In a rarely seen case, a 30-year-old woman presented to the doctors at the emergency department with a worsening pain at the centre of her abdomen. The pain was colicky over the last couple of days and on investigations the team of doctors found that it was due to something she had swallowed years earlier. The report of this case was published this week in the journal BMJ reports.
The woman came to the emergency with abdominal pain that started a couple of days back and was worsening. She had a raised heart rate and normal vital parameters. She was initially suspected to have a biliary colic but her abdominal ultrasound scans and liver and gall bladder scan seemed to be normal flummoxing the doctors. She had normal laboratory tests too. An X ray of her abdomen was not taken. On CT scan of her abdomen it was found that within her abdomen was stuck a metallic wire shaped object. This wire had looped around her gut causing it to twist around itself and leading to an obstruction. This condition is called volvulus. She underwent an emergency surgery where her abdomen was opened up to reveal part of her gut to have been twisted around a wire which was actually a 7-cm piece of orthodontic wire that she had accidentally swallowed ten years earlier. The wire had pierced the gut in two places and had formed a loop around which the gut had twisted to give rise to the obstruction.
Authors of the case report note that most objects that pass through the gullet usually pass out of the body spontaneously. This was a novel case where the wire from ten years back started creating a problem within the gut. Doctors of this team including lead author Talia Shepherd, one of the doctors who treated the woman at Sir Charles Gairdner Hospital in Nedlands in Western Australia, advise looking for a foreign object too within the gut in similar cases as these when there is no other medical or surgical cause to be found. Also, an X ray of the abdomen is a cheaper and more effective way in detecting this problem they write. In this patient, more expensive scans detected what a simple abdominal X ray would have detected.
Volvulus is a surgical emergency situation in which the loops of the bowel twist over itself to cause loops that obstruct the flow of the contents as well as the blood supply to the gut walls. The walls of the gut are thus deprived of blood supply and vital oxygen and nutrients. This leads to death of the tissues.
Volvulus can occur due to a birth defect in some babies. This is called malrotation when the alignment of the gut loops in the baby is incorrect when it is born. The loops of the bowel slip over each other causing a tangle and rotate or twist to create the volvulus. In babies with volvulus, the symptoms may appear within the first year of life. Volvulus may also occur later in life.
Symptoms of volvulus include sudden onset of intense abdominal pain. There may be intense vomiting and the pain seems to be unrelenting with most medications. Some children may also have intermittent pain that comes and goes. The pain comes when the volvulus twists and goes when the gut loops untwist themselves. There is abdominal pain, nausea, vomiting green bilious material, dark red bloody stools, constipation, bloated abdomen and collapse.
Diagnosis can be made with examination of the abdomen, X ray and ultrasound scans, CT scan of the abdomen, blood and stool examinations in the laboratory etc. Treatment involves surgical correction of the volvulus. The affected bowels need to be untwisted and the blood supply restored. If a small segment of bowel has dead or necrotic tissues, it may be removed and the ends of the healthy gut are sewn back together.