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Sigmoid Volvulus: Identifying Patients Requiring Emergency Surgery with the Dark Torsion Knot Sign

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Sigmoid Volvulus: Identifying Patients Requiring Emergency Surgery with the Dark Torsion Knot Sign European Radiology (2019) 29:5723–5730 https://doi.org/10.1007/s00330-019-06194-9 GASTROINTESTINAL Sigmoid volvulus: identifying patients requiring emergency surgery with the dark torsion knot sign Subin Heo1 & Hye Jin Kim1 & Bum Jin Oh2 & Soo Jin Kim3 & Bohyun Kim1 & Jimi Huh1 & Jei Hee Lee1 & Jai Keun Kim1 Received: 20 November 2018 /Revised: 19 March 2019 /Accepted: 21 March 2019 /Published online: 26 April 2019 # European Society of Radiology 2019 Abstract Objectives To determine which clinical or CT imaging factors can help accurately identify complicated sigmoid volvulus (SV), defined as irreversible bowel ischaemia or necrosis requiring emergent surgery in patients with SV. Methods We performed a retrospective study of 51 patients admitted consecutively to the emergency department for SV. All patients attempted endoscopic detorsion as the first treatment. Clinical and contrast-enhanced CT factors were analysed. A newly described dark torsion knot sign (sudden loss of mucosal enhancement in the volvulus torsion knot) was included as a CT factor. Patients were diagnosed with complicated versus simple SV based on either surgery or follow-up endoscopic findings. Univariate and multivariate analyses were used to identify predictors of complicated SV. Results Of 51 study patients, 9 patients (17.6%) had complicated SV. Univariate analysis revealed that three clinical factors (sepsis, elevated C-reactive protein, and elevated lactic acid levels) and four CT factors (reduced bowel wall enhancement, increased bowel wall thickness, dark torsion knot sign, and diffuse omental infiltration) were significantly associated with complicated SV. Multivariate analysis identified only dark torsion knot sign (odds ratio = 104.40; p = 0.002) and sepsis (odds ratio = 16.85; p = 0.043) as independent predictive factors of complicated SV. Conclusion A newly defined CT imaging factor of dark torsion knot sign and a clinical factor of sepsis can predict complicated SV necessitating emergent surgery instead of colonoscopic detorsion as a primary treatment of choice. Key Points • A newly defined CT imaging factor of dark torsion knot sign and a clinical factor of sepsis can be helpful for predicting complicated SV necessitating emergent surgery instead of endoscopic detorsion. Keywords Sigmoid colon . Intestinal volvulus . Multidetector-row computed tomography . Sepsis . Emergency treatment Abbreviations Introduction CRP C-reactive protein NPV Negative predictive value Sigmoid volvulus (SV) is an emergent disease that typically OR Odds ratio causes closed-loop obstruction by abnormal twisting of the PPV Positive predictive value sigmoid colon along its mesenteric axis. This accounts for SV sigmoid volvulus 60–75% of all cases of colonic volvulus and 2–5% of all cases of colonic obstruction [1, 2]. There is rarely an alternative form of organo-axial type [3]. Prompt diagnosis can be made * Hye Jin Kim with computed tomography (CT), which delivers a diagnostic [email protected] accuracy approaching 100% by demonstrating an abrupt tran- sition between a normal and dilated colon as well as conver- 1 Department of Radiology, Ajou University School of Medicine, 206 gence of both ends of the dilated loop toward the fulcrum Worldcup-ro, Yeongtong-gu, Suwon 443-749, South Korea point [4–6]. Urgent endoscopic detorsion of the SV is the 2 Emergency Medicine, University of Ulsan College of Medicine, primary treatment of choice, and thereafter, elective surgery Asan Medical Center, Seoul, South Korea becomes the second treatment of choice to prevent recurrent 3 Office of Biostatistics, Institute of Medical Sciences, Ajou University volvulus in patients with simple SV [7, 8]. However, if left School of Medicine, Kyunggido, Suwon, South Korea untreated or a certain period passes after the onset of SV, 5724 Eur Radiol (2019) 29:5723–5730 venous return to arterial blood supply can be compromised as for the diagnosis of SVare spiral twisting of the colonic lumen colonic obstruction with distension is aggravated. Ultimately, and inability to insert the endoscope into the sigmoid colon simple SV progresses to complicated SV, resulting in irrevers- proximal to the twisted area [7]. Complicated SV was defined ible colonic ischaemia, gangrene, and perforation as a life- as irreversible bowel wall ischaemia or necrosis noted by sur- threatening condition [9]. This explains the persistently high gical and histopathological reports in patients who underwent mortality rates up to 60% in patients with complicated SV [7, endoscopic trial for detorsion followed by emergent or elec- 10], and these patients should undergo emergent laparotomy tive surgery (Fig. 2). Patients who underwent only endoscopic for complete therapeutic cure instead of endoscopic detorsion detorsion were diagnosed with complicated SV if definite [8, 11–13]. Distinguishing between simple and complicated bowel wall necrosis was noted by an endoscopic report and SV is therefore essential before performing urgent endoscopic it did not return to normal by follow-up endoscopy. Patients detorsion. with stable vital signs, normal laboratory findings, and normal Several authors have identified various CT findings, such endoscopic findings obtained during the follow-up period as decreased, absent, or increased bowel wall enhancement, were diagnosed with simple SV (Fig. 3) even though an initial increased bowel wall thickness, ascites, mesenteric haziness, endoscopic report noted an ischaemic bowel. pneumatosis intestinalis, or intraperitoneal free air, as predic- tive factors indicating irreversible bowel ischaemia to infarc- Clinical data analysis tion [14–23]. However, such studies have focused primarily on small bowel strangulation rather than the colon. Study coordinators reviewed the electronic medical records of Furthermore, to the best of our knowledge, there has been all patients for demographic details (age and sex), previous or no previous study demonstrating the comprehensive clinical current medical history (diabetes mellitus, hypertension, neu- and radiological factors that may influence prediction of com- ropsychiatric disorder, constipation, history of previous oper- plicated SV. ations, and previous SVevent), clinical symptoms (abdominal We therefore aimed to identify the clinical and CT factors pain and distension) with duration, physical examinations (di- that can be helpful for predicting patients with complicated rect and indirect abdominal tenderness), vital signs, and labo- SV necessitating emergent surgery. ratory findings obtained at the time of admission to the emer- gency department. Patients’ vital signs, laboratory findings (serum platelet, bilirubin, creatinine, and lactate levels), and Materials and methods mental status required for sepsis criteria were also extracted from the patients’ reports. Sepsis was defined as life- This was a retrospective, observational two-centre study. The threatening organ dysfunction caused by a dysregulated host institutional review boards from each hospital approved this response to infection as described by the BThird International study, and the requirements for informed written consent were Consensus Definitions for Sepsis and Septic Shock (Sepsis- waived. 3)^ [24]. The success rate of endoscopic detorsion, type of surgery (emergent or elective), hospitalisation days, follow- Study population up period, and presence or absence of patients’ death were analysed. Surgeries performed within one year of an endo- The study coordinators searched the electronic medical re- scopic detorsion without recurrent SV were considered elec- cords of two medical centres for patients diagnosed with SV tive operations. among those admitted to an emergency department between January 2006 and October 2017. A total of 86 consecutive CT technique patients were initially eligible for diagnosis of SV in the two centres. Thirty-five patients were excluded because of (1) no All 51 patients underwent abdominopelvic CT examinations available CT scan (n = 16), (2) neither endoscopic detorsion using variable (16–128) multichannel multidetector scanners trial nor surgical treatment (n = 13), (3) no available laboratory (Sensation 16, Somatom Definition Edge, or Somatom results or vital signs at the time of admission (n = 3), or (4) SV Definition AS, Siemens Medical Solutions). After obtaining due to other reasons such as colon cancer (n =3).Theremain- unenhanced CT images, contrast-enhanced portal or delayed ing 51 patients were included in our study. The study popula- phased CT scanning began 70 to 90 s after intravenous injec- tion with exclusion criteria is presented in Fig. 1. tion of 100 to 150 mL of a non-ionic contrast medium (Iopamiro 300, Bracco Imaging; Omnipaque 300, GE Reference standard Healthcare) at a rate of 2.5 to 3 mL/s. The scan parameters for the 16-, 64-, and 128-channel scanners were as follows: Diagnosis of SV was confirmed by a combination of patho- beam collimation, 0.6 to 0.75 mm; slice thickness, 3 to 5 mm; logical, surgical, or endoscopic findings. Endoscopic findings reconstruction interval, 3 to 5 mm; rotation time, 0.3 to 0.5 s; Eur Radiol (2019) 29:5723–5730 5725 Fig. 1 Patient flow diagram; op operation effective tube current-time charge, 200 to 260 mAs; and volt- CT imaging analysis age, 100 to 120 kVp. Contrast-enhanced images were obtain- ed using axial and coronal reconstruction and unenhanced CT All CT images were randomly collected in an anonymized images with axial reconstruction. state in a research folder located on the picture and
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