Intestinal volvulus

　　First, etiology

　　Volvulus of the vermiform appendix is caused by the movement of the vermiform appendix. Normally, the vermiform appendix is attached to the posterior abdominal wall and is completely covered by peritoneum, so it will not twist. If the fixation of the vermiform appendix and the disappearance of the mesentery are not complete during embryonic development, and the mesentery of the vermiform appendix and ascending colon is too long and overly mobile, this is an anatomical factor of vermiform appendix volvulus. The causes of vermiform appendix volvulus include overeating, diarrhea, excessive exertion, adhesions in the abdomen, and especially abdominal surgery is often the direct cause of vermiform appendix volvulus. Pelvic tumors and pregnancy can change the position of the vermiform appendix, or an obstruction at the distal end of the vermiform appendix can cause the vermiform appendix to swell, making it easier to twist.

　　Second, pathogenesis

　　Intestinal volvulus often occurs with a part of the terminal ileum and ascending colon together, with clockwise volvulus being more common (85%), with the degree of volvulus reaching 360° or more. The mesentery also twists, forming a closed-loop intestinal obstruction. Prolonged time can cause necrosis of the volvulus loop, with an incidence rate of about 1/4. After volvulus, the terminal ileum is obstructed, causing complete obstruction of the small intestine.

　　1. Partial volvulus of the vermiform appendix manifests as chronic incomplete intestinal obstruction, and a cystic mass can be palpated in the right lower quadrant. Symptoms disappear after spontaneous reduction, but may recur.

　　Another situation is that the free vermiform appendix folds forward and upward, causing the distal ileum and ascending colon to fold and form an obstruction. This type of vermiform appendix fold does not affect the mesenteric vessels, so there is no necrosis of the vermiform appendix. However, some people believe that vermiform appendix fold does not belong to vermiform appendix volvulus because it does not meet the basic definition of intestinal volvulus.

　　In severe cases, the abdomen may present with asymmetrical bulging and irregularly distended loops of intestines, which can lead to intestinal wall necrosis, perforation, peritonitis, and even death if not复位 in time. Peritonitis is a severe surgical disease caused by bacterial infection, chemical irritation, or injury. Most cases are secondary peritonitis, originating from organ infections in the abdominal cavity, such as necrosis, perforation, trauma, etc.

　　Intestinal volvulus is more common in young people under 40 years old, with more females affected. Normally, due to the movement of the vermiform appendix, chronic periumbilical and right lower quadrant abdominal pain, abdominal distension, and other symptoms may occur. The clinical manifestations can be divided into two types.

　　1. Acute ileocecal intussusception is characterized by sudden and severe pain in the right lower quadrant or middle abdomen, with colicky pain that worsens intermittently. It may also be accompanied by nausea, vomiting, and cessation of defecation and flatus, which are typical symptoms of low-positioned intestinal obstruction. In the late stage of the disease, shock and sepsis may occur.

　　Physical examination: marked distension, asymmetrical distension, muscle tension in the right lower quadrant, tenderness and rebound pain, and an indistinct mass that can be felt in the right lower quadrant. If there is effusion in the abdominal cavity, tenderness can spread throughout the abdomen. Auscultation reveals hyperactive bowel sounds or gurgling sounds.

　　2. Subacute ileocecal intussusception can manifest as recurrent incomplete bowel obstruction symptoms. During an attack, there is pain and discomfort in the right lower quadrant of the abdomen, with varying degrees of bloating. A cystic mass can be felt in the right lower quadrant, with tenderness. The condition can last for several days, and symptoms will improve after the intussusception is automatically复位.

　　1. Intestinal intussusception is a strangulating intestinal obstruction. The twisted bowel can quickly develop necrosis, perforation, and peritonitis. It is a type of intestinal obstruction with a severe condition and rapid development. If not treated in time, the mortality rate is high. Therefore, once diagnosed, timely treatment and early surgery should be performed. This can not only reduce bowel resection and even avoid bowel necrosis but is of great significance for saving the patient's life.

　　2. Strictly control the indications for non-surgical treatment to avoid delaying the timing of surgery and causing adverse consequences.

　　3. Timely treatment of ileocecal intussusception usually has a good prognosis, but if there is bowel strangulation, even rupture and perforation, the prognosis is poor. Delayed or improper treatment results in a high mortality rate. If ileocecal intussusception improves without surgical treatment, further examination of the cause of the disease should be carried out, and if necessary, elective surgery can be performed to eliminate the cause to prevent recurrence.

　　Firstly, the plain film characteristics of ileocecal intussusception in abdominal flat film

　　1. Significant expansion of the cecum: the expanded cecum can be located in any part of the abdomen, but it is commonly found in the upper abdomen or left upper quadrant, with liquid levels. When there is severe bloating and fluid accumulation, it is easy to misdiagnose it as acute gastric dilatation. A nasogastric tube can be inserted to aspirate for differentiation. If it is gastric dilatation, the image of gas and fluid levels in the stomach disappears after aspiration, but there is no change in ileocecal intussusception.

　　2. Symptoms of low-positioned small bowel obstruction: multiple liquid levels are arranged in a stepped manner.

　　3. The distal ileum is distended and displaced: the distal ileum can be filled with gas and abnormally located on the right side of the cecum, while the relative amount of gas in the transverse colon and descending colon is reduced.

　　Secondly, barium enema often shows that barium is obstructed at the colonic flexure

　　It is advisable to consume processed or cooked foods to facilitate mastication and digestion. It is permissible to eat up to 12 whole eggs per week. Diversify the intake of the six major food categories including dairy products, root and tuber crops, meat, fish, beans, eggs, vegetables, fruits, and oils to fully obtain various nutrients; prefer foods rich in protein and iron, such as lean meat, fish and shrimp, animal blood, animal liver and kidneys, yolks, bean products, and jujube, green leafy vegetables, sesame paste, etc.; use vegetable oils, and mainly cook by methods such as boiling, steaming, salad, frying, roasting, pickling, and stewing; avoid high-cholesterol foods such as fatty meat, internal organs, fish eggs, and butter.

　　Once cecum torsion is confirmed, it should be treated according to the principles of intestinal obstruction treatment, including gastrointestinal decompression, fluid replacement, and application of antibiotics. In case of water, electrolyte, acid-base imbalance, or hypovolemia, timely correction and supplementation should be made.

　　Cecum torsion should be treated with emergency laparotomy in principle to relieve intestinal obstruction, resect necrotic bowel segments, and prevent recurrence. The appropriate surgical method is adopted according to the condition of the twisted bowel segment.

　　1. Reduction and fixation of cecum torsion After the reduction of cecum torsion, the cecum is sutured and fixed to the lateral abdominal wall, and it can also be sutured after the posterior peritoneum is incised to form a flap, sutured in front of the cecum and ascending colon, forming a retroperitoneal pouch. The recurrence rate is high. It is applicable to cases without bowel necrosis.

　　2. Reduction of torsion, intubation and stoma of cecum After the reduction of cecum torsion, a small incision is made on the cecum, a mushroom-shaped catheter is inserted, and it is led out from the lower right abdomen. The intubation and stoma of the cecum is not only for postoperative bowel decompression, but mainly for the adhesion of the cecum wall and the peritoneum at the stoma site to achieve the purpose of fixing the cecum and preventing recurrence. The catheter is removed about 2 weeks after the operation, and the stoma site heals spontaneously. However, complications such as wound infection, abdominal abscess, and persistent cecum fistula may occur. It is applicable to cases without bowel necrosis, elderly patients, and patients with poor general condition.

　　3. If the patient's condition is good when the right hemicolectomy and ileotransverse colon anastomosis is performed in one stage without necrosis of the twisted bowel loop, it is possible to perform the right hemicolectomy and ileotransverse colon anastomosis in one stage. This is a radical method with rare recurrence. The postoperative care after one-stage resection and anastomosis is relatively simple, and the patient's pain is less. Although there is a certain degree of risk, careful operation during the operation, attention to the blood supply of the bowel, and the anastomosis can be healed in one stage.

　　4. Resection of necrotic bowel, proximal ileostomy, and distal transverse colon mucosal fistula is applicable to patients with severe illness or perforation and diffuse peritonitis. Resection of the bowel anastomosis is performed 3 months later.