Intestinal obstruction

Definition
 When the intestinal contents fail to move distally, it is called intestinal
obstruction. It is the most common surgical disorder ( emergency) of the
intestines.
Epidemiology
 Few important facts about intestinal obstruction:
 80% occur in small bowel
 20% occur in large bowel
 Majority (more than 80%) of small bowel obstructions are benign in nature. In the
large bowel, more than 70% of colonic obstruction is due to malignancy-others
being inflammatory bowel diseases, ileocaecal tuberculosis, volvulus, etc.
CLASSIFICATION
1. Depending upon the nature of obstruction
A. Dynamic obstruction/mechanical obstruction in which peristalsis is working
against a mechanical obstruction. It may occur in an acute or a chronic form.
B. Adynamic obstruction in which there is no mechanical obstruction; peristalsis is
absent or inadequate (e.g. paralytic ileus or pseudo-obstruction)
2. Depending on the blood supply
A. Simple obstruction: Blood supply is not seriously impaired.
B. Strangulated obstruction: Blood supply is seriously impaired.
C. Closed loop obstruction: It means both proximal and distal ends are blocked.
This occurs in carcinoma of the right colon with constrictive lesions. If the
ileocaecal valve is competent and the obstruction is total, the intraluminal
pressure within the colon increases. As a result of this, the caecum may
perforate. Thus, closed loop obstruction can be dangerous. Another example is
sigmoid volvulus.
3. Depending upon the cause of obstruction
A. In the lumen of the gut
 Gall stones ileus
 Food bolus obstruction
 Roundworm mass
 Foreign body (rare)
 Meconium ileus
B. In the wall of the gut
 Stricture, e.g. tuberculosis
 Crohn 's disease
 Carcinoma
 Atresia
 Adhesions
C. Outside the wall of the gut
 Yolvulus, intussusception
 Congenital bands
 Meckel's diverticulum with band
 Obstructed hernia
4. Depending upon severity of obstruction
A. Acute obstruction: Signs and symptoms appear very early. Usually, it affects
small bowel, obstructed hernia, bands.
 B. Chronic obstruction (e.g. carcinoma colon) affects large bowel (colic comes
first, distension later). Diverticular disease also produces chronic obstructions
(Fig. 30.3).
C. Acute on chronic obstruction develops in carcinoma colon, wherein an acute
obstruction suddenly results due to the accumulation of faecal matter in the
proximal bowel (see Fig. 30.4 for various causes of intestinal obstruction).

PATHOPHYSIOLOGY
 Irrespective of aetiology or acuteness of onset, in dynamic (mechanical) obstruction
the bowel proximal to the obstruction dilates and the bowel below the obstruction
exhibits normal peristalsis and absorption until it becomes empty and collapses.
 Initially, the proximal bowel undergoes hyperperistalsis which is responsible for
colicky pain abdomen. in an attempt to overcome the obstruction. If the obstruction
is not relieved, the bowel continues to dilate; ultimately there is a reduction in
peristaltic strength, resulting in flaccidity and paralysis.
 The distension proximal to an obstruction is caused by two factors:
o Gas: there is a significant overgrowth of both aerobic and anaerobic
organisms, resulting in considerable gas production. Following the
reabsorption of oxygen and carbon dioxide, the majority is made up of
nitrogen (90%) and hydrogen sulphide.
o Fluid: this is made up of the various digestive juices. (saliva 500 mL, bile 500
mL, pancreatic secretions 500 mL, gastric secretions 1 litre – all per 24 hours).
This accumulates in the gut lumen as absorption by the obstucted gut is
retarded. Dehydration and electrolyte loss are therefore due to:
 reduced oral intake;
 defective intestinal absorption;
 losses as a result of vomiting;
 sequestration in the bowel lumen;
 transudation of fluid into the peritoneal cavity.
 After 3-4 hours, distal to the obstruction, all physiological activities of the bowel
are stopped. Intestine becomes contracted, pale and does not exhibit peristalsis.
Role of bacteria
 Bacterial colony count increases following obstruction resulting in stasis. From
less than 106 in jejunum and from I 08 in ileum, counts increase.

STRANGULATION
 It is important to appreciate that the consequences of intestinal obstruction are not
immediately life-threatening unless there is superimposed strangulation.
 When strangulation occurs, the blood supply is compromised and the bowel becomes
ischaemic.
 Ischaemia from direct pressure on the bowel wall from a constricting band such as a
hernial orifice is easy to understand.
 Distension of the obstructed segment of bowel results in high pressure within the
bowel wall. This can happen when only part of the bowel wall is obstructed as seen in
Richter’s hernias. Venous return is compromised before the arterial supply. The
resultant increase in capillary pressure leads to impaired
local perfusion and once the arterial supply is
impaired, haemorrhagic infarction occurs.
 As the viability of the bowel is compromised, translocation
and systemic exposure to anaerobic organisms and
endotoxin occurs.
 The morbidity and mortality associated with strangulation
are largely dependent on the duration of the ischaemia and its extent.
 Elderly patients and those with comorbidities are more vulnerable to its effects.
Although in strangulated external hernias the segment involved is often short, any
length of ischaemic bowel can cause significant systemic effects secondary to sepsis
and obstruction proximal to the obstruction can result in significant dehydration.
When bowel involvement is extensive circulatory failure is common.
Closed-loop obstruction
 This occurs when the bowel is obstructed at both the proximal and distal points
(Figure 71.2). The distension is principally confined to the closed loop; distension
proximal to the obstructed segment is not typically marked.
 A classic form of closed-loop obstruction is seen in the presence of a malignant
stricture of the colon with a competent ileocaecal valve (present in up to one-third of
individuals). This can occur with lesions as far distally as the rectum. The inability of
the distended colon to decompress itself into the small bowel results in an increase in
luminal pressure, which is greatest at the caecum, with subsequent impairment of
blood flow in the wall. Unrelieved, this results in necrosis and perforation (Figure
71.3).

CLINICAL FEATURES OF INTESTINAL OBSTRUCTION

Dynamic obstruction
 The diagnosis of dynamic intestinal obstruction is based on the classic quartet of
pain, distension, vomiting and absolute constipation.
 Obstruction may be classified clinically into two types:
o small bowel obstruction – high or low;
o large bowel obstruction.
 The nature of the presentation will also be influenced by whether the obstruction is:
o complete;
o incomplete.
 A complete small bowel obstruction has all the cardinal features. In cases of
complete large bowel obstruction there is often a surprising lack of preceeding
symptoms. Both small and large bowel obstruction can present with more chronic
symptoms in which the symptoms are intermittent or the obstruction is incomplete.
 Incomplete obstruction is also referred to as partial or subacute. Presentation will be
further influenced by whether the obstruction is:
o simple – in which the blood supply is intact;
o strangulating/strangulated – in which there is interference to blood flow.
 The clinical features vary according to:
o the location of the obstruction;
o the duration of the obstruction;
o the underlying pathology;
o the presence or absence of intestinal ischaemia.
Late manifestations of intestinal obstruction that may be encountered include dehydration,
oliguria, hypovolaemic
shock, pyrexia, septicaemia, respiratory embarrassment and peritonism. In all cases of
suspected intestinal obstruction, the hernial orifices must be examined.
Pain
o Pain is the first symptom encountered; it occurs suddenly and is usually severe.
o It is colicky ( lasts for 5-10 minutes and is intermittent. On pressure, it Decreases)
in nature and usually centred on the umbilicus (small bowel) or lower abdomen (large
bowel).
o The pain coincides with increased peristaltic activity. With increasing distension, the
colicky pain is replaced by a mild and more constant diffuse pain. If there is no
 ischaemia and the obstruction persists over several days, pain reduces and can
disappear.
o The development of severe pain is suggestive of the presence of strangulation,
especially if that severe pain is continuous. Beware the patient whose pain is not
controlled with intravenous opiates.
o Colicky pain may not be a significant feature in postoperative simple mechanical
obstruction and pain does not usually occur in paralytic ileus.
Vomiting
o is due to reverse peristalsis. Vomitus consists of stomach contents initially, then
bile, followed by faeculent matter, as a result of the presence of enteric bacterial
overgrowth.
o Faeculent is not faecal matter but terminal ileal contents which undergo
bacterial degradation and fermentation resulting in the smell of faecal
matter. Vomiting of altered blood indicates haemorrhage and gangrene.
Frequent vomiting reflects jejuna! obstruction
o The more distal the obstruction, the longer the interval between the onset of
symptoms and the appearance of nausea and vomiting.

Distension
o In the small bowel the degree of distension is dependent on the site of the
obstruction and is greater the more distal the lesion.
o It may be central abdominal distension as seen in ileal obstruction, peripheral
abdominal as in large bowel obstruction, or localised to one or two quadrants as
in sigmoid volvulus.
o Distension is a later feature in colonic obstruction and may be minimal or absent in
the presence of mesenteric vascular occlusion
Constipation
o This may be classified as absolute (obstipation) (i.e. neither faeces nor flatus is
passed) or relative (where only flatus is passed).
o Absolute constipation is a cardinal feature of complete intestinal obstruction. Some
patients may pass flatus or faeces after the onset of obstruction as a result of the
evacuation of the distal bowel contents.
o The administration of enemas should be avoided in cases of suspected obstruction.
This merely stimulates evacuation of bowel contents distal to the obstruction and
confuses the clinical picture.
o The rule that absolute constipation is present in intestinal obstruction does not apply
in:
o Richter’s hernia;
o gallstone ileus;
o mesenteric vascular occlusion;
o functional obstruction associated with pelvic abscess;
o all cases of partial obstruction (in which diarrhoea may occur).
Other manifestations
Dehydration
o Dehydration is seen most commonly in small bowel obstruction because of repeated
vomiting and fluid sequestration. It results in dry skin and tongue, poor venous filling
and sunken eyes with oliguria. The blood urea level and haematocrit rise, giving a
secondary polycythaemia.
Hypokalaemia
 o Hypokalaemia is not a common feature in simple mechanical obstruction. An increase
in serum potassium, amylase or lactate dehydrogenase may be associated with the
presence of strangulation, as may leucocytosis or leucopenia.
Pyrexia
o Pyrexia in the presence of obstruction is rare and may indicate:
o the onset of ischaemia;
o intestinal perforation;
o inflammation or abscess associated with the obstructing disease.
o Hypothermia indicates septicaemic shock or neglected cases of long duration.
Abdominal tenderness
o Localised tenderness indicates impending or established ischaemia. The
development of peritonism or peritonitis indicates overt infarction and/or perforation.
In cases of large bowel obstruction, it is important to elicit these findings in the right
iliac fossa as the caecum is most vulnerable to ischaemia.
Bowel sounds
o High-pitched bowel sounds (borborygmi) are present in the vast majority of
patients with intestinal obstruction. Normal bowel sounds are of negative predictive
value. Bowel sounds may be scanty or absent if the obstruction is longstanding and
the small bowel has become inactive.
o Hernial orifices have to be examined, especially for a femoral hernia in females.
Visible perstalysis
o Visible peristalsis may be present. This can sometimes be provoked by ‘flicking’ the
abdominal wall.
o Step ladder peristalsis is seen in terminal ilea! obstruction. Right to left colonic
peristalsis is seen in left-sided colonic obstruction,
Clinical features of strangulation
o It is vital to distinguish strangulating from non-strangulating intestinal obstruction
because the former is a surgical emergency.
o In cases of intestinal obstruction in which pain persists despite conservative
management, even in the absence of the above signs, strangulation should be
presumed.
o The diagnosis is almost entirely clinical. In addition to the features above, it should
be noted that:
o The presence of shock suggests underlying ischemia, especially if the shock is
resistant to simple fluid resuscitation.
o In impending or established strangulation, pain is never completely absent.
o The presence and character of any local tenderness are of great significance and,
however mild, tenderness requires frequent reassessment.
o Generalised tenderness and the presence of rigidity indicate the need for early
laparotomy.
o When strangulation occurs in an external hernia, the lump is tense, tender and
irreducible and there is no expansile cough impulse. Skin changes with erythema or
purplish discolouration are associated with underlying ischaemia
o Rebound tenderness: It is called Blomberg's sign. It is a classical sign of
peritonitis.
o • Guarding and rigidity of the abdominal wall.
o • Absent bowel sounds because rest of the bowel loops undergo paralytic
ileus.
o • Sudden symptoms-spasmodic pain (due to peristalsis) and continuous pain
suggest strangulation
o Features of strangulation and perforation occur quickly in cases of closed loop
obstruction (
Rectal examination
o In small bowel obstruction, rectum is empty and is often ballooned out.
Carcinomatous growth with or without stools can be felt.
o The finger may be stained with blood.The small intestine is considered dilated if
loops of bowel measure more than 3 cm in diameter. Measurements for the
large bowel vary among different anatomic segments, with a relative threshold of
9 cm in diameter for the proximal colon and 5 cm for the sigmoid colon.

INVESTIGATIONS
• Complete blood picture: Low Hb% indicates underlying
malignancy. Increased total WBC count indicates infection
and sepsis (perforation).
• Electrolytes: Most of the electrolytes are low in cases of
intestinal obstruction and require con-ection preoperatively.
Strangulation may be associated with deranged potassium,
amylase or lactic dehydrogenase. Fig. 30.12: Multiple gas fluid
levels-plain X-ray erect abdomen
• Plain X-ray abdomen in the erect position may show
multiple gas fluid levels. Gas levels appear earlier than fluid
level. Normally, two insignificant fluid levels can be
present, one in the terminal ileum and one in the first part
of the duodenum (Key Box 30.7). Supine films indicate
the distal limit of obstruction (Figs 30.12 to 30.16).
PEARLS OF WISDOM
Enteroclysis is rarely performed in acute
intestinal
obstruction but it has greater sensitivity in the detection
of partial small bowel obstruction
• Ultrasound/CT scan-See

SPECIAL TYPES OF MECHANICAL INTESTINAL

OBSTRUCTION
Internal hernia
o Internal herniation occurs when a portion of the small intestine becomes entrapped in
one of the retroperitoneal fossae or in a congenital mesenteric defect.
o The following are potential sites of internal herniation (all are rare):
o the foramen of Winslow;
o a defect in the mesentery;
o a defect in the transverse mesocolon;
o defects in the broad ligament;
o congenital or acquired diaphragmatic hernia;
o duodenal retroperitoneal fossae – left paraduodenal and right duodenojejunal;
.
o caecal/appendiceal retroperitoneal fossae – superior, inferior and retrocaecal;
 o intersigmoid fossa.
o Internal herniation in the absence of adhesions is rare and a preoperative diagnosis is
unusual. The standard treatment of an obstructed hernia is to release the
constricting agent by division. This should not be undertaken in cases of herniation
involving the foramen of Winslow, mesenteric defects and the
paraduodenal/duodenojejunal fossae as major blood vessels run in the edge of the
constriction ring. The distended loop in such circumstances must first be
decompressed (minimizing contamination) and then reduced.
Obstruction from enteric strictures
o Small bowel strictures usually occur secondary to tuberculosis or Crohn’s disease.
Malignant strictures associated with lymphoma are uncommon, whereas carcinoma
and sarcoma are rare.
o Presentation is usually subacute or chronic.
o Standardsurgical management consists of resection and anastomosis. Resection is
important to establish a histological diagnosis as this can be uncertain clinically. In
Crohn’s disease, strictureplasty may be considered in the presence of short multiple
strictures without active sepsis.
Bolus obstruction
o Bolus obstruction in the small bowel may be caused by gallstones, food, trichobezoar,
phytobezoar, stercoliths and worms.
Gallstones
o This type of obstruction tends to occur in the elderly secondary to erosion of a large
gallstone directly through the gall bladder into the duodenum.
o Classically, there is impaction about 60 cm proximal to the ileocaecal valve. The
patient may have recurrent attacks as the obstruction is frequently incomplete or
relapsing as a result of a ball-valve effect.
o The characteristic radiological sign of gallstone ileus is Rigler’s triad, comprising:
small bowel obstruction, pneumobilia and an atypical mineral shadow on radiographs
of the abdomen. The presence of two of these radiological signs has been considered
pathognomic of gallstone ileus and is encountered in 40–50% of the cases (note than
pneumobilia is common following endoscopic retrograde cholangiopancreatography
(ERCP) with sphincterotomy).
o At laparotomy, the stone is milked proximally away from the site of impaction. It may
be possible to crush the stone within the bowel lumen; if not, the intestine is opened
at this point and the gallstone removed. If the gallstone is faceted, a careful check for
other enteric stones should be made. The region of the gall bladder should not be
explored.

Food
o Bolus obstruction may occur after partial or total gastrectomy when unchewed
articles can pass directly into the small bowel. Fruit and vegetables are particularly
liable to cause obstruction. The management is similar to that for gallstone, with
intraluminal crushing usually being successful.
Trychobezoars and phytobezoars
o These are firm masses of undigested hair ball and fruit/ vegetable fibre respectively.
The former is due to persistent hair chewing or sucking, and may be associated with
an underlying psychiatric abnormality. Predisposition to phytobezoars results from a
high fibre intake, inadequate chewing, previous gastric surgery, hypochlorhydria and
loss of the gastric pump mechanism. When possible, the lesion may be kneaded into
the caecum; otherwise open removal is required. A preoperative diagnosis is difficult
even with high-resolution computed tomography (CT) scanning.
Stercoliths
 o These are usually found in the small bowel in association with a jejunal diverticulum
or ileal stricture. Presentation and management are identical to that of gallstones.
Worms
o Ascaris lumbricoides may cause low small bowel obstruction, particularly in children,
the institutionalised and those near the tropics (Figure 71.4). An attack may follow
the initiation of antihelminthic therapy. Debility is frequently out of proportion to that
produced by the obstruction. If worms are not seen in the stool or vomitus the
diagnosis may be indicated by eosinophilia or the sight of worms within gas-filled
small bowel loops on a plain radiograph (Naik). At laparotomy it may be possible to
knead the tangled mass into the caecum; if not it should be removed. Occasionally,
worms may cause a perforation and peritonitis, especially if the enteric wall is
weakened by such conditions as ameobiasis.
Obstruction by adhesions and bands
Adhesions
o In Western countries where abdominal operations are common, adhesions and bands
are the most common cause of intestinal obstruction. The lifetime risk of requiring an
admission to hospital for adhesional small bowel obstruction susequent to abdominal
surgery is around 4% and the risk of requiring a laparotomy around 2%. Adhesions
start to form within hours of abdominal surgery. In the early postoperative period, the
onset of such a mechanical obstruction may be difficult to differentiate from paralytic
ileus. The causes of intraperitoneal adhesions are shown in Any source of peritoneal
irritation results in local fibrin production, which produces adhesions between
apposed surfaces. Early fibrinous adhesions may disappear when the cause is
removed or they may become vascularised and be replaced by mature fibrous tissue.
There are several factors that may limit adhesion formation.
Laparoscopic technique
Numerous substances have been instilled in the peritoneal
cavity to prevent adhesion formation, including hyaluronidase,
hydrocortisone, silicone, dextran, polyvinylpropylene
(PVP), chondroitin and streptomycin, anticoagulants, antihistamines,
non-steroidal anti-inflammatory drugs and streptokinase.
Currently, no single agent or combination of agents
has been convincingly shown to be effective.It is hoped that
with the more widespread use of laparoscopic surgery the incidence
of intra-abdominal adhesions will reduce.
Adhesions may be classified into various types by virtue
of whether they are early (fibrinous) or late (fibrous) or by
underlying aetiology. From a practical perspective there are
only two types – ‘easy’ flimsy ones and ‘difficult’ dense ones.
Postoperative adhesions giving rise to intestinal obstruction
usually involve the lower small bowel and almost never
involve the large bowel.
Bands
Usually only one band is culpable. This may be:
●● congenital, e.g. obliterated vitellointestinal duct;
●● a string band following previous bacterial peritonitis;
●● a portion of greater omentum, usually adherent to the
parietes.
Acute intussusception
This occurs when one portion of the gut invaginates into an
immediately adjacent segment; almost invariably, it is the
proximal into the distal.
The condition is encountered most commonly in children,
with a peak incidence between 5 and 10 months of age.
About 90% of cases are idiopathic but an associated upper
respiratory tract infection or gastroenteritis may precede the
condition. It is believed that hyperplasia of Peyer’s patches in
the terminal ileum may be the initiating event. Weaning, loss
of passively acquired maternal immunity and common viral
pathogens have all been implicated in the pathogenesis of
intussusception in infancy.
Children with intussusception associated with a pathological
lead point such as Meckel’s diverticulum, polyp, duplication,
Henoch–Schönlein purpura or appendix are usually
older than those with idiopathic disease. After the age of

2 years, a pathological lead point is found in at least one-third

of affected children. Adult cases are invariably associated
with a lead point, which is usually a polyp (e.g. Peutz–Jeghers
syndrome), a submucosal lipoma or other tumour.
Pathology
An intussusception is composed of three parts (Figure 71.5):
●● the entering or inner tube (intussusceptum);
●● the returning or middle tube;
●● the sheath or outer tube (intussuscipiens).
The part that advances is the apex, the mass is the intussusception
and the neck is the junction of the entering layer
with the mass.

Intussusception may be anatomically defined according

to the site and extent of invagination (Table 71.2). In most
children, the intussusception is ileocolic. In adults, colocolic
intussusception is more common. The degree of ischaemia
is dependent on the tightness of the invagination, which is
usually greatest as it passes through the ileocaecal valve. On
CT scanning the target sign may be evident and if present is
pathognomonic. It is worth noting that, rarely, intussuception
has been noted on CT scanning in asymptomatic adults.

Volvulus
A volvulus is a twisting or axial rotation of a portion of bowel about
its mesentery. The rotation causes obstruction to the lumen (>180°
torsion) and if tight enough also causes vascular occlusion in the
mesentery (>360° torsion). Bacterial fermentation adds to the
distension and increasing intraluminal pressure impairs capillary
perfusion. Mesenteric veins become obstructed as a result of the
mechanical twisting and thrombosis results and contributes to
the ischaemia. Volvuli may be primary or secondary. The
primary form occurs secondary to congenital malrotation of the gut,
abnormal mesenteric attachments or congenital bands.
Examples include volvulus neonatorum, caecal volvulus
and sigmoid
volvulus. A secondary volvulus, which is the more common
variety, is due to rotation of a segment of bowel
around an
acquired adhesion or stoma.
Volvulus neonatorum
This occurs secondary to intestinal malrotation (see Chapter
9) and is potentially catastrophic.
Sigmoid volvulus
This is uncommon in Europe and the USA but more common
in Eastern Europe and Africa. Indeed, it is the most
common cause of large bowel obstruction in the indigenous
black African population. Rotation nearly always occurs in
the anticlockwise direction. The predisposing clinical features
are summarised in Figure 71.6. Other predisposing
factors include a high-residue diet and constipation. In

western populations, the condition is seen most often in

elderly patients with chronic constipation; comorbidities are
common and chronic psychotropic drug use is associated with
this condition. Younger patients present earlier and the prognosis
is inversely related to the duration of symptoms. Presentation
can be classified as:
●● Fulminant: sudden onset, severe pain, early vomiting, rapidly
deteriorating clinical course;
●● Indolent: insidious onset, slow progressive course, less
pain, late vomiting.
Compound volvulus
This is a rare condition also known as ileosigmoid knotting.
The long pelvic mesocolon allows the ileum to twist around
the sigmoid colon, resulting in gangrene of either or both segments
of bowel. The patient presents with acute intestinal
obstruction, but distension is comparatively mild. Plain radiography
reveals distended ileal loops in a distended sigmoid
colon. At operation, decompression, resection and anastomosis
are required.

VOLVULUS OF THE SIGMOID COLON

• Common in North India (Punjab), Eastern Europe, Uganda.
• In certain parts of India as mentioned above, it is one of
the common surgical emergencies in elderly population
(Key Box 30.13).

Precipitating factors (Fig. 30.21)

1. Long mesentery of the pelvic colon
2. Narrow attachment at the base

3. Long, redundant, pendulous sigmoid

4. Loaded colon due to high residue diet
5. Diverticulitis with a band, or adhesions
Sigmoid volvulus is a definite occurrence in mentally
disturbed patients, hypothyroidism, Parkinson's disease,
multiple sclerosis, etc. probably due to severe constipation
due to medications

Clinical features
1. Acute sigmoid volvulus (fulminant) presents as intestinal
obstruction. It starts usually after straining at stools.
Volvulus is usually in anticlockwise direction and after one
and a half turns, the entire loop becomes gangrenous.
Enormous distension of the abdomen takes place, which
gives a tympanitic note all over the abdomen. It is due to
diffusion of CO2 (Fig. 30.22). Due to gross distension,

severe hypovolaemic shock develops within 6-8 hours of

volvulus. Gangrene sets in, which gives rise to features of
strangulation. A dilated loop can be seen and felt. Features
of peritonitis are seen within 1-2 days. Per rectal
examination shows rectum to be empty.
PEARLS OF WISDOM
Distended tympanitic drum like abdomen-sigmoid
volvulus.
2. Chronic (indolent) recurrent sigmoid volvulus: It occurs
due to partial twisting and untwisting of the bowel. Elderly
patients present with recuITent lower abdominal pain on
the left side and distension of the abdomen which is relieved
on passing large amount of flatus.
Diagnosis
• Plain X-ray abdomen erect shows a hugely dilated sigmoid
loop which is described as 'bent inner tube sign'. The
dilated loop may be visible on the right side, centre and to
the left of abdomen, having two fluid levels, one on right
side and one on left side. This is also described as 'omega
sign' (Figs 30.23 and 30.24).
• Contrast enema: As the barium enters the rectum, it tapers
into the sigmoid colon-Bird's beak sign.