EP616 - Plot Twist: Transverse Colon Volvulus As A Rare Cause Of Large‑Bowel Obstruction In An 83‑Year‑Old Woman

Purpose/Background: Transverse colon volvulus is the rarest colonic volvulus and an uncommon cause of large-bowel obstruction. Early English summaries listed fewer than 100 cases; later syntheses cataloged several hundred worldwide, confirming persistent rarity. Predisposition reflects colonic/mesocolic redundancy, a narrow mesenteric base, and poor fixation, often with megacolon, constipation, prior operations, adhesions, or distal obstruction. CT may show a mesenteric whirl and a transverse transition, but level and viability are often determined intraoperatively; detorsion is unreliable, so resection; whether segmental or subtotal, is preferred.

Methods/Interventions: An 83-year-old woman with cholecystectomy, GERD, chronic constipation, and a negative diagnostic laparoscopy (June 2025) presented after one day of cramping lower-abdominal pain, obstipation, and poor oral intake without fever, nausea, or vomiting. She was afebrile; vitals 152/98 mmHg, HR 92, RR 18. RUQ/right-flank tenderness with guarding. Labs: WBC 5.3×10⁹/L, hemoglobin 13.0 g/dL, lactate 1.6 mmol/L. CT A/P with contrast on Aug 31, 2025 showed dilated small-bowel loops with a transition at a 360° mesenteric swirl involving distal small bowel and the transverse colon, with swirl of the ileocolic vessels, venous compression, and mesenteric edema. Urgent diagnostic laparoscopy revealed transverse colon volvulus with dilation and pan-colonic redundancy with minimal fixation. Converted to open and detorsed; the transverse mesocolon was redundant with a narrow mesenteric pedicle and paucity of mesenteric fat. Subtotal colectomy with primary ileocolic anastomosis was performed. Postoperatively she developed hypotension refractory to fluids, requiring SICU transfer, transfusion, and vasopressors. On POD1, CTA showed pelvic and left-mesenteric hematomas without active extravasation and no bowel obstruction; reoperation was recommended but declined. The course included electrolyte derangements, persistent ileus requiring NGT and trickle feeds, bilateral pleural effusions, and, on POD9, sepsis, returning to SICU.

Results/Outcomes: On POD10 she remained tachycardic and pressor-dependent; CT chest/abdomen/pelvis showed aspiration pneumonia and marked volume overload. After discussions with the patient and sister, she chose comfort-focused care and was discharged to hospice. Final pathology showed small bowel and colon with ischemic-hemorrhagic changes, serositis, and serosal adhesions.

Conclusion/Discussion: This case highlights the rarity of transverse colon volvulus, the permissive anatomy (redundancy, narrow mesenteric base, inadequate fixation), and the value but limits of CT. Detorsion is unreliable; resection is standard, with subtotal colectomy appropriate when megacolon or diffuse redundancy is present to reduce recurrence. In frail older adults, early recognition, timely operation, and goals-of-care discussions are essential as complications evolve, the risk-benefit balance of reintervention narrows, and multidisciplinary palliative input can be invaluable.

Figure 1.
CT abdomen/pelvis in axial view showing mesenteric swirling and suspected transition in the transverse colon (arrow) and mesenteric edema.
Figure 3.
Intra-operative photograph demonstrating the fecal burden, significant loss of mesenteric fat and colonic redundancy.