Volvulus is axial twisting or rotation of the intestine around its vascular pedicle. Among the colonic volvuli, most common is sigmoid colon (75%) followed by cecum (22%). Rare sites in colon include transverse colon (about 2%) and splenic flexure (1-2%) (1-3, 9). Simultaneous transverse and sigmoid volvulus is extremely rare (4-9). Parrish et al. described a case of coexistent volvulus of the transverse, sigmoid and right colon (10). To our knowledge, few such reports have been published till date. We hereby enumerate our experience of successful surgery of such a rare case.

A 77 year old man was admitted to the department of surgery, CNMCH on 16th october, 2019 through the ER with severe respiratory distress, abdominal distention and absolute constipation of 10 days duration (Fig 1). Clinically there was no fever, heart rate at 56 beats per minute and presenting blood pressure of 90/60 with the patient dehydrated. A grossly distended abdomen was obvious, though there was no rebound tenderness. Intestinal peristaltic sounds were absent on auscultation. Rectal examination revealed a dilated empty rectum. The straight erect plain x-ray of abdomen revealed massively dilated loops of large bowel, displacing left hemidiaphragm superiorly, causing left lung to collapse, and mediastenal shifting to the right side The patient was resuscitated vigorously with IV fluids and taken up for emergency exploratory laparotomy under general anaesthesia. Intraoperatively, hugely dilated colonic segment was encountered, which, on complete delineation, was found to involve both sigmoid and transverse colon along with splenic flexure, causing megacolon (Fig 3a, 3b, 3c). After untwisting of the volvulus, the massively dilated, but not necrosed, sigmoid colon, splenic flexure and transverse colon was resected. In view of the unstable condition of the patient, an end colostomy with normal ascending colon and Hurtmann's procedure was deemed appropriate and was performed. Postoperative period was uneventful and the patient was discharged on the 8th postoperative day after initial 2 days of icu care. The histopathology results of the resected gut showed mucosal and submucosal congestion, chronic inflammation compatible with volvulus and no evidence of malignancy.

Volvulus of multiple colonic segments, though rare, must be considered in the differential diagnosis when dealing with acute intestinal obstruction, especially those which are longer in duration. Any misinterpretation may lead to unfavourable outcomes.

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