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Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.

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Surgical Treatment: Evidence-Based and Problem-Oriented.

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Obstruction of the colon (benign pathology)

, M.D., , and , M.D.

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Obstruction of the colon is mostly caused by carcinoma of the left colon, but diverticulitis of the sigmoid, colonic volvulus, and endometriosis may also cause acute obstruction.

Volvulus of the colon

Volvulus of the sigmoid

The sigmoid colon is the most common site for colonic volvulus occurring often in patients over 60 years with a history of chronic constipation. Other contributing factors may include neurologic or psychiatric disorders (neuropsychotropic drugs alter the bowel motility), adhesions from previous surgery, and pregnancy.

Clinical features

The symptoms of volvulus of the sigmoid are colicky abdominal pain, complete constipation, and gross, usually asymmetric distention of the abdomen. Physical examination reveals marked abdominal tenderness frequently with a palpable tympanitic mass. Rectal examination commonly shows absence of feces. If gangrenous changes have occurred, tachycardia, toxicity and peritonitis may be present.


A plain X-ray examination of the abdomen reveals dilated loops of large bowel forming the “omega loop” sign, with the convexity of the loop lying away from the site of obstruction. Pointing towards the obstruction is the “bird's beak”.


The initial treatment is an attempt at deflation and untwisting of the sigmoid loop by the passage of a well lubricated rubber rectal tube through a sigmoidoscope with the patient in the lateral knee-chest position. After decompression, the involved segment usually undergoes spontaneous detorsion, the immediate escape of flatus and liquid faeces through the sigmoidoscope or catheter indicates that the obstruction has been removed. The tube is left in place for 48 hours. This treatment can be expected to be successful in 80% of patients. If the segment is viable at exploration simple detorsion should be performed, further treatment should be considered because of the high recurrence rate (35–60%). Elective resection of the sigmoid loop following adequate preparation with primary anastomosis should be performed through laparotomy or laparoscopic approach.

If decompression is unsuccessful or if mucosa of doubtful viability is seen, immediate laparotomy is mandatory. The resection may be accompanied by primary anastomosis with peroperative colonic lavage in most of the cases. When gangrene is associated with peritonitis a Hartmann procedure may be performed, eventually accompanied by Mikulicz drainage. Colostomy alone is contraindicated because it will not prevent recurrent volvulus.

Perioperative colonic lavage

A 24 F foley catheter is inserted into the cecum through the appendicular stump or through the terminal ileum if the patient has had an appendectomy. A balloon catheter is inflated. The distal bowel is draped over the side of the patient and secured in a polyethylene bag. The colon is lavaged with warm, isotonic saline solution until the lavage fluid is clear (4 to 6 liters) and is then severed at the site chosen for anastomosis.

Volvulus of the right colon

Acute volvulus of the right colon accounts for 1–10% of all intestinal obstructions and 18–44% of all cases of colonic volvulus. Autopsies have shown that in 11–22% of the population the right colon is sufficiently mobile to allow the development of volvulus. Adhesions from previous surgery, congenital band, pregnancy, malrotation and obstructing lesions of the left colon have been discussed as triggers.

Female predominance has been frequently reported; many authors observed a significantly higher frequency in elderly women.

Clinical features

The diagnosis is not easy, the clinical picture is that of bowel obstruction with a tympanic mass extending from the right lower to the right upper quadrant. Radiological examination of the abdomen remains the key to diagnosis: typically, the cedal shadow is absent from the lower quadrant, the cecal air fluid level may be seen in the left upper quadrant mimicking the stomach shadow. Cecum is greatly dilated, distended small bowel loops are often present, the terminal ileum may be filled with air and visualized in an abnormal position to the right of the distended cecum. A single, long air-fluid level is usually noted in the distended cecum, there may be a relative absence of gas in the transverse and left colon.

Many authors advocate a preoperative water-soluble contrast enema examination to confirm the diagnosis and to exclude a concomitant obstructing lesion of the left colon, but this examination is potentially dangerous.


The treatment of choice for volvulus of the right colon without gangrene is discussed controversially. Cecostomy and cecopexy have been recommended but postoperative mortality and recurrence rates (28%) were high. Total resection of the right colon eliminates the risk of recurrence. Colic resection is easy to realise because of the mobility of the right colon. Postoperative mortality after resection is about 8% without gangrene and 26% with gangrene.

Many authors advocate (Table 1) right hemicolectomy as the method of choice for the treatment of volvulus of the right colon, even in the absence of gangrene.

Volvulus of the transverse colon and the splenic flexure

Volvulus of the transverse colon and the splenic flexure is uncommon. Diagnosis is generally made at laparotomy, the principles of treatment are similar to those for cecal volvulus.

Sigmoid diverticulitis

Obstruction is an indication for surgery in 5–10% of patients suffering from diverticulitis.

Obstruction occurs in patients over 45 years with advanced diverticulitis preceded by many acute attacks.

The clinical features are those of an “acute on chronic” obstruction of the distal colon.

A water-soluble contrast enema shows a stricture usually longer and less definite than that found in carcinoma. Proximally or distally to the area of diverticulitis uninflamed diverticula are often evident radiologically. A CT scan can demonstrate the presence of an abscess or an inflammatory mass. If the obstruction is complete a decompressive colostomy should be performed, followed later by resection of the affected colon; some authors advocated in the absence of peritonitis to perform resection with primary anastomosis and peroperative colonic lavage.



Endometriosis may affect rectum and sigmoid of fertile female patients. The intestine is involved in 12–37% of cases. Intestinal endometriosis is usually asymptomatic and complete obstruction of the bowel lumen occurs in less than 1% of cases. Endometriosis usually does not produce complete obstruction but endometriosis may extend circumferentially round the bowel producing a stenosis. Symptoms related to the menstrual cycle and the length of the history may suggest the diagnosis of endometriosis. At laparotomy endometriosis may mimick a constricting colon carcinoma. Establishing an accurate pre- and peroperative diagnosis is very difficult.

Fecal impaction

Fecal impaction is a common cause of obstruction in elderly, chronically ill, bed-ridden patients and can be detected by rectal examination. When the colon has been emptied of fecal material by enemas repeated over a period of several days, colonoscopy or barium contrast enema may be necessary to exclude other causes of obstruction.


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Copyright © 2001, W. Zuckschwerdt Verlag GmbH.
Bookshelf ID: NBK6984


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