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Letters to the Editor  |   November 2010
Elderly Patient With Small Bowel Volvulus
Author Affiliations
  • Matthew D. Davidson, DO
    Department of Surgery, Community General Osteopathic Hospital, Harrisburg, Pennsylvania
Article Information
Gastroenterology / Geriatric Medicine
Letters to the Editor   |   November 2010
Elderly Patient With Small Bowel Volvulus
The Journal of the American Osteopathic Association, November 2010, Vol. 110, 678-679. doi:10.7556/jaoa.2010.110.11.678
The Journal of the American Osteopathic Association, November 2010, Vol. 110, 678-679. doi:10.7556/jaoa.2010.110.11.678
To the Editor:  
A 90-year-old man came to our emergency department complaining of a 3-day history of progressively worsening abdominal pain. He reported that prior to the occurrence of abdominal pain, he had one loose bowel movement—but no loose bowel movements since. He denied any nausea or vomiting. Physical examination revealed the patient to be slightly distended and mildly tender to palpation at the periumbilical region. His medical history was significant only for an inguinal hernia repair, and he had no other abdominal operations. 
The hospital's general surgery team was consulted. A computed tomography (CT) scan was ordered, and results were reviewed with radiology staff. The CT scan demonstrated dilated loops of small bowel but no clear cause of obstruction. 
Because the patient was not improving clinically the day after the CT scan results, he was taken to the operating room for an exploratory laparotomy. Dilated loops of small bowel were found, with a transition to decompressed small bowel at the midileum level. Close examination showed the dilated small bowel to be twisted at its mesenteric root, forming a small bowel volvulus (SBV). Surgeons (including M.D.D.) untwisted the volvulus and decompressed the dilated loops of bowel. Evaluation of the remaining small bowel showed no other obstructions and no intraabdominal adhesions. The abdomen was closed, and the patient was moved to the recovery room in stable condition. 
An extensive review of the literature (using MEDLINE, PubMed, and Google) indicated that when a patient has no history of abdominal surgery and is obstructed, SBV is not a common etiologic factor for the obstruction.1,2 When an SBV is present in elderly individuals, it is typically caused by intraabdominal adhesions. This form of SBV, called secondary SBV, generally occurs in patients aged in their 60s to 80s. Because the patient in our case had no history of abdominal surgery, his SBV is classified as primary SBV, a type of volvulus for which no clear anatomic etiologic factor can be found.1 
Primary SBV is more common in children and young adults than in elderly individuals. The mechanism of primary SBV has been correlated with the ingestion of a large amount of fiber-rich foods in a short time.3,4 The subsequent forceful small bowel peristalsis is believed to be the cause of the primary SBV. 
Countries with fiber-rich diets have a 10-fold increase in the occurrence of primary SBV, compared to countries with less fiber in their diets.2-4 Although rare in Western countries, SBV has been noted in cultures in which people ingest large amounts of fiber-rich foods, such as during festivals or after prolonged fasts. Such cultures originate in parts of Africa and the Middle East.1,3 
Certain anatomic variations have been proposed as etiologic factors for SBV. For example, some researchers have asked whether either a short or long mesenteric root may be associated with primary SBV.1,2 Frazee et al1 proposed that a long mesenteric length and short mesenteric base are linked to SBV. In addition, changes in gut motility have been noted as a cause of primary SBV. In Uganda, for example, primary SBV has occurred in individuals after consumption of local beer containing gut motility stimulant.3 In areas with widespread parasitic infections, close correlation has been made among these infections, changes in small bowel motility, and primary SBV.3 
Diagnosis of SBV can be made with a CT scan of the abdomen and pelvis. The CT images typically show a whirl-like pattern of mesentery, which is caused by the small bowel rotating around the mesenteric axis.3,4 This whirl-like pattern was not clearly demonstrated in the CT scan of our patient. Because this pattern was not seen, the presence of an SBV was not expected to be found during this patient's exploratory laparotomy. 
Our extensive literature search did not indicate that primary SBV is a common etiologic factor in elderly patients with no history of abdominal surgery.5 We have written this letter to counter the lack of literature information on this topic and to inform readers of JAOA—The Journal of the American Osteopathic Association to keep primary SBV in mind as a possible cause of obstruction when no clear etiologic mechanism is demonstrated by radiologic examination. 
Frazee RC, Mucha P Jr, Farnell MB, van Heerden JA. Volvulus of the small intestine. Ann Surg.. (1988). ;208(5):565-568.
Roggo A, Ottinger LW. Acute small bowel volvulus in adults. A sporadic form of strangulating intestinal obstruction. Ann Surg. 1992;216 (2): 135-141.
Iwuagwu O, Deans GT. Small bowel volvulus: a review. JR Coll Surg Edinb.. (1999). ;44(3):150-155.
Wert MA, Sarpel U, Divino CM. Small bowel volvulus: time is of the essence. Surg Rounds.. (2007). ;30(8):392-394.
Huang JC, Shin JS, Huang YT, et al. Small bowel volvulus among adults. J Gastroenterol Hepatol.. (2005). ;20(12):1906-1912.