Abdominal manipulation during water-soluble contrast enema--an alternative method of nonoperative decompression of sigmoid volvulus?
Abstract: Sigmoid volvulus is common in some developing countries. We describe a new method of decompression using a Urograffin and saline enema with additional extra-abdominal manual massage.
Article Type: Case study
Subject: Colonoscopy (Usage)
Intestines (Obstructions)
Intestines (Diagnosis)
Intestines (Case studies)
Intestines (Care and treatment)
Intestines (Prevention)
Authors: Boshoff, P.E.
Andronikou, S.
Pub Date: 08/01/2011
Publication: Name: South African Journal of Surgery Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 South African Medical Association ISSN: 0038-2361
Issue: Date: August, 2011 Source Volume: 49 Source Issue: 3
Geographic: Geographic Scope: South Africa Geographic Code: 6SOUT South Africa
Accession Number: 268310800
Full Text: Sigmoid volvulus is common in some developing countries, where it represents 20-54% of intestinal obstruction. In Africa it occurs more commonly in the black than in the white population.

Sigmoid volvulus is diagnosed on clinical and radiological grounds. (1) Management involves relief of obstruction, either with surgery or non-operatively using colonoscopy or contrast enema, and prevention of recurrent attacks.

We describe a new method of decompression of sigmoid volvulus using a Urograffin and saline enema with additional extra-abdominal manual massage.

Case report

A 30-year-old black woman presented with symptoms suggestive of sigmoid volvulus. Plain abdominal supine radiographs showed a typical distended loop of large bowel and 'coffee bean' appearance (Fig. 1). A contrast enema was requested to confirm the diagnosis.

A 20F Foley's catheter was inserted per rectum. Urograffin was instilled through the catheter until the obstruction was noted with the typical 'bird's beak' sign (Fig. 2a). Administration of 750 ml Urograffin and normal saline resulted in opacification of the descending colon proximal to the point of torsion. The patient was placed in the left posterior oblique position. Soft abdominal pressure was applied by hand over the distal part of the volvulus. Circular anticlockwise movements were then made from lateral to medial over the volvulus under fluoroscopic guidance (Fig. 2b - f).

After 5 minutes contrast flowed freely into the more proximal bowel and the patient urgently requested to void her bowels. The catheter was removed and she passed stool and flatus. An abdominal radiograph taken after the procedure shows resolution of the proven sigmoid volvulus (Fig. 3). The patient returned to the ward and had an uneventful elective laparoscopic sigmoidectomy for a redundant sigmoid colon 3 days later.

Discussion

Madiba et al. showed that there was a higher prevalence of redundant sigmoid colon in blacks than in Indians and whites. This might explain the higher number of sigmoid volvuli seen in the black population. (2) Risk factors for sigmoid volvulus include chronic constipation in developed countries and a high-fibre diet in African countries. High altitude and enemas containing pepper, ginger and herbal extracts have also been implicated. (2,3)

[FIGURE 1 OMITTED]

Non-operative management includes flexible or rigid sigmoidoscopy and colonoscopy with decompression rates between 70% and 90%, and barium enema with a 5% success rate in de-torsion of sigmoid volvulus in adults. (3)

In patients with suspected bowel perforation or peritonitis, barium enemas can be life-threatening and water-soluble contrast enemas should be used to confirm the diagnosis. (4)

In up to 80% of cases, sigmoid volvulus can be diagnosed from the supine abdominal radiograph alone. If this is not diagnostic, a single-contrast water-soluble enema should be performed. (5)

In Ericksen et al.'s review, barium enemas were used in 83% of patients initially diagnosed with large-bowel obstruction and were 100% accurate in localising the site of obstruction. (4)

[FIGURE 2a OMITTED]

[FIGURES 2b-f OMITTED]

The imaging diagnosis is based on: (i) a vertical dense white line on abdominal film, signifying apposed inner walls of sigmoid colon pointing towards the pelvis; (ii) gas in the proximal large bowel with no gas in the rectum; (iii) inverted U-shape of the sigmoid colon with absent haustra; (iv) the 'northern exposure' sign--dilated twisted sigmoid colon projecting above the transverse colon on a supine abdominal film; (v) apex of the sigmoid volvulus above T10 vertebra and under the left hemidiaphragm; and (vi) 'beaking' seen in the distal sigmoid colon with contrast enema--smooth tapered narrowing or point of torsion at the rectosigmoid junction. (6)

De-torsion without resection is associated with a high recurrence rate (up to 90%).

Barium enema has been shown to be especially useful in children. Salas et al. had a 77% success rate of de-torsion using barium enema under fluoroscopic control (10 out of 13 cases) (7) and Mellor and Drake achieved a 79% success rate (11 out of 14). (8)

In a recent review by Oren et al., a barium enema was used in 13 out of 575 patients (2.3%). (1) The mortality was highest in the barium enema group (7.7%), deaths being related to perforation. De-torsion was successful in 9 out of 13 patients (69.2%). The patients' ages were not mentioned. (1) Arnold and Nance report successful de-torsion in 12 out of 18 attempts using barium enemas (67%). (9) This study also does not mention the patients' ages.

[FIGURE 3 OMITTED]

In the event of a perforation, barium will cause peritonitis; water-soluble contrast media will reduce this risk. Both Ericksen et al. and Salas et al. suggest the use of water-soluble contrast where bowel perforation cannot be excluded and where the patients have peritonitis. (4,7)

Decompression of sigmoid volvulus using a Urografin and saline enema as well as extra-abdominal manual massage has not been described before. Only after manual manipulation was the volvulus of the sigmoid colon fully relieved in our patient, thereby avoiding additional colonoscopy or urgent surgery.

We therefore suggest the further study of water-soluble contrast media such as Urograffin with fluoroscopic-guided manipulation for the diagnosis and initial non-operative treatment of sigmoid volvulus.

Conflict of interest: None.

REFERENCES

(1.) Oren D, Atamanalp SS, Aydinli B, et al. An algorithm for the management of sigmoid colon volvulus and the safety of primary resection: experience with 827 cases. Dis Colon Rectum 2007;50:489-497.

(2.) Madiba TE, Haffajee MR, Sikhosana MH. Radiological anatomy of the sigmoid colon. Surg Radiol Anat 2008;30:409-415.

(3.) Madiba TE, Thomson SR. The management of sigmoid volvulus. J R Coll Surg Edinb 2000;45:74-80.

(4.) Ericksen AS, Krasna MJ, Mast BA, Nosher JL, Brolin RE. Use of gastrointestinal contrast studies in obstruction of the small and large bowel. Dis Colon Rectum 1990;33:56-64.

(5.) Feldman D. The coffee bean sign. Radiology 2000;216:178-179.

(6.) Jeffrey R, Manaster BJ, Gurney JW, Zimmerman RD, Cure JK, Donnelly LF. Diagnostic Imaging Emergency. 1st ed. Canada: Elsevier, 2007:11-3-96.

(7.) Salas S, Angel CA, Salas N, Murillo C, Swischuk L. Sigmoid volvulus in children and adolescents. J Am Coll Surg 2000;190:717-723.

(8.) Mellor MF, Drake DG. Colonic volvulus in children: value of barium enema for diagnosis and treatment in 14 children. AJR Am J Roentgenol 1994;162:1157-1159.

(9.) Arnold GJ, Nance FC. Volvulus of the sigmoid colon. Ann Surg 1973;177:527-537.

P.E. BOSHOFF, M.B. CH.B., M.R.C.P. S. ANDRONIKOU, M.B. B.CH., F.C.RAD., F.R.C.R., PH.D.

Department of Radiology, University of the Witwatersrand, Johannesburg
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