VOLVULUS

PRESENTATION OUTLINEDefinition CausesIncidencePathophysiologyClinical featuresDiagnostic investigationPredisposing factorsNursing intervention

OUTLINE CONT’Treatment Pre-Operative CarePost Operative CareComplicationsCare plan (Nursing Diagnosis and

outcomes)References

VOLVULUS

It is the term applied to twisting of a loop of bowel so that the mesenteric vessel and the lumen of the bowel become occluded. It therefore is an obstruction of the bowel.

Volvulus

Obstruction caused by twisting of the intestines more than 180 degrees about the axis of the mesentery

1-5% of large bowel obstructions◦ Sigmoid ~ 65%◦ Cecum ~25%◦ Transverse colon ~4%◦ Splenic Flexure

TYPES OF VOLVULUSVolvulus neonatorumVolvulus of the small intestineCeacal volvulus (volvulus of the caecum)Sigmoid volvulus (which is most

common and responsible for most intestinal obstruction)

Gastric volvulus

GASTRIC VOLVULUS (ORGANO-AXIAL)

GASTRIC VOLVULUS (MESENTERO-AXIAL)

GASTRIC VOLVULUS (Combined Volvulus)

Sigmoid Volvulus

CAUSESNo actual cause is known but certain

predisposing conditions which results or complicates into volvulus will be discussed in subsequent slides.

PREDISPOSING FACTORSPerson’s with a redundant colonOne with a normal anatomic variation

resulting in extra colonic loopsPatients with muscular dystrophy due to

the smooth muscle dysfunctionCongenital intestinal malrotationAbnormal intestinal contents e.g.

meconium ileus or adhesions

PREDISPOSING FACTORS TO GASTRIC VOLVULUS CONT’Abnormalities of adjacent organs

like:Diaphragm (hernia, rupture,

nerve palsy)Liver (dislocation)Spleen (splenomegaly, wandering

spleen, polyspenia)

INCIDENCEOccurs commonly in middle aged and

elderly people especially in men.

PATHOPHYSIOLOGYThe sigmoid colon twists upon itself

resulting in the intestinal obstruction (vovulus) which could be:

Acute (total vascular impairment)Sub-acute (without vascular impairment)Chronic (twisting occurs followed by a

correction but twisting reoccurs this time to form a double knot known as ileosigmoid knotting which involves the sigmoid colon and ileum.

CLINICAL FEATURESAbdominal distension and vomiting Ischemia (loss of blood flow) to the

affected portion of intestineAbsolute constipationThere may be visible peristalsis as well as

features of peritonitisSevere pain and progressive injury to the

intestinal wall

CLINICAL FEATURES CONT’Accumulation of gas and fluid in the

portion of the bowelNecrosis of the affected intestinal

DIAGNOSTIC INVESTIGATIONS

This includes:An Upper GI series (the use of barium

meal swallow to perform a GIT radiography)

A Digital rectal examination with rectal tube

And the taking of a straight x-ray film of the abdomen

Barium Enema

NURSING INTERVENTIONAdminister analgesics required to client

to ease off painEncourage client to avoid copious foods

that will induce vomitingGive anti-emetics prescribed.IV fluid administration is done to replace

body fluids and prevent acidosis by maintaining electrolyte balance.

NURSING INTERVENTION CONT’

Examine abdomen for distension and tenderness

Auscultate for bowel sounds and movements

TREATMENTThis is a surgical intervention done by

untwisting the gut in a procedure called sigmoidoscopy (sigmoidoscopic reduction)

Also laparotomy can be done to have a sigmoid resection or untwisting

Incision into the abdomen to untwist the knot (volvulus) and possibly resecting any unsalvageable portion

Operative management for sigmoid volvulus

Elective resection◦ Same admission

Emergent laparotomy◦ Operation depends on

viability of the bowel Resection and

anastomosis Hartmann resection Exteriorization resection Detorsion Detorsion with colopexy Percutaneous colostomy Percutaneous

sigmoidpexy

PRE-OPERATIVE ACTIVITIESExplain procedure to client and relief of

psychological stressSkin preparations e.g. Shaving the abdomenGive patient a low residue diet to have less

stools formedAntibiotic administration 3-5 days before

surgery in an attempt to decrease the bacteria of the bowel content with the aim of decreasing wound infection. E.g. include neomycin, streptomycin, etc

PRE-OPERATIVE ACTIVITIES CONT’A nasogastric or intestinal tube is inserted

before operation and connected to a suction machine to clear the intestinal contents.

POST OPERATIVE ACTIVITIES

Until peristalsis return, anything to be given is introduced parenteral

Moisten mouth with clean water as a result of dryness created by anaesthetic agent

All fluids given as infusions should be recorded

Catheterize patient to ease difficulty in voiding and to prevent urine retention

POST OPERATIVE ACTIVITIES CONT’Give opiod analgesics to relieve painEncourage patient to do deep breathing

and to change position every 1 hourManage rectal tube sutured in the anus to

facilitate the passage of stoolDrugs such as neostigmine is given to

prevent straining the intestine during expulsion

Early ambulation to start peristalsis

COMPLICATIONS

A serious condition that could result in death especially in the acute type of volvulus.

NURSING DIAGNOSISPain in patient related to bowel

obstruction

High risk for fluid volume deficit related to fluid shifts and losses from vomiting.

Fear and anxiety of patient and family related to undergoing invasive procedures

EXPECTED OUTCOMESPain will subside in 3-5 hrs as normal

peristaltic movements returns to normal and allow oral intake of foods

Patient will maintain a normal electrolyte balance and skin turgor within 24 hrs.

Fear and anxiety will be alleviated by making client have the confidence and conviction that all will be well.

REFERENCESColmer. M.R. Moroney’s Surgery for

Nurses, London: Churchil Livingston.Bloom. , A and Bloom, S.R. Toohey’s

Medicine for Nurses, London: churchil Livingstone

Reynolds Watson, J.E., Watson’s Medical-Surgical Nursing and Related Physiology, London: Baillierre Tindall.

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