Sigmoid volvulus in children: a case report
Sigmoid volvulus is frequently reported in the “volvulus belt” (Middle East, Africa, the Indian subcontinent, Turkey, and South America) and is the third leading cause of large bowel obstruction in North America.
It is an uncommon problem in children and adolescents, and is rarely considered a diagnosis in this group. A high index of suspicion is necessary to diagnose sigmoid volvulus in children.
We present a 13-year-old Arabian girl who came with features suggestive of intestinal obstruction. Plain abdominal film revealed classic omega (coffee bean) sign of sigmoid volvulus. The volvulus was successfully decompressed by means of a rectal tube in our emergency department. The next day during the same admission the volvulus recurred and was successfully decompressed by endoscopy. She was discharged home on her parents’ request; she presented again 1 month later. This time the volvulus could not be decompressed non-operatively, so she underwent sigmoidectomy with primary anastomosis. Postoperatively she developed paralytic ileus that resolved after 10 days. Following that she did well and was discharged home. She is still free of symptoms 1 year after the resection.
Sigmoid volvulus is an uncommon problem in children and adolescents, and is rarely considered a diagnosis in this group as a cause of intestinal obstruction. Pediatric surgeons should maintain a high index of suspicion, in order not to miss this important diagnosis, as any delay in instituting treatment has a devastating effect on morbidity as well as mortality. Early diagnosis and prompt treatment confer an excellent prognosis.
KeywordsCase report Sigmoid volvulus Children Adolescents Decompression Endoscopy Sigmoidectomy Primary anastomosis Coffee bean sign
From The Papyrus Ebers: “If he doesn’t evacuate for a twist in the bowel and the phlegm does not find a way out then it shall rot in the belly” .
Sigmoid volvulus is frequently reported in the “volvulus belt” (Middle East, Africa, the Indian subcontinent, Turkey, and South America) and is the third leading cause of large bowel obstruction in North America . It is an uncommon problem in children and adolescents, and is rarely considered a diagnosis in this group . Sigmoid volvulus is an exceptionally rare and potentially life-threatening condition in the pediatric age group. A high index of suspicion is necessary to reach a diagnosis and avoid morbidity and mortality.
Although volvulus in adults is common in Asian populations, more cases in pediatric practice have been reported from the West, including North America. Among children several predisposing factors have been identified. Hirschsprung’s disease has been implicated in both transverse colonic as well as sigmoid volvulus . This was ruled out in our patient as a cause for her sigmoid volvulus by the findings of abundant ganglia shown in biopsy section. Chronic constipation is another advocated factor for the development of sigmoid volvulus, but our patient and her family denied any history of constipation. So, the causative factor in this reported case will remain unknown after the definitive treatment .
In pediatric surgical practice volvulus of the sigmoid colon remains a rare occurrence. Only a few isolated case reports and case series have been reported to date in the literature . The median age was 7 years and the male to female ratio was 3.5:1 . Volvulus is more common in males, possibly because the large volume of the female pelvis facilitates spontaneous untwisting.
Two distinct presentations (acute and recurrent) were identified. Abdominal symptoms dominated the clinical picture. The most common symptoms are abdominal pain that is relieved by passage of stool or flatus, abdominal distention, and vomiting . All three symptoms were present in our patient.
The sensitivity of the coffee bean sign for sigmoid volvulus in children is reported to be only 16 to 29% in a review of pediatric cases in the literature . A plain abdominal X-ray is suggestive of sigmoid volvulus in 29% of cases, while barium enema is diagnostic in 61% of cases . While the literature says plain film is not highly sensitive in detecting sigmoid volvulus signs in children, our patient showed a classic finding.
Although, the classic bird’s beak deformity seen on contrast enema is pathognomonic for volvulus, Mellor and Drake described a twisted appearance to be more common . This twist was highly evident in our case in both barium enema studies. Barium enemas either confirmed or were highly suggestive of sigmoid volvulus. Reduction by barium enema was successful in 77% (10 of 13) of the attempts .
Treatment for sigmoid volvulus remains controversial in children. If the patient is stable, non-operative reduction of the volvulus with barium enema or sigmoidoscopy may first be attempted . When there are no signs of peritonitis and an endoscopy unit is available with both pediatric and adult expertise, endoscopic decompression and detorsion should be the initial step of treatment in order to relieve symptoms and to prepare the patient for the surgical exploration .
The definitive treatment is sigmoidectomy, either with primary anastomosis or colostomy. Recurrence is common when detorsion without resection is performed (operative 25%, non-operative 35%) . The prognosis of definitive treatment of sigmoid volvulus is excellent, provided it is diagnosed early and treated promptly .
Sigmoid volvulus is an uncommon problem in children and adolescents, and is rarely considered a diagnosis in this group as a cause of intestinal obstruction. Hence, pediatric surgeons should maintain a high index of suspicion, in order not to miss them, as any delay in instituting treatment has a devastating effect on morbidity as well as mortality. Early diagnosis and prompt treatment confer an excellent prognosis.
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FH wrote the article, reviewed it, did the whole literature review, and provided the endoscopic images and the operative images. NA is part of the surgical team who reviewed the manuscript. BA managed the case twice in emergency and reviewed the manuscript with valuable comments. EA is part of the surgical team and reviewed the manuscript and added some valuable information. JK managed to decompress the patient endoscopically the first time and reviewed the case presentation. HI reviewed the whole manuscript with few changes. HN provided all the radiological images and the comments in the manuscript and captions. FA provided all the pathological images, comments and captions. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Approval obtained from Department of Surgery Ethical Board.
Consent for publication
Written informed consent was obtained from the patient’s legal guardian(s) for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors declare that they have no competing interests.
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