Introduction. Sigmoid colon volvulus (SV) represents the most common etiology of antepartum gastrointestinal obstruction, with repetitive antepartum episodes rarely reported. Case Presentation. A 25-year-old multiparous patient with history of SV at 26 weeks in her previous pregnancy presented with recurrent episodes of SV at 32 0/7, 32 4/7, 37 0/7, and 38 1/7 weeks successfully managed with colonoscopic decompression. Labor was successfully induced at 38 4/7 weeks, and she experienced two further episodes on postpartum days #1 and #32 also treated with colonoscopic decompression, followed by laparoscopic resection. Conclusion. Successful treatment of antepartum SV with colonoscopic decompression does not preclude recurrence later in gestation and in future pregnancies

Carl H. Rose

Jaclyn Rivington

Layan Alrahmani

Case Reports in Obstetrics and Gynecology

English

Directory of Open Access Journals

Recurrent Volvulus during Pregnancy: Case Report and Review of the Literature

Introduction. Sigmoid colon volvulus (SV) represents the most common etiology of antepartum gastrointestinal obstruction, with repetitive antepartum episodes rarely reported. Case Presentation. A 25-year-old multiparous patient with history of SV at 26 weeks in her previous pregnancy presented with recurrent episodes of SV at 32 0/7, 32 4/7, 37 0/7, and 38 1/7 weeks successfully managed with colonoscopic decompression. Labor was successfully induced at 38 4/7 weeks, and she experienced two further episodes on postpartum days #1 and #32 also treated with colonoscopic decompression, followed by laparoscopic resection. Conclusion. Successful treatment of antepartum SV with colonoscopic decompression does not preclude recurrence later in gestation and in future pregnancies.</jats:p

Crossref

Case ReportRecurrent Volvulus during Pregnancy: Case Report andReview of the LiteratureLayan Alrahmani ,1 Jaclyn Rivington,2 and Carl H. Rose11Mayo Clinic, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, 200 First St. SW, Rochester,MN 55905, USA2Metrohealth Medical Center, Department of Internal Medicine, 2500 Metrohealth Dr., Cleveland, OH 44109, USACorrespondence should be addressed to Layan Alrahmani; layan.md@gmail.comReceived 30 November 2017; Accepted 5 February 2018; Published 1 March 2018Academic Editor: Maria Grazia PorporaCopyright © 2018 Layan Alrahmani et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.Introduction. Sigmoid colon volvulus (SV) represents the most common etiology of antepartum gastrointestinal obstruction, withrepetitive antepartum episodes rarely reported. Case Presentation. A 25-year-old multiparous patient with history of SV at 26 weeksin her previous pregnancy presented with recurrent episodes of SV at 32 0/7, 32 4/7, 37 0/7, and 38 1/7 weeks successfully managedwith colonoscopic decompression. Labor was successfully induced at 38 4/7 weeks, and she experienced two further episodeson postpartum days #1 and #32 also treated with colonoscopic decompression, followed by laparoscopic resection. Conclusion.Successful treatment of antepartum SV with colonoscopic decompression does not preclude recurrence later in gestation and infuture pregnancies.1. BackgroundVolvulus of the sigmoid colon represents the most commonetiology of antepartum bowel obstruction [1, 2]. Circumfer-ential torsion of an intestinal segment around its mesentericorigin produces symptoms of gastrointestinal colic, and ifuntreated may progress to bowel ischemia and perforation[1, 2]. The increase in uterine size accompanying advancinggestational age with subsequent cephalad displacement ofpelvic segment of the colon has been proposed as a risk factor;most reported cases are isolated solitary occurrences, withrecurrent episodes only rarely described. In this report, wepresent a case with recurrent sigmoid volvulus (SV) in twosuccessive pregnancies treated with temporizing endoscopicdecompression and elective postpartum sigmoid resection.2. Case PresentationA 25-year-old gravida 3, para 2002 at 32 0/7 weeks’ gestationwas referred with a 24-hour history of intermittent severeabdominal pain and obstipation. Her past medical historywas significant for hypothyroidism, a microcytic anemia,and sigmoid volvulus in her previous pregnancy two yearsprior requiring endoscopic reduction at 26 weeks’ gestation.Physical examination revealed suprapubic and right lowerquadrant tenderness, with normal bowel sounds on auscul-tation; peritoneal signs of rebound and/or guarding wereabsent. Obstetric ultrasound demonstrated a nonanomaloussingleton fetus with biometry consistent with gestationalage, no evidence of placental abruption, and normal cervixlength. Due to gravid status, abdominal radiography wasinconclusive but suggestive of colonic distention. Laboratoryevaluation was remarkable for normal leukocyte count andlactate, amylase, and hepatic transaminase levels. Two tapwater enemas were efficacious in prompting adequate stooloutput with alleviation of clinical symptoms, and she wasdischarged.Subsequently, she returned at 32 4/7 weeks with similarcomplaints; the gastroenterology service was consulted, andmagnetic resonance imaging confirmed a 90-degree twistof the colon 30 cm from the anal verge (Figure 1). Colono-scopic decompression followed by rectal tube placement for24 hours was successful, and she was discharged home.Unfortunately, symptoms recurred at 37 0/7 weeks, and sheHindawiCase Reports in Obstetrics and GynecologyVolume 2018, Article ID 4510754, 5 pageshttps://doi.org/10.1155/2018/45107542 Case Reports in Obstetrics and GynecologyFigure 1: Magnetic resonance imaging without contrast performedat 32 weeks’ gestation. There is marked distention of the sigmoidcolon beginning at the level of the sigmoid along the left lateralaspect of the uterus where there appears to be a small, early (90degree) twist of the sigmoid colon. The fetus may also be seen inthis image.Figure 2: Computer tomography imaging with intravascular con-trast performed on postpartum day 1. There is twisting of themesentery and focal mesenteric edema in the mid lower abdomen.The findings are consistent with sigmoid volvulus.underwent a second colonoscopy with decompression, withrectal tube left in place. At 38 1/7 weeks, she underwenta third colonoscopic decompression procedure, and thedecision was made to proceed with delivery. Labor wasinduced, culminating in a spontaneous vaginal delivery of ahealthy female infant. Unfortunately she again experiencedworsening abdominal pain on the first day postpartum,with computer tomography imaging confirming sigmoiddistention with recurrence of volvulus (Figure 2). A fourthcolonoscopic decompression was performed, and she wasdischarged home on the second day postpartum. Symptomsagain recurred on postpartum day 32 and were managedby a fifth colonoscopic decompression followed by uncom-plicated laparoscopic sigmoidectomy on postpartum day34. Histopathologic evaluation of the excised specimen wasbenign.3. Discussion and ConclusionA literature search of the PubMed, Google Scholar, Scopus,and the Cochrane Library databases from January, 01, 1900,to January, 22, 2017, was performed using search terms“recurrent”, “sigmoid volvulus”, and “pregnancy” alone orin combination using the Boolean operator “AND”. Onlypatients with recurrent sigmoid volvulus in pregnancy wereconsidered for this review. The search initially yielded 8articles, and after careful review by two of the authors (JaclynRivington, LayanAlrahmani) only 3met the inclusion criteriaof multiple episodes of sigmoid volvulus recurring in thesame pregnancy; specific characteristics are summarized inTable 1.Intestinal obstruction in pregnancy is relatively rare,with an incidence of 1 in 1500 to 1 in 66,431 deliveries. Todate, only 105 cases of volvulus have been reported duringpregnancy [6], with only 3 authors describing repetitiveepisodes. Typical risk factors include older age, high fiberdiet, constipation, and an elongated redundant sigmoid colon[7, 8]; the disproportionate incidence during pregnancy istheorized to occur due to the physical size of the enlarginggravid uterus displacing the colon out of the pelvis, perhapsexplanatory of the frequency of third-trimester presentation.Furthermore, elevated gestational progesterone levels causehypomotility of the gastrointestinal tract through smoothmuscle relaxation, increasing constipation and volvulus risk[3]. Age and multigravidity do not appear to constitute sig-nificant factors [9]. Although in the nonpregnant populationeventual recurrence of sigmoid volvulus is considered to beapproximately 50%, it has only rarely been documented inpregnancy [10].Management of sigmoid volvulus in pregnancy is similarto the nonpregnant state.The American Society of Colon andRectal Surgeons suggest initial rigid or flexible endoscopyto assess for intestinal viability and to effect therapeuticdetorsion and decompression (Grade 1c) [11]; this is reportedto be successful in 75–95% of cases [11–13]. Definitivesigmoidectomy is considered in the acute setting if thereis evidence of nonviable or perforated colon, or after theresolution of the acute phase of sigmoid volvulus to preventrecurrence (Grade 1c) [11]. A decompression tube is oftenplaced for 1–3 days after the endoscopic procedure; howeverthe utility of this intervention has not been established [14].Alshawi suggests that elective sigmoidectomy be consid-ered in the second trimester of recurrent cases of SV [4], dueto the potential for continued recurrence with developmentof bowel necrosis later in gestation. However, due to the smallcohort of patients actually reported to experience antepartumrecurrence of SV, the optimal course of action is difficultto conclusively extrapolate. In our case, the patient wasmanaged with repetitive endoscopic decompressions in thethird trimester, which is considered to pose a low maternalCase Reports in Obstetrics and Gynecology 3Table1:Previouslypublishedcasesofrecurrentsigmoidvolvulusduringpregnancy.Author(year)PatientdemographicInitialepisode(weeksgestation)InterventionRecurrence(weeksgestation)InterventionDeliveryOutcomeBajajetal.(2015)[3]23yoG3P25Endoscopicdecompression365/7Rigidsigmoidoscopy,onlypartialdecompressionSVDat36weeksSigmoidectomyat6weekspostpartumAlshawi(2005)[4]22yoG2P120Sigmoidoscopicdetorsionandrectaltube28,35ColonoscopicdetorsionandrectaltubeSVDat38weeksSigmoidectomyat2weekspostpartumBandleretal.(1964)[5]28yoG1P016Laparotomywithderotationandpinningofsigmoid371/7DerotationduringCDCDat37weeksSubtotalcolectomyat4weekspostpartumOurcase25yoG3P232Sigmoidoscopicdetorsionandrectaltube325/7,37,381/7EndoscopicdecompressionandrectaltubeSVDat38weeksSigmoidcolectomyat4weekspostpartumCD,cesareandelivery;SVD,spontaneousvaginaldelivery.4 Case Reports in Obstetrics and Gynecologyand fetal risk irrespective of gestational age [15]. The riskof elective or emergent surgical bowel resection must beweighed against the challenge of repeated endoscopic treat-ments; with anticipated reduction in uterine size followingdelivery, one could argue that the instigating factor would“resolve” postpartum, possibly eliminating the need for colonresection.It is difficult to ascertain whether volvulus is more likelyto recur in pregnancy. Since pregnancy is a predisposingfactor, we can assume that since the enticing factor still exists,namely, pregnancy, the chance for recurrence is high. Timeto recurrence of volvulus is variable. Prevention strategies forrecurrence other than definitive surgery are unknown. Pre-vention of constipation with dietary modifications and stoolsofteners is safe but short-term efficacy is not determined.Obstetrical management in these situations must beindividualized; the authors would recommend a multi-disciplinary approach involving Obstetrics, Maternal-FetalMedicine, Anesthesiology, Gastroenterology, and ColorectalSurgery. Vaginal delivery is not contraindicated, and cesareandelivery should be reserved for routine obstetrical indica-tions; of note, in all reported cases of recurrent SV (includingthe current), vaginal delivery was accomplished. Monitoringfor symptoms of intrapartum recurrence, particularly ifneuraxial anesthesia is elected, is important; in the eventthat cesarean delivery is required, depending on preoperativepreparation, concurrent elective bowel resection may beconsidered.Reported prognosis of SV varies widely, with maternalmortality rates of 5–12% and fetal mortality of 20–26% [1].Almost all maternal deaths occurredwhen patients presentedmore than 48 hours following onset of symptoms. Similarly,maternal mortality associated with viable bowel is only 5%but increases to greater than 50% once bowel perforationhas occurred [6], underscoring the importance of timelydiagnosis and intervention. Recurrence of SV in subsequentpregnancies and/or postpartum has not previously beendescribed; interestingly the current case occurred at a similargestational age in two successive pregnancies, suggestingthe basic underlying anatomy with the additional uterinecompression as the precipitating factor. Patients experiencingSV in pregnancy successfully treated with colonoscopicdecompression should be counseled on the potential forrecurrence both later in gestation and in future pregnancies.AbbreviationsSV: Sigmoid volvulus.Data AvailabilityData sharing is not applicable to this article as no datasetswere generated or analysed during the current study.Ethical ApprovalThis study was exempt from Institutional Review Board atMayo Clinic due to being of minimal risk.ConsentThe patient consented to participate in research. Consent forpublication was obtained.Conflicts of InterestThe authors declare that they have no conflicts of interest.Authors’ ContributionsLayanAlrahmani and Jaclyn Rivington reviewed the case andcontributed to writing and editing the manuscript. Carl H.Rose reviewed and edited the manuscript.References[1] Z. Aftab, A. Toro, A. Abdelaal et al., “Endoscopic reductionof a volvulus of the sigmoid colon in pregnancy: case reportand a comprehensive review of the literature,”World Journal ofEmergency Surgery (WJES), vol. 9, p. 41, 2014.[2] M. R. Khan and S. ur Rehman, “Sigmoid volvulus in pregnancyand puerperium: a surgical and obstetric catastrophe. Reportof a case and review of the world literature,” World Journal ofEmergency Surgery, vol. 7, no. 1, article 10, 2012.[3] M. Bajaj, C. Gillespie, and J. Dale, “Recurrent sigmoid volvulusin pregnancy,” ANZ Journal of Surgery, 2 pages, 2015.[4] J. S. Alshawi, “Recurrent sigmoid volvulus in pregnancy: Reportof a case and review of the literature,” Diseases of the Colon &Rectum, vol. 48, no. 9, pp. 1811–1813, 2005.[5] M. Bandler, S. Freidman, and M. Roberts, “Recurrent volvulusof the sigmoid colon during pregnancy complicated by toxemiaof pregnancy,”TheAmerican Journal of Gastroenterology, vol. 42,pp. 447–453, 1964.[6] A.M. AlMaksoud, A. K. Barsoum, andM.M.Moneer, “Surgerycase reports signet ring cell carcinoma of the ampulla of vater?:report of a case and a review of the literature,” InternationalJournal of Surgery Case Reports, vol. 12, pp. 108–111, 2015.[7] T. E. Madiba, C. Aldous, and M. R. Haffajee, “The morphologyof the foetal sigmoid colon in theAfrican population: A possiblepredisposition to sigmoid volvulus,” Colorectal Disease, vol. 17,no. 12, pp. 1114–1120, 2015.[8] S. A. Michael and S. Rabi, “Morphology of sigmoid colon insouth indian population: a cadaveric study,” Journal of Clinicaland Diagnostic Research, vol. 9, no. 8, pp. AC04–AC07, 2015.[9] W. B. Jr. Harer and W. B. Sr. Harer, “Volvulus complicatingpregnancy and puerperium: report of three cases and review ofliterature,” Obstetrics & Gynecology, vol. 12, no. 4, pp. 399–406,1958.[10] E. C. Mangiante, M. A. Croce, T. C. Fabian, O. F. Moore III, andL. G. Britt, “Sigmoid volvulus. A four-decade experience,” TheAmerican Surgeon, vol. 55, no. 1, pp. 41–44, 1989.[11] J. D. Vogel, D. L. Feingold, D. B. Stewart et al., “Clinical PracticeGuidelines for Colon Volvulus and Acute Colonic Pseudo-Obstruction,” Diseases of the Colon and Rectum, vol. 59, no. 7,pp. 589–600, 2016.[12] S. S. Atamanalp, “Treatment of sigmoid volvulus: A single-center experience of 952 patients over 46.5 years,” Techniquesin Coloproctology, vol. 17, no. 5, pp. 561–569, 2013.[13] J. R. Anderson and D. Lee, “The management of acute sigmoidvolvulus,” British Journal of Surgery, vol. 68, no. 2, pp. 1–4, 1981.Case Reports in Obstetrics and Gynecology 5[14] M. E. Harrison, M. A. Anderson, and V. Appalaneni, “Therole of endoscopy in the management of patients with knownand suspected colonic obstruction and pseudo-obstruction,”Gastrointestinal Endoscopy, vol. 71, no. 4, pp. 669–679, 2010.[15] A. De Lima, B. Galjart, P. H. A. Wisse et al., “Does lowergastrointestinal endoscopy during pregnancy pose a risk formother and child? - a systematic review,”BMCGastroenterology,vol. 15, no. 1, pp. 10–1186, 2015.Stem Cells InternationalHindawiwww.hindawi.com Volume 2018Hindawiwww.hindawi.com Volume 2018MEDIATORSINFLAMMATIONofEndocrinologyInternational Journal ofHindawiwww.hindawi.com Volume 2018Hindawiwww.hindawi.com Volume 2018Disease MarkersHindawiwww.hindawi.com Volume 2018BioMed Research InternationalOncologyJournal ofHindawiwww.hindawi.com Volume 2013Hindawiwww.hindawi.com Volume 2018Oxidative Medicine and Cellular LongevityHindawiwww.hindawi.com Volume 2018PPAR ResearchHindawi Publishing Corporation http://www.hindawi.com Volume 2013www.hindawi.comThe Scientific World Journal8Immunology ResearchHindawiwww.hindawi.com Volume 2018Journal ofObesityJournal ofHindawiwww.hindawi.com Volume 2018Hindawiwww.hindawi.com Volume 2018 Computational and  Mathematical Methods in MedicineHindawiwww.hindawi.com Volume 2018Behavioural NeurologyOphthalmologyJournal ofHindawiwww.hindawi.com Volume 2018Diabetes ResearchJournal ofHindawiwww.hindawi.com Volume 2018Hindawiwww.hindawi.com Volume 2018Research and TreatmentAIDSHindawiwww.hindawi.com Volume 2018Gastroenterology Research and PracticeHindawiwww.hindawi.com Volume 2018Parkinson’s DiseaseEvidence-Based Complementary andAlternative MedicineVolume 2018Hindawiwww.hindawi.comSubmit your manuscripts atwww.hindawi.com

http://downloads.hindawi.com/journals/criog/2018/4510754.pdf

Recurrent Volvulus during Pregnancy: Case Report and Review of the Literature

Abstract

Similar works

Full text

Available Versions

Directory of Open Access Journals

Crossref