Transverse volvulus occurs when the part of the large intestine that lies horizontally across from the right end of the upper part of the abdominal cavity to the left end (i.e. the transverse colon) twist on itself.
It accounts for 4 in 100 cases of volvulus , and it is a well recognised cause of bowel obstruction, though rare ( only 75 cases have been reported worldwide!).
Commonly affecting young adults in their second and third decade of life, it is rare in children. A nine year old girl from Denmark was reported with this problem, and a few Japanese kids. Between the 7th and 8th decades of life, the probability of developing this problem increases again.
For some reasons, more women tend to develop volvulus of the transverse colon than their male counter part (ratio 2:1) It is also thought to be commoner in Eastern Europeans and the Scandinavians.
That this is a serious condition to develop is seen in the fact that 1 of every 3 persons who come up with transverse volvulus would end up dead. But why do people develop transverse colonic volvulus?
Normally, the transverse colon is held in place across the right and left side of the abdominal cavity by a short mesocolon or band of hanging tissue.
With problems like chronic constipation, the colon may become overstretched, thus becoming very long and more mobile. If this happens, the excessively mobile colon can easily twist upon itself, leading to transverse colon volvulus.
The presence of congenital bands or abnormal rotations from birth can also lead to this problem.
Other causes of transverse volvulus include:
• Previous gastric or abdominal surgery
• Fluid accumulating in the abdomen, causing the liver to float (floating liver or Chilaiditis Syndrome) as in ascites
• Tumour or cancer at one of the ends of the transverse colon, acting as a fulcrum on which the colon can twist
• Crohn’s Disease with stricture affecting the transverse colon
• Clostridium Difficile Pseudomembraneous colitis
• Excessive high fibre diet
Transverse volvulus is often mistaken for sigmoid volvulus.
It may be seen as one of two forms: the very acute fulminating attack or the sub-acute to chronic intermittent disease.
In acute fulminating transverse volvulus, the patient develops sudden onset central abdominal pain, crampy, with or without vomiting. Abdominal distension is an early sign, and patient may become constipated. If this continues for a few hours or days, there may be fever, and the patient becomes severely unwell.
The whole of the abdominal would be sore to touch, and very loud bowel sounds may be heard in the early phase or may even become silent later, which of course is a sign of worsening disease.
In the sub-acute or chronic transverse volvulus, these same symptoms may occur, in mild to moderate proportion and may well resolve spontaneously and re-occur again.
This will demonstrate a distended right colon and a so called upright U-shaped transverse colon.
In transverse volvulus, a gastrografin enema will show the well described bird beak appearance on which diagnosis can be confidently based.
Lactate will also be elevated in acute obstruction with bowel ischaemia or compromise of blood supply to the gut.
The electrolytes and urea may be deranged following vomiting and dehydration, or previously underlying liver or kidney problems.
Please see more resources on transverse volvulus below:
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