Cecal Volvulus – MD Nexus

Epidemiology

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

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]])

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]])

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

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

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

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)

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)

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

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

Metabolic Acidosis (see Metabolic Acidosis-Elevated Anion Gap, [[Metabolic Acidosis-Elevated Anion Gap]]): present in cases with bowel ischemia/infarction or perforation

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

Procedures
- Barium Enema (see Barium Enema, [[Barium Enema]])
- Colonoscopy (see Colonoscopy, [[Colonoscopy]])
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

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

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]])

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]