Rare disease
Case report
1
Department of Surgery,
Salmaniya Medical Complex,
Manama, Bahrain
2
Department of General Surgery,
King Hamad University Hospital,
Busaiteen, Bahrain
Correspondence to
Dr Hussain Adnan Abdulla,
​hussainaabdulla@​yahoo.​com
Accepted 15 February 2019
© BMJ Publishing Group
Limited 2019. No commercial
re-use. See rights and
permissions. Published by BMJ.
To cite: Abdulla HA,
Hamza E, Dhaif A. BMJ Case
Rep 2019;12:e228863.
doi:10.1136/bcr-2018-
228863
Transverse colon volvulus in a patient with sickle
cell disease
Hussain Adnan Abdulla,1 Eman Hamza,2 Ali Dhaif1
Summary
Although colonic volvulus is a relatively rare cause of
large bowel obstruction, accounting for up to 5% of all
cases of intestinal obstruction, transverse colon volvulus
is extremely uncommon compared with volvulus of the
sigmoid colon or caecum and is responsible for only
3% of all reported cases. We report an unusual case of
spontaneous volvulus of the transverse colon in a young
man with sickle cell disease who underwent resection
with primary anastamosis. Having a high index of
suspicion and early operative intervention allowed for
this patient to have an uneventful postoperative course.
Background
Volvulus of the transverse colon constitutes a rare
surgical emergency. It was first described in 1932 by
the Finnish surgeon Kallio.1 Its clinical presentation
and radiological findings are that of large bowel
obstruction. Prompt surgical intervention is key to
reducing the morbidity and mortality associated
with transverse colon volvulus. To date, <100 cases
of transverse colon volvulus have been reported in
the literature.2 To the best of our knowledge, this is
Figure 1  Abdominal X-ray showing air–fluid levels,
dilated small bowel loops and ‘U-shaped’ loop in the left
hemidiaphragm.
Abdulla HA, et al. BMJ Case Rep 2019;12:e228863. doi:10.1136/bcr-2018-228863
BMJ Case Rep: first published as 10.1136/bcr-2018-228863 on 8 March 2019. Downloaded from http://casereports.bmj.com/ on 5 May 2019 by guest. Protected by copyright.
the first reported case in a patient with sickle cell
disease.
Case presentation
An 18-year-old Bahraini male, known to have sickle
cell disease, was admitted for sudden onset vaso-oc-
clusive pain crisis. After seeking a surgical consulta-
tion for abdominal pain, the patient was reviewed
in the ward. He reported a 2-day history of severe
abdominal pain and constipation with vomiting. His
medical history was significant for sickle cell painful
crises treated with opioid analgesics. There was no
surgical history. Physical examination showed a
distended abdomen; there was generalised tender-
ness associated with voluntary guarding, but no
rigidity or rebound tenderness. The abdomen was
tympanic to percussion with absent bowel sounds.
Digital rectal examination demonstrated an empty
rectum.
Investigations
Laboratory investigations revealed anaemia
(haemoglobin 7.9  g/dL), leukocytosis (white cell
count of 16.6×109/L) with neutrophilia (66.9%)
and liver function tests showed picture of sickle
cell hepatopathy. The abdominal X-ray suggested
bowel obstruction, with multiple air–fluid levels
and distended small bowel and ‘U-shaped’ large
bowel loop in the left hemidiaphragm (figure 1).
An urgent CT scan reported a dilated, stool-filled
transverse colon as well as dilated proximal small
bowel, raising possibility of large bowel obstruction
(figure 2).
Treatment
The patient was transfused two units of packed
red blood cells and was taken to the operating
room for exploratory laparotomy. Intraoperative
findings were dilated small bowel and redundant
transverse colon that was rotated 360° clockwise
on its mesentery, with no evidence of bowel isch-
aemia (figure 3). The volvulus was delivered into
the incision and detorsed. Segmental resection of
the transverse colon with primary anastomosis was
performed.
Outcome and follow-up
The postoperative course was uneventful, and
the patient was discharged from the hospital after
6 days. Histologically, there was no evidence of any
ischaemic changes with viable resection margins.
1
 Rare disease
Figure 2  CT scan showing dilated small bowel and transverse colon
filled with faecal matter.
Discussion
Volvulus is a rare cause of colonic obstruction, accounting for
3%–5% of all cases of intestinal obstruction.3 Transverse colon
volvulus is extremely uncommon, representing ~3% of all cases
of colonic volvulus.4 Risk factors for the development of trans-
verse colon volvulus may be divided into anatomical, mechanical
and physiological.3 5 The two anatomical factors are redundancy
and non-fixation,2 as in our case. Mechanical causes include
previous volvulus, distal colonic obstruction, adhesions, malpo-
sition of the colon during previous surgery, mobility of the right
colon, inflammatory strictures and carcinoma.3 Physiological
factors include large bowel distension secondary to distal imped-
iment to defecation in chronic constipation.2 5 Other causes
have been reported, such as Chilaiditi's syndrome,6Clostridium
difficile associated pseudomembranous colitis7 and impaired
intestinal motility in pregnancy.8 In our case, constipation from
Figure 3  Gross specimen showing dilated small bowel and transverse
colon rotated 360o on its mesentery.
2 Abdulla HA, et al. BMJ Case Rep 2019;12:e228863. doi:10.1136/bcr-2018-228863
use of chronic opioids for controlling symptoms of sickle cell
BMJ Case Rep: first published as 10.1136/bcr-2018-228863 on 8 March 2019. Downloaded from http://casereports.bmj.com/ on 5 May 2019 by guest. Protected by copyright.
disease might have precipitated the condition. This complicates
the diagnosis given his ongoing abdominal pain. Additionally,
his young age and gender are also complicating factors as these
patients are often female with a mean age of 51 years.4
It can present either as acute fulminating or subacute progres-
sive transverse colon volvulus.3 6 The former is characterised by
sudden onset of severe abdominal pain associated with rebound
tenderness, nausea, vomiting, limited abdominal distension and
marked leukocytosis.2 Bowel sounds are initially hyperactive but
later may become absent.6 Our patient presented with the acute
fulminating type, despite absence of typical peritoneal signs
on physical examination, which were possibly masked by his
long-term use of opioids as well as inpatient administration of
opioid analgesics at the time of examination. In the latter, there
is massive abdominal distension in the setting of mild abdominal
pain without rebound tenderness, nausea or vomiting, and the
leucocyte count is either normal or only mildly elevated.3 The
progressive onset of symptoms in the subacute progressive type
can delay the diagnosis and result in failure to provide timely
intervention, causing disease progression to the acute fulmi-
nating type with bowel infarction, peritonitis and death.2 3
Diagnosis of transverse colon volvulus is usually not made
preoperatively, as radiological findings are not characteristic,
unlike in sigmoid colon volvulus, and is made intraoperatively.9
In our case, dilated bowel loops with air–fluid levels and the
presence of U-shaped loop in the left upper quadrant on abdom-
inal X-ray raised the possibility of diagnosis, but this is not a
consistent radiological finding.5 There are no typical radiological
features for transverse colon volvulus on CT scan.10 The classic
‘bird’s beak’ deformity in the transverse colon seen on contrast
enema is diagnostic, but in the acute setting, surgery should not
be delayed to perform contrast study.6
A colonoscopic decompression is the initial treatment of
sigmoid colon volvulus, it is not recommended for trans-
verse colon volvulus, due to high probability of failure and
necrosis.9 11 Resection with primary anastomosis, as in our case,
or with stoma formation is the treatment of choice in cases of
transverse colon volvulus to prevent recurrence.3 6 Compared
with resection, simple detorsion of the bowel or untwisting with
colopexy is associated with higher rate of recurrence or even
Learning points
►► Volvulus of the transverse colon is an extremely rare entity
and should be recognised as a surgical emergency.
►► Diagnosis requires a high index of suspicion in a patient
who presents with abdominal pain and features of bowel
obstruction. It is difficult to identify radiologically, so
preoperative diagnosis becomes even more difficult to make
with certainty.
►► Delay in diagnosis can result in bowel strangulation with
perforation, peritonitis and sepsis with increased morbidity
and mortality.
►► Prompt recognition with emergency surgical intervention,
through resection with or without primary anastomosis, is
necessary to minimise these complications and achieve a
successful outcome.
►► An additional learning point from this case would be that in
a sickle cell disease patient presenting with abdominal pain,
one should also consider surgical causes of acute abdomen
other than sickle cell crisis as a cause of pain.
 Rare disease
death.2 4 At operation, there were no signs of bowel ischaemia, 3 Sana L, Ali G, Kallel H, et al. Spontaneous transverse colon volvulus. Pan Afr Med J

attributable to the lack of ischaemia at early stages, especially if
immediate surgical intervention is undertaken.2 3
Contributors  HAA participated in the management of the patient in the case
report and the preparation of the manuscript. EH participated in the preparation
of the manuscript. AD participated in the clinical management of the patient and
editing of the manuscript.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Provenance and peer review  Not commissioned; externally peer reviewed.
10 Vandendries C, Jullès MC, Boulay-Coletta I, et al. Diagnosis of colonic volvulus:
References
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Abdulla HA, et al. BMJ Case Rep 2019;12:e228863. doi:10.1136/bcr-2018-228863 3