1. VOLVULUS

2. PRESENTATION OUTLINE
 Definition
 Causes
 Incidence
 Pathophysiology
 Clinical features
 Diagnostic investigation
 Predisposing factors
 Nursing intervention

3. OUTLINE CONT’
 Treatment
 Pre-Operative Care
 Post Operative Care
 Complications
 Care plan (Nursing Diagnosis and
outcomes)
 References

4. 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.

5. 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

6. TYPES OF VOLVULUS
 Volvulus neonatorum
 Volvulus of the small intestine
 Ceacal volvulus (volvulus of the caecum)
 Sigmoid volvulus (which is most common
and responsible for most intestinal
obstruction)
 Gastric volvulus

7. GASTRIC VOLVULUS
(ORGANO-AXIAL)

8. GASTRIC VOLVULUS
(MESENTERO-AXIAL)

9. GASTRIC VOLVULUS
(Combined Volvulus)

10. Sigmoid Volvulus

11. CAUSES
 No actual cause is known but certain
predisposing conditions which results or
complicates into volvulus will be
discussed in subsequent slides.

12. PREDISPOSING FACTORS
 Person’s with a redundant colon
 One with a normal anatomic variation
resulting in extra colonic loops
 Patients with muscular dystrophy due to
the smooth muscle dysfunction
 Congenital intestinal malrotation
 Abnormal intestinal contents e.g.
meconium ileus or adhesions

13. PREDISPOSING FACTORS TO
GASTRIC VOLVULUS CONT’
Abnormalities of adjacent organs like:
Diaphragm (hernia, rupture, nerve
palsy)
Liver (dislocation)
Spleen (splenomegaly, wandering
spleen, polyspenia)

14. INCIDENCE
 Occurs commonly in middle aged and
elderly people especially in men.

15. PATHOPHYSIOLOGY
 The 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.

16. CLINICAL FEATURES
 Abdominal distension and vomiting
 Ischemia (loss of blood flow) to the
affected portion of intestine
 Absolute constipation
 There may be visible peristalsis as well as
features of peritonitis
 Severe pain and progressive injury to the
intestinal wall

17. CLINICAL FEATURES CONT’
 Accumulation of gas and fluid in the
portion of the bowel
 Necrosis of the affected intestinal

18. 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

19. Barium Enema

24. NURSING INTERVENTION
 Administer analgesics required to client to
ease off pain
 Encourage client to avoid copious foods
that will induce vomiting
 Give anti-emetics prescribed.
 IV fluid administration is done to replace
body fluids and prevent acidosis by
maintaining electrolyte balance.

25. NURSING INTERVENTION
CONT’
 Examine abdomen for distension and
tenderness
 Auscultate for bowel sounds and
movements

26. TREATMENT
 This 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

27. 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

28. PRE-OPERATIVE ACTIVITIES
 Explain procedure to client and relief of
psychological stress
 Skin preparations e.g. Shaving the abdomen
 Give patient a low residue diet to have less
stools formed
 Antibiotic 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

29. PRE-OPERATIVE ACTIVITIES
CONT’
 A nasogastric or intestinal tube is inserted
before operation and connected to a
suction machine to clear the intestinal
contents.

30. 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

31. POST OPERATIVE ACTIVITIES
CONT’
 Give opiod analgesics to relieve pain
 Encourage patient to do deep breathing
and to change position every 1 hour
 Manage rectal tube sutured in the anus to
facilitate the passage of stool
 Drugs such as neostigmine is given to
prevent straining the intestine during
expulsion
 Early ambulation to start peristalsis

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

33. NURSING DIAGNOSIS
 Pain 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

34. EXPECTED OUTCOMES
 Pain 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.

35. REFERENCES
 Colmer. 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.