The term volvulus is derived from the Latin word volvere (“to twist”.) Cecal volvulus is the second most common site of colonic volvulus after the sigmoid colon. It is regarded as a misnomer because, in most patients, the torsion is located in the ascending colon. Cecal volvulus is essentially a closed-loop obstruction that may lead to vascular compromise with consequent gangrene and perforation. It is a disease of the elderly, predominately affecting women.
Cecal volvulus is responsible for 10%-15% of all cases of large-bowel obstruction; the most common site of large-bowel torsion being the sigmoid colon (80%), followed by the cecum (15%), the transverse colon (3%), and the splenic flexure (2%). People with incomplete intestinal rotation generally have inadequate right colon fixation which is associated with clockwise torsion of the cecum, terminal ileum, and ascending colon. Based on autopsy reports, sufficient cecal mobility for volvulus and bascule formation is found in 11% and 25% of adults, respectively. Prior abdominal surgery with colonic mobilization, recent surgical manipulation, adhesion formation, congenital bands, distal colonic obstruction, pregnancy, pelvic masses, extreme exertion, and hyperperistalsis have all been implicated as causative.
The usual presentation is acute obstruction with progression to cecal gangrene and perforation. There is an associated distension of the abdomen, usually in the lower part. In contrast gastric volvulus presents as epigastric pain, upper abdominal distension and enderness. The diagnosis is based on the combination of clinical presentation, plain abdominal x-ray and barium enema. In gastric volvulus the Borchardt’s triad of pain, retching, and the inability to pass a nasogastric tube is diagnostic and reportedly occurs in 70% of cases. This triad was absent in the present case. X-ray findings of cecal volvulus differ from gastric volvulus in its location being in the right lower abdomen rather than the epigastrium or the thorax. CT is widely replacing barium contrast imaging as the preferred imaging modality for the diagnosis of volvulus. However in this case it was unable to identify the segment of bowel involved in the volvulus.
Early diagnosis is essential to reduce the substantial morbidity and mortality. The treatment is essentially surgical. Five surgical procedures have been used in the treatment of cecal volvulus: detorsion alone, cecopexy, cecostomy, both cecopexy and cecostomy, and resection. There are reports of decompression of cecal volvulus using a colonoscope or decompression tube and this modality of treatment can be given a chance. The recurrence rate for detorsion alone was 13%, which is the same recurrence rate as for cecopexy. Cecostomy had a recurrence rate of 1%, but there is a high incidence of wound infection, limiting the use of this procedure mainly in moribund patients. Resection eliminates the risk of recurrence entirely and is the procedure of choice in stable patients.
- Caecal volvulus is an uncommon cause of largebowel obstruction, which is commonly associated with gangrene and perforation.
- A high degree to suspicion is required to diagnose this condition early.
- Surgical management remains the treatment of choice in this condition.
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