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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00986-6
10.1016/j.ijscr.2024.110205
110205
Case Report
Gangrenous transverse colon volvulus in a male patient who underwent Hartman procedure. A rare case report
Kebede Molla Asnake mollaasnake75@gmail.com
a⁎
Gossaye Bizuayehu Tassew b
Tekle Alemayehu Beharu c
Gebre Tariku Gero b
Mesfine Yohanes Yoseph yohanesyoseph@mtu.edu.et
b
Abebe Tesfahun Mengistu tesfahunabebe@mtu.edu.et
b
a Department of Medicine, School of Medicine, College of Medicine and Health Sciences, Mizan - Tepi University, Mizan-Teferi 260, Ethiopia
b Department of Surgery, School of Medicine, College of Medicine and Health Sciences, Mizan - Tepi University, Mizan-Teferi, Ethiopia
c Department of Emergency and Critical care medicine, School of Medicine, College of Medicine and Health Sciences, Mizan - Tepi University, Mizan-Teferi, Ethiopia
⁎ Corresponding author. mollaasnake75@gmail.com
22 8 2024
10 2024
22 8 2024
123 11020518 7 2024
16 8 2024
20 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Transverse colon volvulus is an uncommon cause of large bowel obstruction, often presenting as a surgical emergency. This case report details a rare instance of gangrenous transverse colon volvulus in a 50-year-old male patient with a history of Hartmann's procedure performed six years prior.

Case presentation

The patient presented with acute abdominal pain, diffuse abdominal distension, and failure to pass feces and flatus. An emergency laparotomy was performed, revealing a gangrenous segment of the transverse colon. Despite surgical intervention, the patient died due to Multi organ failure (MOF).

Discussion

A patient diagnosed with transverse colon volvulus typically presents with colicky abdominal pain, vomiting, constipation or obstipation, and abdominal distension. Physical signs may include abdominal distention, a palpable mass, circulatory collapse, fever, and leukocytosis.

Conclusion

This case underscores the importance of early recognition and prompt surgical intervention in managing transverse colon volvulus.

Highlights

• Only a few cases of Transverse colon volvulus have been reported.

• It is a challenging to diagnose transverse colon volvulus preoperatively.

• Patient with diagnosed lately have a high risk of complication.

• Hartman procedure may pose future risk of transverse colon volvulus.

Keywords

Gangrenous
Transverse colon volvulus
Surgical emergency
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pmc1 Introduction

Transverse colon volvulus is an uncommon but serious condition that results in bowel obstruction due to the twisting of the transverse colon around its mesenteric axis. Risk factors for transverse colon volvulus include non-fixation of the colon, chronic constipation, and megacolon. Patients typically present with signs and symptoms of bowel obstruction, such as acute abdominal pain, distension, nausea, and vomiting. If not promptly diagnosed and treated, this condition can lead to ischemia, necrosis, and perforation, posing significant health risks [[1], [2], [3]].

The Hartmann procedure, typically performed for conditions such as diverticulitis, colorectal cancer, or traumatic injuries, involves the resection of the rectosigmoid colon, the creation of an end colostomy, and the closure of the rectal stump. While it can be lifesaving and effectively manage the primary condition, it is also associated with some potential complications like transverse volvulus, which is extremely rare [[4], [5], [6], [7], [8]].

In this case report, we present a rare instance of transverse colon volvulus in a patient with a history of the Hartmann procedure. We discuss the clinical presentation, diagnostic challenges, and management strategies used in this case, highlighting the need to recognize this potential complication in patients. Our aim is to enhance current knowledge and aid clinicians in the prompt and effective diagnosis and treatment of transverse colon volvulus in similar surgical contexts.

2 Case presentation

A 50-year-old male patient presented with abdominal pain, diffuse distension, and failure to pass feces and flatus for two days. He had no vomiting. The patient had a history of previous surgery for gangrenous sigmoid volvulus six years ago, for which a Hartmann's procedure was performed and subsequently reversed after three months, as noted in the previous operation record. On physical examination, the patient appeared lethargic, with vital signs showing Pulse rate (PR) = 140, Blood Pressure (BP) = 80/40, Respiratory rate (RR) = 30 but maintains oxygen saturation on room air, and Temperature (T) = 38 °C. He had clinical futures of anemia, and pertinent physical findings included diffuse abdominal distension, tenderness, and a midline surgical scar. The patient was resuscitated with 3000 milliliters (ml) of normal saline over two hours via a double IV line, but his vital signs remained tachycardia with a BP of 90/50 and urine output of 50 ml over 2 h. DRE revealed an empty rectum.

An erect abdominal X-ray revealed a large bowel obstruction (Fig. 1). After obtaining informed consent, the patient was taken to the OR. The abdomen was entered through the previous midline incision. Intraoperative findings revealed a gangrenous transverse colon volvulus twisted on its mesentery, with no stricture at the previous anastomosis site (Fig. 2). A resection of the gangrenous transverse colon with a spectacle colostomy was performed. Estimated blood loss was 300 ml. During the procedure, the patient's blood pressure dropped, and intraoperatively the patient was transfused with one unit of cross-matched blood. After the procedure, the patient was transferred to the ICU (Fig. 3). Arterial blood gas analysis, Serum Lactate level and CT of abdomen haven't been done because it is not available at our setup as we located in the remote area of Ethiopia.Fig. 1 Erect plain abdominal X-ray shows dilated large bowel segment with multiple air-fluid level located peripherally.

Fig. 1

Fig. 2 Intraoperative pictures showing gangrenous volvulus at different angles.

Fig. 2

Fig. 3 The patient in the ICU with midline dressing and spectacle colostomy and on MV.

Fig. 3

In the ICU, the patient was placed on a mechanical ventilator as he was transferred intubated from the operation room (OR). His FBC revealed total WBC of 33,000/ul(87 % Neutrophil and MID of 5000/ul), HGB of 9 mg/dl(HCT = 27) and PLT of 127,000/ul. And the systolic blood pressure was 70 mmHg and the urine output was 0.3 ml/kg/h. The initial preoperative CBC was WBC = 12,000/ul, hematocrit (HCT) =41(indicating possible hemoconcentration) and PLT = 170,000/ul. With consideration of sepsis of gastrointestinal focus with septic shock, the patient was continued on broad spectrum antibiotics (Vancomycin, ceftazidime and metronidazole) and vasopressor with Noradrenaline and Hydrocortisone was initiated in the ICU. As the patient's mean arterial pressure (MAP) remained below 65 mmHg, dopamine was added to the treatment regimen (double pressor). Despite the use of double inotropes at the maximum dose, his MAP remained below 65. On subsequent day the mentation drops (GCS 5T/15-E2VTM3) and the Renal function tests showed a Creatinine level of 3 and urea of 20. On the second day of ICU admission the patient arrested with possible cause of arrest refractory septic shock with multiple organ failure (MOF).

3 Discussion

Colonic volvulus occurs when the bowel twists around its mesentery, leading to intestinal obstruction. It accounts for 3–5 % of all cases of intestinal blockage, with the sigmoid colon being the most common site (76 %), followed by the caecum (22 %), and less frequently, the transverse colon (2 %). [3,9]. In Africa, particularly in Ethiopia, sigmoid volvulus is the most commonly reported cause of large intestine obstruction. However, there are very few documented cases of transverse colon volvulus [10]. In 1932, Finnish surgeon Kallio reported the first case of transverse colon volvulus as a cause of large bowel obstruction [11]. What makes our case particularly interesting is that there are only two reported instances of transverse colon volvulus occurring in patients who underwent sigmoidectomy (Hartman procedure) in medical literature to date [4,8].

A patient diagnosed with transverse colon volvulus typically presents with colicky abdominal pain, vomiting, constipation or obstipation, and abdominal distension. Physical signs may include abdominal distention, a palpable mass, circulatory collapse, fever, and leukocytosis [3,7,12]. Early diagnosis is crucial; plain films often reveal proximal colon distention with an empty distal bowel and two air-fluid levels, resembling this patient's X-ray. In cases without gangrenous bowel, a contrast examination is recommended to define the obstruction site and type and to rule out distal lesions that could affect surgical decisions [7,13]. The diagnostic challenge lies in the lack of distinctive radiographic features seen in other colonic volvuli, like cecal and sigmoid, and the absence of typical symptoms in the first 24 h, which can lead to delayed diagnosis and treatment, increasing the risk of complications. Consequently, it is often diagnosed intraoperative, as described in this case report [7,14].

Transverse colon volvulus is a surgical emergency requiring prompt intervention to prevent bowel gangrene and perforation. The treatment typically involves resection of the affected segment, followed by either primary anastomosis in a one-stage procedure or creating a stoma in a two-stage procedure, with end-to-end anastomosis performed 2–3 months later [4,7,15].

The choice of procedure depends on the patient's overall condition, presence of peritonitis, and local bowel condition. In the discussed case, a two-stage procedure was chosen due to the patient's hemodynamic instability as he was in shock. Although colostomy reversal was scheduled, the patient was died due to septic shock. Patients with severe sepsis or septic shock of colonic require early hemodynamic support, source control, and early antimicrobial therapy start from at emergency. Early fluid resuscitation is vital for these patients, with crystalloids or colloids recommended initially. If fluid resuscitation fails, vasopressor agents should be used to maintain adequate blood pressure and organ perfusion, optimizing blood flow in various organs. The patient started treated as recommended [7,16,17]. The work has been reported in line with the SCARE criteria [18].

4 Conclusion

We write this case report to highlight the critical importance of prompt recognition and intervention in cases of transverse colon volvulus, especially in patients with a history of Hartmann procedure. In addition to its rarity of transverse colon volvulus, its non-specific early symptoms and the potential for rapid progression to bowel necrosis (gangrene) which is a risk for septic shock and multiple organ failure, poses significant therapeutic challenges as explained in this case report. Additionally, the case underscore the necessity for heightened clinical awareness and timely surgical management to prevent such adverse outcomes.

Informed consent

Informed written consent was received from the patient's family for publication.

Funding

The case report, authorship, and/or publication of this work were done without outside funding.

Ethics approval

Ethical approval for this study was obtained from the College Research Committee and Reference No. HSE/00429/2012.

Author contribution

All authors are equally involved in the conception and design of the study, drafting and revising of the article and final approval of the version to be submitted.

All authors agreed to be accountable for all aspects of the manuscript.

Guarantor

Molla Asnake Kebede.

Research registration number

Not applicable.

Conflict of interest statement

No potential conflicts of interest were disclosed by the author(s) with regard to the case report, writing, or publication of this article.

Molla Asnake Kebede is an Assistant Professor, Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences at Mizan – Tepi University, Ethiopia. MA is a Medical Doctor and specialty certificate in Drug resistant tuberculosis management.

Bizuayehu Tassew Gossaye Assistant Professors of Surgery, Department of Surgery, School of Medicine, College of Medicine and Health Sciences at Mizan – Tepi University, Ethiopia. BT is Medical Doctors and has Specialty Certificate in General Surgery

Alemayehu Beharu Tekle is Assistant Professors of Emergency and Critical care medicine, Department of Emergency and critical care medicine, School of Medicine, College of Medicine and Health Sciences at Mizan – Tepi University, Ethiopia. AB is Medical Doctors and has Specialty Certificate in Emergency and critical care medicine.

Tariku Gero Gebre. Assistant Professors of Surgery, Department of Surgery, School of Medicine, College of Medicine and Health Sciences at Mizan – Tepi University, Ethiopia. TG is Medical Doctors and has Specialty Certificate in General Surgery.

Yohanes Yoseph Mesfine is a General Practitioner in the Department of Surgery, School of Medicine, College of Medicine and Health Sciences at Mizan – Tepi University, Ethiopia. YM is a Medical Doctor.

Tesfahun Mengistu Abebe. Assistant Professors of Surgery, Department of Surgery, School of Medicine, College of Medicine and Health Sciences at Mizan – Tepi University, Ethiopia. TMA is Medical Doctors and has Specialty Certificate in General Surgery.

Data availability

On a valid request, the corresponding author will provide access to the datasets that were gathered and used to conduct this article.
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