Transverse colon volvulus following normal delivery: report of a rare case and review of the world literature

Abstract

The incidence of volvulus increases during pregnancy and the postpartum period. This condition can be challenging to diagnose and can lead to increased morbidity and mortality for both the mother and fetus. Recently, our center successfully treated a 33-year-old woman who developed transverse colon volvulus after normal delivery. After conducting a literature review, the case of volvulus occurring after normal delivery was rarely reported. Finally, the twisted mesocolon was restored by laparotomy, and the patient recovered well after the operation. This case report highlights the importance of prompt diagnosis and treatment of this rare complication during the postpartum period. The key to successful treatment is minimizing delays in decision-making and ensuring timely surgery.

Introduction

Volvulus can be a critical factor in causing intestinal obstruction during pregnancy and postpartum. The incidence of intestinal obstruction during pregnancy has been reported to range from 1 in 1500 to 1 in 66,431 births or deliveries, making it a rare but serious complication [1, 2]. If left untreated, it can lead to severe maternal complications such as perforation, peritonitis, and sepsis. The prognosis is closely linked to the degree of bowel ischemia and subsequent systemic sepsis. Additionally, volvulus during pregnancy can significantly increase the risk of fetal complications, including preterm delivery, intrauterine death, and neonatal sepsis [3]. Volvulus during pregnancy and the puerperal period has been sporadically reported since the 1950s. After a literature review, we found that most previous studies focused on volvulus during pregnancy. Since 1950s, there have been more than 270 volvulus cases reported in pregnant women. However, only less than 20 cases were reported occurring volvulus after delivery, and is more likely to occur after a cesarean section (Table 1) [4,5,6,7,8,9,10,11,12,13,14,15]. Acute postpartum abdominal pain was the first symptom in all cases. The purpose of this case analysis is reminding a high suspicion of volvulus when atypical abdominal pain, constipation, and vomiting occurring in pregnancy and puperium, which can help a definitive diagnosis in a short amount of time and determines the exact site of obstruction for further intervention.

Table 1 Cases report of volvulus occurring after delivery

Case presentation

A 33-year-old Asian woman from China, with her first pregnancy, was diagnosed with gestational diabetes at 24 weeks of pregnancy. Her oral glucose tolerance test results were 5.00-10.80-8.78mmol/L (5.1-10.0-8.5mmol/L is a normal range). With diet and exercise control, her fasting and postprandial blood sugar levels were well managed during the later stages of her pregnancy. She had no significant disease history or any abdominal surgery history. At 39 + 2 weeks, she was admitted to the hospital due to irregular contractions and a bloody show. Her BMI upon admission was 29.76 kg/ m². After admission, she went into labor naturally and delivered a healthy baby girl after five hours. The delivery went smoothly without the need for forceps or vacuum extraction. A perineotomy was performed to protect her perineum during delivery. The baby weighed 3580 g and had Apgar scores of 10 at 1 min and 5 min. The placenta was delivered smoothly after five minutes. The total duration of labor was four hours, and the estimated blood loss during delivery was 400 mL. The patient was then transferred to the general ward and given routine oxytocics. However, after about 20 h after delivery, she began experiencing lumbar pain. Physical examination revealed that blood pressure (120/72mmHg), respiratory rate (16 breaths /min), and body temperature (36.8℃) were normal; heart rate was fast to 98 bpm. Abdominal distention and bilateral renal percussion pain. Despite receiving massage treatment, the pain did not subside and even worsened over the next two hours. The patient also complained of pain around her belly button and began vomiting. Physical examination showed abdominal distension and obvious tenderness and rebound pain, particularly around the belly button.

Investigations

An abdominal ultrasound scan was first conducted, revealing that the uterus was anterior (112 × 101 × 92 mm), full shape, and had a smooth outline. The internal echo of the myometrium was not uniform, and the endometrium was centered with an uneven echo (approximately 8 mm). A free liquid dark area was also found in the uterine rectal fossa (approximately 22 mm). Next, a whole abdomen CT scan was performed immediately after treatment with antispasmodics. The CT scan results showed an increased uterine volume with a flocculent high-density film, swirling changes in the mesenteric blood vessels, edema and thickening of the small intestine wall, and partial intestinal dilation and gas accumulation. There was also evidence of seroperitoneum and pelvic cavity effusion (Fig. 1A-C). The results of the blood examination showed mildly abnormal serum biochemical indices (GGT 10U/L, AST:47.0U/L, Urea 10.02mmol/L, Scr 252.7ummol/L, UA 406umol/L). The blood cell routine examination also showed significant abnormalities, with a significantly elevated white blood cell count (WBC 20.3* 10^9/L, NEU% 81.3%, NEU 16.5*10^9/L) and an elevated CRP (169.75 mg/L). There were no abnormalities in the results of the PCT, blood electrolytes, coagulation function, or amylase examinations.

Fig. 1

The whole abdomen CT scan of this patient. (A) The transverse section of the CT scan. The white arrow refers to the transverse colon with torsion, and the above part is the dilated bowel. The red arrow refers to the ascites. (B) The coronal plane of the CT scan. The white arrow refers to the transverse colon with torsion. (C) The sagittal plane of the CT scan

Surgical procedure

After an urgent joint consultation with the department of surgery, the patient was diagnosed with an intestinal twist, and immediate surgery was performed. During the laparotomy, an exploration of the abdomen revealed a large amount of hemorrhagic fluid, approximately 1500 ml, which was fully absorbed. No abnormalities were found in the liver, stomach, gallbladder, duodenum, or small intestine. The top of the uterus was located 5 cm below the umbilical cord. There was no obvious adhesion or congenital colonic malrotation. The colon was significantly expanded from the ileocecal part to the splenic curvature, with a diameter of approximately 10 cm at its widest point of the splenic curvature (Fig. 2). The transverse colon was visibly prolonged, and the transverse mesocolic root was twisted about 360°, approximately 10 cm from the splenic flexure. The colon showed signs of hyperemia and edema, but no necrosis was observed. Based on these findings, the patient was diagnosed with transverse colonic volvulus (TCV) and acute peritonitis. Primary colectomy was not performed because of significant intestinal dilation and edema above the torsion. The twisted mesocolon was restored, and the colon was sutured to the peritoneum, sarcomembrane, and skin. A double-lumen transcolon stomy was performed to drain the intestinal fluid.

Fig. 2

The operative photograph

Postoperative course

After the surgery, the patient was transferred to the intensive care unit, where they received parenteral nutrition and antibiotic therapy. The abdominal pain was significantly relieved following the surgery. On the first day after the surgery, the results of blood examinations showed a significant improvement in the blood cell count (WBC 16.1%, NEU 87.3 NEU 14*10^9/L) and a rapid decrease in CRP levels from 169.75 mg/L to 84.14 mg/L. Additionally, the serum biochemical indices returned to normal. The patient was then transferred to the general ward of the gastrointestinal surgery department. She had normal bowel movements and was discharged from the hospital in good condition after 16 days. The patient had normal exhaustion and defecation during the follow-up period after discharge. Four months later, the patient underwent a second operation to close abdominal colostomy, resect part of the transverse colon, and perform an intestinal anastomosis.

Discussion

Volvulus during pregnancy and the puerperal period can be challenging to diagnose. Typical symptoms of intestinal obstruction during pregnancy include abdominal pain, constipation, and vomiting. Abnormal peristalsis is found in 55% of cases, and abdominal tenderness in 71% of cases [16]. However, abdominal pain can sometimes be atypical and easily confused with other pregnancy-related conditions or diseases of the urinary system [17]. It is important to distinguish volvulus during the puerperium from acute intestinal pseudoobstruction (ACPO), especially following a cesarean section. ACPO is characterized by significant colonic dilation in the absence of mechanical obstruction [18]. It is diagnosed through radiological confirmation of colon distension at the cecum (> 9 cm), lack of air in the sigmoid colon and rectum, and exclusion of mechanical obstruction. It is also important to inquire about the patient’s diet and defecation after vaginal delivery, as these can provide important clues to the diagnosis. In this case, the patient had a semi-liquid diet and no bowel movements after delivery until the onset of abdominal pain. TCV is a rare condition, accounting for only 1–3% of all colonic volvuli cases [19, 20]. It is often complicated by the absence of characteristic radiological findings and is typically diagnosed during surgery. It is a surgical emergency as it can lead to bowel necrosis and a mortality rate of up to 33% [21]. There are two clinical forms of TCV: sub-acute and acute fulminant. The sub-acute form is characterized by a mild clinical picture, with symptoms such as massive abdominal distension and mild abdominal pain without signs of peritoneal irritation. The white blood cell count is usually normal or increased [22]. However, if diagnosis and treatment are delayed, it can progress to the acute fulminant form. The physio-pathological mechanism of volvulus formation is based on two factors: redundancy and non-fixation [23]. Like the sigmoid colon, the transverse colon is a mobile portion of the peritoneum attached by its mesocolon transversum, making it susceptible to volvulus formation. Risk factors for TCV include a history of volvulus, previous abdominal surgery, congenital malformations, Chilaiditi syndrome, pregnancy, and chronic constipation. An enlarging uterus changes the anatomical location of bowel and colon, and the elevated level of progesterone and the release of relaxin during pregnancy makes the tissues more motile, which may lead to volvulus in a susceptible woman with congenital mal-rotation or adhesions [24, 25]. The patient had no history of chronic constipation or other gastrointestinal symptoms in this case. However, a long congenital transverse colon was considered an important factor in the occurrence of TCV. Other factors, such as displacement and compression by the gravid uterus, abdominal pressure during labor, and displacement of abdominal organs after the enlarged pelvic cavity space in the postpartum period, may also contribute to the development of TCV in this patient. However, due to limitations in the existing literature, other risk factors for intestinal torsion after vaginal delivery, such as fetal weight and maternal weight, could not be summarized. The classical “bird’s beak” appearance of the transverse colon can be seen on a contrast enema, but this is not recommended in acute settings as it can delay surgical intervention [26]. There are no typical radiographic findings of transverse colon volvulus on a CT scan.

In all cases of volvulus, surgery is the first-line treatment, which can make a definitive diagnosis. Broad-spectrum antibiotics should be administered preoperatively. The resumption of enteral feeds may be delayed in patients with perforation peritonitis or those who have undergone resection of necrotic bowel with anastomosis. In these cases, total parenteral nutrition may be necessary. Patients and their relatives should also be taught to care for a colostomy and/or ileostomy if necessary. It is worth noting that surgical site infection (SSI) is a common postoperative complication, occurring in up to 30% of patients after colorectal surgery [27]. SSI poses significant morbidity and consequences for long-term disability rates [28, 29]. Risk factors of SSI after colorectal surgery are still controversial. Obesity, contamination class 3–4, American Society of Anesthesiologists grade III-IV, open surgery, organ-space SSI present at the time of surgery and operative time seems to be associated with an increased risk of SSI [30, 31]. Interventions, such as negative pressure wound therapy, sterile closure trays, and strict temperature and glucose control monitoring, can reduce the risk of SSI [32]. Postoperative sepsis represents a significant problem in colorectal surgery patients, and the most frequent cause was anastomotic leakage. The elderly age, ASA score > 2, and comorbidities such as diabetes and cardiovascular disease were associated with a significantly higher incidence of postoperative sepsis [33]. A recent study reported that low Butyrylcholinesterase levels on the first and third day after colorectal surgery were associated with an increased risk for the development of SSI [34]. Further exploration of potential markers is warranted, which represent the risk of developing SSI and septic complications in patients undergoing colorectal surgery.

Conclusion

The diagnosis of intestinal obstruction or volvulus is often delayed due to atypical presentation, lack of knowledge about the condition, and hesitation to use radiological investigations. These factors may be attributed to mistaking the clinical features for other pregnancy-related conditions. Therefore, it is crucial to have a high clinical suspicion and to involve both surgeons and obstetricians in the management of these cases. The key to successful treatment is minimizing delays in decision-making and ensuring timely surgery.