& Hastal›klar› DergisiJournal of Diseases of the Colon and Rectum

© TKRCD 2012

Cecal Volvulus: Report of Two Cases

Çekal Volvulus: ‹ki Olgu Sunumu

MUSTAFA HASBAHÇEC‹, FAT‹H BAfiAK, AL‹ KILIÇ, fiAHAP TÜMERDEM, TOLGA CANBAK,ORHAN AL‹MO⁄LUÜmraniye E¤itim ve Araflt›rma Hastanesi Genel Cerrahi Klini¤i, ‹stanbul-Türkiye

CASE REPORT

Baflvuru Tarihi: 15.12.2011, Kabul Tarihi: 08.02.2012

Dr. Mustafa Hasbahçeci

H›rkai fierif M Keçeci Çeflmesi S DoktorlarS B Bl 6/7 Fatih 34766 ‹stanbul - TürkiyeTel: 0533.3560132e-mail: hasbahceci@yahoo.com

Kolon Rektum Hast Derg 2012;22:21-24

ÖZETAmaç: Çekal volvulus akut intestinal obstruksiyonunnadir bir sebebi olarak, çekum ve terminal ileumun kendimezenterleri etraf›nda ve aksial planda bükülmesidir.Nadir olarak görülmesinin yan›nda, bilinebilirlili¤in azolmas› da tan›da flüpheye ve bunu takiben tedavidegecikmeye yol açmaktad›r.Olgu Sunumlar›: Bu yaz›da iki farkl› çekal volvulusolgusunun klinik özellikleri ile sunulmas› amaçland›.Birinci olguda daha önceki laparotomilere ba¤l›adezyonlar, ikinci olguda ise tedavi edilmemiflhipotiroidizm çekal volvulusun en olas› sebepleri olarakde¤erlendirildi. Sa¤ hemikolektomi ve primer anastomozher iki hastaya sorunsuz olarak uyguland›.Sonuçlar: Çekal volvulusun erken tan›s› ve acil tedavisibarsaklar›n gangrenöz de¤iflimine engel olabilir. Erkentan› için öncelikle direkt kar›n grafisi istenmelidir. Çekalvolvulusun kesin tan›s› için, hastan›n klinik özellikleridikkate al›narak bilgisayarl› tomografi ya da kolonoskopidüflünülebilir. Hastan›n genel durumuna ba¤l› olmak

ABSTRACTPurpose: Cecal volvulus as an uncommon cause of acuteintestinal obstruction is axial twist of the cecum andterminal ileum around their mesentery. In addition to itsrarity, lack of familiarity causes diagnostic doubt andconsequently delays in treatment.Case Reports: In this paper, we describe two cevalvolvulus cases with their clinical properties. Adhesionscaused by previous laparotomies and untreatedhypothyroidism were accepted as the most probablecauses of the first and second cases, respectively. Righthemicolectomy and anastomosis was applied to bothuneventfully.Conclusions: Prompt recognition and urgent treatmentof cecal volvulus may avoid gangrenous changes of thebowel. Abdominal radiographs should be used primarilyfor early diagnosis. Depending on clinical findings,computed tomography or colonoscopy can be consideredfor definitive diagnosis. Resection and anastomosis isthe proposed choice of the operation depending on the

Figure 2. Distended cecumwith its axis running fromthe right to the left (coffee-bean sign) and laterallydilated loop of smallintestinal segments.

kayd› ile rezeksiyon ve anastomoz önerilen tedaviseçene¤idir.

Anahtar Kelimeler: Volvulus, Çekum, Cerrahi

general condition of the patient.

Key words: Volvulus, Cecum, Surgery

IntroductionCecal volvulus (CV) as an uncommon cause of intestinalobstruction is axial twist of the cecum, ascending colonand terminal ileum around their mesenteric pedicle.1,2

Although most of the volvulus occurs in the sigmoidcolon, cecum is the second in its frequency of occurrence.3

Lack of familiarity with this condition usually causesdiagnostic doubt and consequently delays in treatment,which are all contributing factors for development ofgangrene with probable high morbidity and mortality.3,4

We report two cases of CV describing their presentation,management and subsequent outcome.

Case Descriptions

Case 1A 55-year-old female patient presented to the EmergencyDepartment with a two day history of severe colickyabdominal pain and obstipation with vomiting. She hadappendectomy, cholecystectomy and caesarian sectionoperations. Her medical history was insignificant.Physical examination revealed diffuse abdominal rigidityand rebound tenderness. The laboratory tests showedonly leukocytosis with normal biochemical analysis. Aplain supine X-ray of the abdomen revealed colonic andsmall intestinal air-fluid levels. In computed tomography,massive dilatation of the right colon dilated smallintestinal segments and the coffee-bean sign indicatingCV were detected. Exploratory laparotomy wasperformed with presumptive diagnoses of CV andmechanical intestinal obstruction, because of the possibleadhesions caused by previous laparotomies. At operation,dilated cecum with ischemic changes involving distalileum was found (Figure 1). Right hemicolectomy andside to side ileotransversostomy was performed. Shemade an uncomplicated recovery and was dischargedon the fifth postoperative day. Histopathology confirmedhemorrhagic infarction on the mucosa and effacementof muscularis propria.The patient has been followed for two and a half yearswithout any complaint.

Figure 1. Intraoperative appearance of CV with minimalischemic changes on the cecum.

Case 2A 59-year-old female patient presented to the EmergencyDepartment with a three day history of mild abdominalpain, obstipation and abdominal distention which werenot associated with nausea and vomiting. The patienthas not had a prior laparotomy and her medical historywas significant for congenital hypothyroidism with mildmental retardation, and previous myocardial infarction.On physical examination, diffuse tenderness withoutrigidity and rebound tenderness were found. Thelaboratory analysis was normal except thyroid stimulatinghormone level of 18.91 uIU/mL (normal range: 0.49-4.67 uIU/mL). A plain supine abdominal radiographshowed markedly distended loop of bowel with its axisrunning from the right to the left (coffee-bean sign) andlaterally dilated loop of small intestinal segments(Figure 2).

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23Vol. 22, No.1 CECAL VOLVULUS

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The underlying etiology and predisposing factors forCV include conditions such as chronic constipation,abdominal masses, pregnancy, prior abdominal surgery,prolonged immobility, constipation and colonoscopy.1,3,5

According to the clinical series, previous abdominalsurgery was identified as an important contributing factorfor CV.3 However, lack of fixation of the right colon,cecum, terminal ileum and mesentery to the posteriorparietal peritoneum causing a mobile cecum is primarilyrequired for this twisting to occur.4,5 Despite this possibleanatomic predisposition in certain individuals, the exactetiology is most likely multifactorial.4 In the first caseof this paper, we thought that the possible etiology wasadhesions due to the previous laparotomies, and for thesecond case, hypothyroidism may be the triggering factorfor the development of CV. Although the evolution ofmegacolon and pseudovolvulus caused by hypothyroidismto true volvulus is not known to occur, the edematousfocus in the bowel may serve as a pivot point upon whichthe colon may twist.6 In the second case, the presenceof minimally dilated colonic segments in addition to CVand full recovery after surgical treatment with intensethyroid hormone replacement may connote thathypothyroidism causing megacolon and volvulus is thesuspected etiology.Clinical presentation could be highly variable, rangingfrom intermittent episodes of abdominal pain toabdominal catastrophe.1,4 Preoperative diagnosis of CVis rarely achieved in most cases because of its rarity andnonspecific presentation.4,5 It is believed that abdominalradiographs often can be abnormal and detect CV inmore than 50 % of the cases.3 The point of the coffee-bean deformity in CV is directed toward the left upperquadrant as our in second case. A dilated ectopic cecuma single air-fluid level in the right lower quadrant, smallbowel dilatation and absence of gas in the distal colonare reported as the most commonly visualizedabnormalities in CV.3,4 So, they can play a critical rolein the early evaluation of patients suspected of volvulus.However, computed tomography has been recommendedin recent years for the definitive diagnosis of CV.4,7

Colonoscopy as a diagnostic and therapeutic modalitycan be used in selected cases.2,4 Colonoscopic reductionfor CV is less invasive than surgery, so when the patient’sgeneral condition is stable and emergency surgery is notconsidered as necessary, it may be suggested to perform

The patient was admitted to the surgical ward, andlevothyroxine sodium treatment was initiated immediatelyfor hypothyroidism. A trial of diagnostic anddecompressive colonoscopy was planned. At colonoscopy,passage through the proximal transverse colonic segmentcould not be performed because of the stenosis withconcentricity of mucosal folds indicating CV at the levelof distal right colon. The decision was made to exploratorylaparotomy. The dilated and thin-walled cecum twistingaround its mesentery without strangulation, and dilateddistal small intestinal segments were seen at laparotomy(Figure 3). Minimal dilatation of the other colonicsegments was seen during exploration. Righthemicolectomy and side to side ileotransversostomy wasperformed. She made an uncomplicated recovery andwas discharged on the eighth postoperative day.Histopathology confirmed hyperemia and edema on themucosa of the resected segments and serosal vascularcongestion.The patient has been followed for one year without anycomplaint.

Figure 3. Massive dilatation of the cecum and distalsmall intestinal segments.

DiscussionTwisting of a loop of bowel and its mesentery on a fixedpoint at the base is known as volvulus and it may arisein the sigmoid colon, cecum, splenic flexure, andtransverse colon, in descending order of frequency.4

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References1. Katoh T, Shigemori T, Fukaya R, et al. Cecal

volvulus: report of a case and review of Japaneseliterature. World J Gastroenterol 2009;15:2547-9.

2. Majeski J. Operative therapy for cecal volvuluscombining resection with colopexy. Am J Surg2005;189:211-3.

3. Consorti ET, Liu TH. Diagnosis and treatment ofcaecal volvulus. Postgrad Med J 2005;81:772-6.

4. Madiba TE, Thomson SR. The management of cecalvolvulus. Dis Colon Rectum 2002;45:264-7.

5. Valsdottir E, Marks JH. Volvulus: small bowel andcolon. Clin Colon Rectal Surg 2008;21:91-3.

6. Tran HA, Foy A. Myxedema pseudovolvulus. J ClinEndocrinol Metab., 2006;91:2819-20.

7. Delabrousse E, Sarliève P, Sailley N, et al. Cecalvolvulus: CT findings and correlation withpathophysiology. Emerg Radiol 2007;14:411-5.

8. Ballantyne GH, Brandner MD, Beart RW Jr, et al.Volvulus of the colon. Incidence and mortality. AnnSurg 1985;202:83-92.

the reduction of CV colonoscopically.8 This therapeuticmodality was not attempted in the first case of our reportbecause of diffuse abdominal rigidity and reboundtenderness. Although it was possible to detect CV in thesecond case, colonoscopic reduction could not be carriedout effectively.Immediate surgical reduction of the twisted segment isthe most effective treatment to prevent progression tonecrosis.2-4 Resection is mandatory for gangrene as inCase1, and also should be strongly considered whenencountering a grossly distended and thin-walled cecumas in Case 2.2,3 Following resection, reconstruction as

to anastomosis or ileostomy should be chosen on thebasis of the patient’s condition and the condition of thebowel at the time of surgery.3

In conclusion, the occurrence of CV is a multifactorialprocess in the presence of abnormally mobile cecum.Prompt recognition and urgent treatment may avoidgangrenous changes of the bowel. Although abdominalradiographs should play an important role in earlydiagnosis, computed tomography can be considered fordefinitive diagnosis of CV. Resection and primaryanastomosis is the choice of the operation depending onthe general condition of the patient.