distension. The diagnosis can be difficult since it does not present the same radiographic findings as cecal and sigmoid volvulus. Transverse colon volvulus should be treated as a surgical emergency.

The surgical options in the management of bowel obstruction as a consequence of transverse volvulus are: one-phase procedure which consists of resection of non-viable intestine and primary anastomosis to avoid stoma creation. In the two-phase procedure the intestine is resected, the proximal end is exteriorized for a colostomy and the distal end is used as a mucosal fistula. A two-phase procedure is preferred when there is intestinal perforation and hemodynamic instability. In the absence of hemodynamic compromise, a one-stage procedure is sufficient.Conclusion/

Discussion: Transverse colon volvulus is a rare entity with an extremely high mortality rate. Early diagnosis and timely treatment are of utmost importance to reduce the risk of mortality."Abdominal CT scan

Abdominal CT scan with IV contrast revealing ""swirling of the mesenteric vessels""
Large intestine dilation

Transverse colon volvulus leading to retrograde bowel dilation
Surgical specimen

Ascending colon and transverse colon with prominent dilation"