Global Journal of Digestive Diseases

Endoscopic detorsion of sigmoid volvulus in pregnancy: A case report and literature

Sigmoid volvulus is a very rare condition causing intestinal obstruction in pregnancy associated with extremely high rate of morbidity and mortality for both mother and fetus, early diagnosis based on clinical judgment and use of modern imaging modalities are required for achieving better results and avoiding any surgical intervention. We report the case of a 23-week pregnant lady, present with severe abdominal distention and constipation, diagnosis was achieved using magnetic resonance image, emergency flexible sigmoidoscopy with detorsion of volvulus was done successfully with no complication to the mother or fetus, she was maintained on stool softener and remained well on follow-up. We have reviewed the available literature on this topic, as of 2017, less than 100 cases had been reported since first reported case in 1885, most of them ended by surgical resection of gangrenous part of the colon and the need for colostomy. One case had been managed by endoscopy is reported in Brunei. Sigmoid volvulus is the most cause of intestinal obstruction during pregnancy accounting for up to 44% of reported cases. Delay in diagnosis usually goes back to similarity between common gastro-enteric symptoms in pregnancy that can mask truly obstructive one and also hesitate in use of radiologic image for evaluation. Effective management represents a challenge, as a delayed presentation and diagnosis will lead to catastrophic feto-maternal complications. A high incidence of clinical suspicion and timely intervention are the key to a favorable outcome.

 

Sigmoid volvulus emerges when the air filled colon bends because of its limited stretched mesentery and absence of colonic obsession to the retroperitoneum. Sigmoid volvulus is the most well-known reason for intestinal hindrance representing 25-44% of cases. Indications emerge either through entrail deterrent or ischemia. This case is introduced to feature that pregnancy can postpone introduction and determination, and nonsurgical administration can be similarly fruitful in the third trimester gave there is no proof of confusion like gangrenous entrail or puncturing. Endoscopic decrease of a sigmoid volvulus has been accounted for to be fruitful in 75-95% of cases. Fetal and maternal death rates have been noted to be high during pregnancy because of deferred conclusion.

 

Intestinal impediment in pregnancy is extraordinary with an announced frequency going from one of every 1500 to one of every 66,431. The most widely recognized reasons for intestinal block in pregnancy are grip, intestinal volvulus, intussusception, carcinoma, hernia and an infected appendix. In 1885, Braun was the principal specialist to depict an instance of sigmoid volvulus during pregnanc. Intestinal deterrent because of sigmoid volvulus during pregnancy remains amazingly uncommon and is of outrageous gravity particularly if not perceived and rewarded intelligently. The clinical introduction is like that in non-pregnant females, yet is conceal by the amplified uterus and the physiological changes of pregnancy. The sigmoid volvulus happens when the sigmoid colon folds over itself and its mesentery. The expanding size of the uterus may raise a versatile sigmoid colon from the pelvis and produce a halfway block either because of weight or crimping of this bit of the entrail. This troublesome introduction, alongside a deferral in determination, is the fundamental explanation for the high dismalness and mortality of this condition. Results may incorporate gut ischemia, putrefaction, gangrene, aperture, peritonitis, preterm conveyance and both fetal and maternal passing.

 

The etiology of SV is multifactorial and questionable. The anatomical constitution of the sigmoid colon is an essential for SV. The repetition of the sigmoid colon, dolichomesentery, which is portrayed as 'mesentery that is more extensive than long, and the narrowing of the base of the sigmoid mesentery are viewed as successful components for the improvement of SV. These anatomical qualities might be procured, and, in uncommon cases, they are inherent. A few creators have demonstrated positive connections between's cutting edge age and sigmoid colon excess just as dolichomesentery, which may clarify the connection between cutting edge age and SV. Thus, dolichomesentery and littler pelvic channel are progressively regular in guys, and these reason torsion and don't take into account unconstrained detorsion. This may clarify the connection between the male sex and SV. Then again, pregnancy makes torsion almost certain in females, and it is imagined that the developed uterus pushes the repetitive sigmoid colon out of the pelvis and causes volvulus.

 

High-height may prompt high colonic weight, which causes a repetitive sigmoid colon, and it might be a potential explanation behind the geographic scattering of SV. Likewise, a high-fiber vegetable eating regimen propensity may cause repetitive sigmoid colon and may clarify the relationship of SV with both geographic scattering and financial status. Then again, ongoing clogging may cause lengthening of the sigmoid colon, and this might be the reason the old and individuals with neurologic, mental or metabolic ailments are at higher hazard for SV. A few sicknesses, including postoperative attachments, inner herniations, omphalo-mesenteric variations from the norm, malrotations, intussusceptions, intrinsic megacolon, an infected appendix, and carcinomas, might be uncommon inclining factors for SV.

 

Two significant issues emerge in SV: luminal block and vascular impediment. Both mechanical deterrent and bacterial maturation cause the widening of the turned circle and the proximal colon. Expanded intracolonic pressure diminishes narrow perfusion. Both mechanical impediment and apoplexy of the vessels add to ischemia. Mucosal ischemic injury causes bacterial translocation and toxemia, bringing about colonic gangrene. Expanded intra-stomach pressure causes stomach compartment disorder.

 

Hypertrophied colonic divider, thickened mesentery, unmistakable vessels, spread out teniae, and abrogated haustrations are the morphological changes seen in SV. In grown-ups, reasons for a sigmoid volvulus include: a broadened colon. stomach attachments that create after medical procedure, injury, or disease. infections of the digestive organ, for example, Hirschsprung's ailment. Elective laparoscopic sigmoid resection and right hemicolectomy after endoscopic decompression is progressively being depicted and performed to treat patients with volvulus. In these patients, who are frequently older and constantly sick, insignificantly intrusive medical procedure may give huge advantage. Sigmoid volvulus is viewed as a health related crisis and should incite prompt treatment. In the event that the colon is contorted and the blood flexibly is unblemished, at that point a colonoscopy might be performed to untwist the colon. This typically settle the blockage rapidly.

Author(s):

Ibtihal Y Mahboob, Hani A Jawa and Laila K Ashkar

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