Gangrene sigmoid volvulus: A rare case report from Vietnam

Background: Sigmoid volvulus is a gastrointestinal condition and a medical emergency that occurs when a segment of the colon twists upon its mesentery, leading to bowel obstruction and gangrene of the intestine. Male patients and seniors with persistent constipation are the primary populations affected by this condition. We present a rare case of a gangrene sigmoid volvulus diagnosed timely by CT-Scan. Case presentation: A 72-year-old Vietnamese male with a 3-day history of abdominal pain presented at the emergency department. A thorough medical history and physical examination revealed signs of bowel obstruction without evidence of peritonitis. Computed CT confirmed the diagnosis of sigmoid volvulus; it also led the surgical team to the decision to conduct an emergency laparotomy surgery due to the sigmoid ischemic sign depicted on the CT scan. Conclusion: This case report emphasizes the importance of radiographic tests in diagnosing and treating bowel obstruction. Especially in suspicion of volvulus, even without signs of peritonitis.


INTRODUCTION
The incidence of sigmoid volvulus is from 2% to 5% of colonic obstruction in Western countries and 20-50% in Eastern countries, according to recent data (Raveenthiran et al., 2010;Lal et al., 2006;Madiba et al., 1997).Sigmoid volvulus accounts for 9.2% of all cases of colonic obstruction.It is common in adults over 70 (Halabi et al., 2014).The cause of the sigmoid volvulus has yet to be fully understood.Numerous disorders can lead to sigmoid volvulus, including inflammation of the pelvis, adhesions around the sigmoid colon, and the setting of persistent constipation.The main symptoms are abdominal pain, constipation, and nausea.On physical examination, the abdomen is distended and tender.

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Colon volvulus is an emergency disease that needs to be detected promptly.If left untreated, the disorder quickly progresses to obstruction and colon gangrene, which can lead to electrolyte imbalances or septic shock.The overall mortality is 10% to 50%, while the overall morbidity is 6% to 24%.The sigmoidoscopy is the first treatment to decompress the sigmoid colon and restore the luminal flow.
However, emergency surgery is necessary for patients presenting with bowel gangrene signs.We present a case of a 72-year-old Vietnamese male who underwent an emergency laparotomy due to gangrene sigmoid volvulus.Early recognition and timely surgical treatment reduce mortality and morbidity.

CASE PRESENTATION
A 72-year-old male presented at the emergency department with a three-day history of colicky pain localized around the periumbilical region, accompanied by abdominal distension and inability to pass stool and flatus.The patient had no other symptoms, such as fever, nausea, or rectal bleeding.There was also no history of chronic illness or allergies to drugs or foods.
The vital signs in the emergency room were as follows: Pulse: 99 times/minute.Temperature: 37oC.
Respiratory rate: 18 times per minute.
Clinical examinations revealed a sickly and dehydrated appearance.Abdominal examination revealed distension remarkably in the hypogastric region, tympanic, with no sign of peritonitis.A digital rectal examination noted the empty rectum with no stool nor blood on the examining finger, and the anal sphincter was normal in tone.Laboratory tests showed leukocytosis as WBC was 11.18 K/µL (%Neu: 89.4%), hyponatremia with normal renal function test.A plain radiograph indicated the feature of bowel obstruction.The ultrasonography indicated bowel distension with hyperactive peristalsis.The computed tomography revealed a substantial intestinal closed-loop blockage; the caecum dilated up to 67 mm distally to the sigmoid colon, and the colonic region was the location of the transition point (Figure 1).The obstructed colonic wall was hypoattenuating with the contrast agent, which raised the suspicion of colonic ischemia.bowel and performed a Hartmann's procedure for later safety anastomosis (Figure 2).Postoperatively, the patient recovered well and had a good bowel movement on the third postoperative day; the colostomy worked well with no signs of ischemia.After surgery, there was no abnormality recorded.On the seventh day following surgery, the patient was discharged.The removed colon underwent histopathology, which revealed gangrenous bowel tissues.

DISCUSSION
Colonic volvulus most frequently occurs in the sigmoid colon.The age at presentation is usually over 70 years of age, and there is a 2:1 male-to-female ratio.Sigmoid volvulus is more common in areas where a high-fiber diet is prevalent, such as Africa, India, and the Middle East.Institutionalized patients and those with disability via neurologic and psychiatric disorders experience higher rates (Halabi et al., 2014;Mangiante et al., 1989;Baker et al., 1994).Sigmoid volvulus causes a close-loop colon obstruction, manifesting as a sluggish, sneaky start of nausea, constipation, abdominal discomfort, and distention.Vascular compromise and rapid colonic dilatation occur when the twisting continues or worsens, which may result in necrosis and perforation (Ballantyne et al., 1985;Oren et al., 2007).
The senior population may have less clinically apparent symptoms.A dilated sigmoid colon with the apex of the bend pointing toward the right upper quadrant is a typical radiography finding in 60% of the cases.
CT scan is necessary if a plain film is inconclusive.The coffee bean sign, the appropriately located X-marks-the-spot sign, the splitwall sign, the whirl sign, and the absence of rectal gas are all clues to a sigmoid volvulus.Treatments aim to reduce the twisted bowel and prevent a recurrence.An urgent operation is necessary if peritonitis, sepsis, gangrene, or bowel perforation is suspected based on clinical examination, laboratory results, and imaging investigations or discovered during an endoscopic evaluation.There have been descriptions of both open and laparoscopic techniques, with the latter being increasingly popular.A lower midline laparotomy is suitable to approach open resection.Following mobilization, the colon can be exteriorized through the laparotomy incision or a wound protector in situations requiring laparoscopic surgery.
The remaining are covered with towels to prevent contamination.The most reliable method of preventing recurrent volvulus is to conduct a sigmoid colectomy with colorectal anastomosis.Ostomy creation (either Hartmann's procedure with end-colostomy or a primary anastomosis with a diverting loop ileostomy) is uncommon in non-emergent cases.However, it may be necessary in the case of a deteriorating clinical picture, significant colonic distension, fecal spoilage, insufficient length, compromised blood supply, or

Figure 1
Figure 1 CT scan of the patient's sigmoid volvulus.A: Horizontal plane with air-fluid levels; B: Frontal plane with coffee bean sign