Cecal Volvulus

Epidemiology

Incidence

  • Cecal Volvulus Accounts for 1-3% of All Colonic Obstructions
  • Clinical Data
    • Incidence of Cecal Volvulus Has Increased Approximately 5.5% Per Year Between 2002-2010 (Ann Surg, 2014) [MEDLINE]
      • In Contrast, the Incidence of Sigmoid Volvulus Has Remained Stable from 2002-2010 (see Sigmoid Volvulus, [[Sigmoid Volvulus]])
      • Sigmoid Volvulus was More Common in Older Males >70 y/o, African-Americans, Patients with Diabetes Mellitus, and Patients with Neuropsychiatric Disorders (see Sigmoid Volvulus, [[Sigmoid Volvulus]])
      • Cecal Volvulus was More Common in Younger Females

Site of Volvulus of the Gastrointestinal Tract

  • Volvulus of the Gastrointestinal Tract May Occur in the Colon, Stomach, Gallbladder, and Small Intestine (see Gastric Volvulus, [[Gastric Volvulus]])
    • Colon is the Most Common Site of Volvulus
      • Cecum and Sigmoid Colon are the Most Common Sites of Colonic Volvulus (see also Sigmoid Volvulus, [[Sigmoid Volvulus]])

Etiology

  • General Comments
    • All Types of Cecil Volvuli Require a Mobile Cecum and Ascending Colon
  • Congenital Mobile Cecum
    • Possibly Due to Failed Fusion of the Ascending Colon Mesentery to the Posterior Parietal Peritoneum
  • Acquired Mobile Cecum
    • Adhesions from Prior Abdominal Surgery
    • Colonic Atony
    • Colonoscopy (see Colonoscopy, [[Colonoscopy]])
    • Hirschsprung Disease (Congenital Aganglionic Megacolon) (see Hirschsprung Disease, [[Hirschsprung Disease]])
    • Pregnancy (see Pregnancy, [[Pregnancy]])

Physiology

  • Rotation or Torsion of a Mobile Cecum (and Ascending Colon)
    • May Result in Cecal Ischemia/Infarction and/or Perforation

Types of Cecal Volvulus

  • General Comments
    • All Types of Cecil Volvuli Require a Mobile Cecum and Ascending Colon
    • Type I and Type II Account for 80% of All Cecal Volvuli
  • Type I (Axial Cecal Volvulus): clockwise axial twisting of the cecum along its long axis, with the volvulized cecum remaining in the right lower quadrant
  • Type II (Loop Cecal Volvulus): twisting of the cecum and a portion of the terminal ileum (usually counterclockwise), resulting in the cecum being relocated to an ectopic location (usually the left upper quadrant) in an inverted orientation
  • Type III (Cecal Bascule): upward folding of the cecum

Diagnosis

Upright Kidneys-Ureter-Bladder X-Ray (KUB) (see Kidneys-Ureters-Bladder X-Ray, [[Kidneys-Ureters-Bladder X-Ray]])

  • May Be Useful Prior to CT Scan to Identify Pneumoperitoneum
    • When Pneumoperitoneum is Found, Surgery is Indicated and Further Imaging with CT Scan is Usually Not Necessary (see Pneumoperitoneum, [[Pneumoperitoneum]])
    • KUB is Diagnostic of Cecal Volvulus in Only 17% of Cases (Dis Colon Rectum, 1990) [MEDLINE]
  • Findings
    • “Coffee Bean” or “Comma-Shaped” Cecum with Air-Fluid Level: seen in approximately 25% of patients with cecal volvulus
    • Dilated Cecum is Usually Displaced Medially and Superiorly
      • However, the Cecum Can Be Displaced Anywhere in the Abdomen
      • In the Case of a Cecal Bascule (Type III), the Dilated Cecum is Usually Displaced More Centrally in the Abdomen
    • Distended Small Bowel with Air-Fluid Levels
    • Decompressed Colon Distal to the Cecum

Abdominal-Pelvic CT (see Abdominal-Pelvic Computed Tomography, [[Abdominal-Pelvic Computed Tomography]])

  • Diagnostic in 90% of Cases: remaining care are diagnosed at surgery\
  • Findings
    • “Whirl Sign”: pathognomonic for cecal volvulus (types I and II)
    • Upward Folding of the Cecum with Obstruction and without an Axial Twist of the Mesentery: diagnostic for cecal volvulus (type III)

Barium Enema (see Barium Enema, [[Barium Enema]])

  • Indications
    • May Be Used in Some Cases When CT Scan is Non-Diagnostic
      • Diagnostic in Approximately 88% of Cases of Cecal Volvulus (Dis Colon Rectum, 1990) [MEDLINE]
  • Contraindications
    • Presence of Peritonitis (see Peritonitis, [[Peritonitis]])
  • Findings
    • “Birds-Beak” in Right Colon: diagnostic
    • Termination of Contrast Appears More Rounded in Cecal Bascule (Type III)

Clinical Manifestations

Gastrointestinal Manifestations

  • General Comments
    • *Clinical Presentation is Variable, Ranging from Insidious Intermittent Abdominal Pain to an Acute Abdominal Catastrophe: symptoms may be present for hours-days
  • Abdominal Pain (see Abdominal Pain, [[Abdominal Pain]])
    • Clinical
      • Gradual Onset of Steady Abdominal Pain: typical
      • Episodic Cramping (Due to Peristalsis)
      • Distended, Tympanitic Abdomen
      • Rebound Tenderness: in cases with peritonitis/bowel ischemia
  • Nausea/Vomiting (see Nausea and Vomiting, [[Nausea and Vomiting]])
  • Obstipation: failure to pass stools or flatus

Hematologic Manifestations

  • Leukocytosis (see Leukocytosis, [[Leukocytosis]]): present in cases with bowel ischemia/infarction or perforation

Renal Manifestations

Other Manifestations

  • Fever (see Fever, [[Fever]]): may be present in cases with bowel ischemia/perforation
  • Hypotension (see Hypotension, [[Hypotension]]): may be present in cases with colonic ischemia/perforation

Treatment

Non-Operative Reduction of Cecal Volvulus

  • Procedures
  • Clinical Efficacy: non-operative reduction of cecal volvulus is successful in <5% of cases -> not recommended
  • Adverse Effects/Complications
    • Inability to Identify Colonic Ischemia/Infarction: in 20-25% of cases
      • May Ultimately Lead to Perforation
    • Perforation

Laparoscopy or Exploratory Laparotomy (see Laparoscopy, [[Laparoscopy]] and Laparotomy, [[Laparotomy]])

  • Indications
    • Failure of Imaging Studies to Establish a Diagnosis in a Patient with Worsening Obstructive Symptoms
    • Evidence of Bowel Ischemia/Infarction or Perforation

Technique

  • Absence of Bowel Compromise
    • Hemodynamically-Stable Patient
      • Detorsion, Followed by Ileocecal Resection/Right Hemicolectomy
    • Hemodynamically-Unstable Patient
      • Detorsion, Followed by Cecopexy with/without Cecostomy Tube Placement
  • Presence of Bowel Compromise
    • Hemodynamically-Stable Patient
      • Detorsion is Contraindicated: to avoid reperfusion injury
      • Ileocolic Resection/Right Hemicolectomy
    • Hemodynamically-Unstable Patient
      • Detorsion is Contraindicated: to avoid reperfusion injury
      • Ileostomy (see Ileostomy, [[Ileostomy]])

References

  • Cecal volvulus. Dis Colon Rectum. 1990;33(9):765 [MEDLINE]
  • Diagnosis and treatment of caecal volvulus. Postgrad Med J. 2005 Dec;81(962):772-6 [MEDLINE]
  • Cecal volvulus: report of a case and review of Japanese literature. World J Gastroenterol. 2009 May;15(20):2547-9 [MEDLINE]
  • Colonic volvulus in the United States: trends, outcomes, and predictors of mortality. Ann Surg. 2014 Feb;259(2):293-301 [MEDLINE]