many reports have described sigmoid volvulus , but fatal hemorrhagic shock resulting from the rupture of the involved artery has not been reported as a complication of a sigmoid volvulus .
a 71-year - old man with slight abdominal pain and obstipation in hypotension died at a nursing home without seeing a doctor . at autopsy ,
a mesenteric hematoma and hemoperitoneum was observed with approximately 1,000 ml of blood in the abdominal cavity .
the sigmoid colon and the mesentery were twisted at an adhesion site of a sigmoid colon to an ileum , and the condition was determined to be a sigmoid volvulus .
the inferior mesenteric artery was incorporated into the twisted part of the mesentery , but remained patent , and its peripheral branch near the hematoma ruptured without histological abnormality .
since ischemic - reperfusion injury occurs with a temporarily occluded artery , the acute re - loading of blood flow may injure the distal vessels after spontaneous reduction of compression by loosening of the volvulus .
a colon obstruction may result in complications such as dehydration , shock and septic toxemia , all of which are life - threatening .
a sigmoid colon volvulus may cause ischemic changes in the large intestine through compression of the mesenteric vessels and reduction of the blood supply , which result in necrosis .
it is important for the patient to receive an emergent surgical decompression with the replacements of fluids and electrolytes , and the administration of antibiotics [ 24 ] .
however , in the case of a low grade obstruction with no sign of abdominal gangrene or peritonitis , non - operative treatments such as rectal tube insertion and sigmoidoscopic decompression are effective with few fatal complications [ 2,57 ] . in this report
, we describe an atypical case of a low grade sigmoid volvulus that resulted in death from hemorrhagic shock induced by the rupture of an inferior mesenteric artery branch following non - operative treatment .
the case was a male ( 71 years old , 45 kg in weight ) who was diagnosed with hypertension and medicated for depression .
he showed no symptoms and had no history of abdominal disorders or abdominal surgeries . at 12hours before death at a nursing home , the man felt a slight abdominal pain and obstipation , with pallid and frigid extremities , but he did not receive any medical examination or medications . at 4 hours before the death , his extremities were extremely frigid and showed severe pallor .
an intravenous drip injection of saline was started by a night nurse . at several hours after the injection , the victim was found in cardiopulmonary arrest , and attempts at resuscitation were immediately started by the nurse . at approximately 15 minutes after the arrest , the victim was confirmed dead by paramedics .
he had received no medical examinations by a doctor since the clinical symptoms appeared . at autopsy ,
no surgical scars were observed on the abdomen . a heavy massive adhesion between the sigmoid colon and ileum was observed ( figure 1 ) .
one end of the adhesion on the sigmoid colon was located approximately 60 cm proximal to the anus , and the other end of the adhesion on the ileum was located approximately 30 cm proximal to ileocecal junction .
the artery was running into the twisted part of mesentery , and was determined to be patent by the easy insertion of a probe ( figure 2 ) .
in the mesentery , an approximately 500 g hematoma and a perforated mesentery membrane were observed around the dilated descending colon . in the abdominal cavity , 500 ml of hemoperitoneum was observed .
histologically , the serosa was strongly fibrous , degenerated but anatomical anomalies were not observed at the adhesion .
the engorgement and hemorrhage were observed at the dilated colon wall , although very little necrosis was observed .
the ruptured vessel was a peripheral branch of the involved inferior mesenteric artery ( figure 3 ) .
no pathological abnormalities such as arteriosclerosis , aneurysm or arteritis that may have resulted in the arteriorrhexis were observed .
we speculate that the victim died from hemorrhagic shock induced by rupture of the peripheral branch of the twisted inferior mesenteric artery .
approximately 60 to 70% of all cases of large bowel obstruction are due to carcinoma of the colon .
volvulus at the sigmoid colon is the second most common cause of large bowel obstruction , and accounts for 5 to 10% of all cases .
previous abdominal surgery is the most common cause of intestinal volvulus , although anatomical anomalies , such as diverticulum and hernia , may cause intestinal volvulus . in this case , no previous abdominal surgery was reported and no anatomical anomalies were confirmed at autopsy .
the adhesion between the sigmoid colon and an the ileum became an axis of the sigmoid colon volvulus , which was highly fibrous and degenerated on histological examination .
past partial peritonitis may have been the cause of the adhesion . in the case of colon obstruction , bacteria and bacterial products
pass through the damaged bowel wall and enter systemic circulation , which may induce septic shock state . in this case , the victim fell into a shock state after the appearance of clinical symptoms such as constipation , abdominal distension and abdominal pain , which are known as distinctive findings of sigmoid colon volvulus . during the early stage of septic shock ,
vasodilatory mediators predominate and present warm extremities , so - called  warm shock  to patient . however , the extremities of this case showed pallor and were frigid after appearance of the symptoms .
hypersecretion of the dilated bowel and hypoabsorption of the damaged intestinal wall have been described to cause fluid loss and bring severe dehydration to the victim of large colon obstruction .
dehydration following sigmoid colon volvulus may induce hypovolemic shock , which corresponds to the  cold shock  state of this case .
the hematoma and hemoperitoneum amounted to 1,000 ml in the abdominal cavity of the present victim .
the ruptured vessel was the peripheral branch of the inferior mesenteric artery , which ran into the twisted part of the mesentery .
pathological abnormalities , such as arteriosclerosis , aneurysm and arteritis , may cause arteriorrhexis easily , but these abnormalities were not observed in the present victim . taking these findings into consideration , we suggested that hemorrhagic shock , and not septic shock , was the cause of death . to our knowledge
, fatal hemorrhagic shock has not been described in a case of intestinal volvulus . in intestinal volvulus ,
compression of the mesenteric vessels may occur very early , followed by blood flow decrease in the distal vessels .
when the blood outflow from the venous side is interrupted by volvulus , engorgement and frank hemorrhage into bowel lumen or wall may appear .
when the blood supply to arterial side is interrupted due to vasospasm or mechanical obstruction of the mesenteric arteries , both the intestinal wall and arterial wall fall into a relative tissue anoxia . in this case , ischemic changes were scarcely observed in the dilated intestinal wall , though engorgement and frank hemorrhage were confirmed probably due to a reduction in venous blood outflow .
the low grade twist of mesentery may have caused a brief and mild decrease in the blood flow of the inferior mesenteric artery , resulting in fragility of the arterial wall .
arterial patency by spontaneous loosening of the volvulus in this case may have caused the acute recovery of arterial blood flow and blood pressure .
however , the re - loading of blood flow may eventually result in the rupture of the fragile arterial wall , similar to an ischemic - reperfusion injury of a temporary occluded artery .
furthermore , persistent intramesenteric bleeding may enlarge the hematoma , perforate the mesenteric membrane , and result in the hemoperitoneum observed in this case .
the most common symptoms of sigmoid volvulus are described as abdominal pain , obstipation , vomiting and abdominal distention .
when a sigmoid volvulus is suspected , the diagnostic study is performed using a plain abdominal radiograph data such as  coffee bean  or 
treatment of large bowel obstruction is designed to relieve colonic distention with treatment for dehydration , shock and toxemia .
the definitive treatment is surgical decompression of the obstructed bowel . in the case of a low grade obstruction with no sign of bowel gangrene or peritonitis , as in this case
, it is sufficient to relieve the obstruction by non - operative treatments such as rectal tube insertion and sigmoidoscopic decompression without significant complications [ 57 ] .
however , a fatal mesenteric hemorrhage can be induced by the rupture of twisted vessels following spontaneous sigmoid volvulus improvement .
many reports have demonstrated the cause , diagnosis , treatments and complications of colon obstruction .
this is the first report on the fatal complication of hemorrhagic shock following a sigmoid colon volvulus .
 summarybackgroundmany reports have described sigmoid volvulus , but fatal hemorrhagic shock resulting from the rupture of the involved artery has not been reported as a complication of a sigmoid volvulus.case reporta 71-year - old man with slight abdominal pain and obstipation in hypotension died at a nursing home without seeing a doctor . at autopsy , 
 a mesenteric hematoma and hemoperitoneum was observed with approximately 1,000 ml of blood in the abdominal cavity . 
 the sigmoid colon and the mesentery were twisted at an adhesion site of a sigmoid colon to an ileum , and the condition was determined to be a sigmoid volvulus . 
 the volvulus was observed to be loosened . 
 the inferior mesenteric artery was incorporated into the twisted part of the mesentery , but remained patent , and its peripheral branch near the hematoma ruptured without histological abnormality.conclusionssince ischemic - reperfusion injury occurs with a temporarily occluded artery , the acute re - loading of blood flow may injure the distal vessels after spontaneous reduction of compression by loosening of the volvulus . 
Background
Case Report
Conclusions
Background
Case Report
Discussion
Conclusions