EP226 - Splenic Flexure Volvulus in a Young Male: A Rare Case report and Surgical Management.

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Purpose/Background: Volvulus is defined as the twisting of a portion of the alimentary tract There is usually the involvement of either the sigmoid colon or cecum in which the bowel twists around its mesentery, leading to obstruction and possible impairment of vascular supply. Torsion beyond 180 degrees causes obstruction, while torsion beyond 360 degrees leads to ischemia. Sigmoid and cecal volvulus are common, whereas SFV is an infrequent occurrence and accounts for less than 2% of all colonic volvulus cases. There is usually a nonspecific clinical presentation, hence it usually results in delaying the diagnosis, and thereby prolonging the complications which include bowel ischemia and gangrene.

Methods/Interventions: Case report of splenic flexure volvulus in a young male.

Results/Outcomes: A 19-year-old male with chronic constipation presented with left lower quadrant pain, nausea, and non-bloody emesis lasting one day. He had experienced a similar episode two months earlier, which resolved without treatment. On examination, the patient was distended with left upper and lower quadrant tenderness but no peritonitis. Labs were unremarkable, with no lactic acidosis.
A CT scan revealed marked dilation of the splenic flexure (10.7 cm) and mesenteric twisting, confirming splenic flexure volvulus. Endoscopic detorsion relieved the volvulus, but mucosal ischemia was noted, and a rectal tube was placed. On hospital day two, after a large bowel movement displaced the rectal tube, an abdominal X-ray revealed recurrent volvulus. The patient developed peritonitis and underwent emergency exploratory laparotomy, where 50 cm from the mid-transverse just distal to the middle colic artery to the splenic flexure and proximal left descending colon were resected. He was transferred to the ICU.
The following day, the patient had a second surgery for a transverse-to-sigmoid side-to-side anastomosis. Although stable postoperatively, he developed ileus, and pathology showed pseudomembranes, leading to a confirmed diagnosis of Clostridium difficile (C. diff) infection. He was started on oral vancomycin. Two weeks later, the patient returned with nausea, vomiting, and imaging findings of ileus. He continued oral vancomycin and showed improvement, with diarrhea resolution and a return to a low-residue diet before discharge.

Conclusion/Discussion: Splenic flexure volvulus is an infrequent cause of colonic obstruction, only less than 2% of obstructed cases of volvulus involve the splenic flexure. The fixed position of the splenic flexure, maintained by ligaments, usually prevents torsion. Chronic constipation or lack of ligaments are some of the causes that may predispose patients to SFV. As per other case reports, the management has included resection of the involved segment.
Sesumi et al. reported a 14-year-old male with a redundant colon, resected after laparoscopic exploration. Sharifi et al. described an 82-year-old female requiring left hemicolectomy after failed endoscopic decompression due to bowel ischemia. Chin et al. presented subacute SFV cases, including one post-low anterior resection managed by endoscopic decompression, highlighting its role in stepwise management.
Praveen et al. discussed a 50-year-old woman with recurrent SFV requiring left hemicolectomy after failed decompression. Umbu et al. described a similar case in a 56-year-old male, where CT revealed a "whorled appearance," necessitating surgery. In our case, initial detorsion failed due to ischemia, requiring resection, underscoring the need for early intervention.