Delivering Safe and Effective Analgesia for Management of Renal Colic in the Emergency Department


TAKE-HOME MESSAGE

 The searing pain of renal colic is unforgettable to those who experience it. This well designed study demonstrated that the intramuscular administration of diclofenac, an NSAID, produced better and more durable analgesia than morphine delivered intravenously with a superior side effect profile.  While the intravenous administration of paracetamol (acetaminophen) produced a similar rapid reduction in pain intensity, analgesic rescue was needed more frequently.  Thus, an NSAID shot appears to be the preferred initial management for those experiencing renal colic.

Abstract

Cecal Volvulus Presenting as Epigastric Swelling and Mimicking Gastric Volvulus.


Caecal volvulus is the second most common volvulus involving the large bowel, following sigmoid volvulus. It usually manifests as closed-loop obstruction and patient usually presents with early gangrene and perforation. It is unusual for caecal volvulus to present as an epigastric swelling. We report a case of caecal volvulus in a 90-year-old patient who presented with an epigastric swelling.Case ReportA 90-year-old man presented to surgical emergency with complaints of progressive abdominal distension, obstipation and pain for 3 days; he had no associated comorbid conditions. On examination, the patient was dehydrated and had tachycardia. The supra-umbilical half of the abdomen was distended and associated with tenderness and guarding. X-rays findings were of multiple air fluid levels with a large air filled viscus occupying the upper abdomen (Figure 1).Computer tomography (CT) at the level of L2 also showed a large air filled viscus. On exploration, large bowel popped into the operative field as soon as the peritoneal cavity was opened (Figure 2).It included the cecum and ascending colon which were grossly distended, reaching upto 14 cm in diameter, rotated on the longitudinal axis clockwise and lying in the upper abdomen. There were signs of rupture of the tenia coli and impending perforation. The patient underwent derotation of the gut with right hemicolectomy and ileo-transverse anastomosis. Postoperative period was uneventful and patient was discharged in a stable condition and is healthy on follow up.

Discussion

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.[1]

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%).[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.[3] 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.[4]

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.[6] 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.[7] 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.[8] The recurrence rate for detorsion alone was 13%, which is the same recurrence rate as for cecopexy.[9] 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.

Key Points

  • 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.

References

  1. Rabinovici R, Simansky DA, Kaplan O, Kaplan O, Mavor E. Cecal volvulus. Dis Colon Rectum. 1990;33:765–69.
  2. Rogers RL, Harford FJ: Mobile cecum syndrome. Dis Colon Rect. 1984;27:399-402.
  3. Wolfer JA, Beaton LE, Anson BJ. Volvulus of the cecum. Anatomical factors in its etiology: report of case. Surg Gynecol Obstet. 1942;74:882-94.
  4. Margolin DA, Whitlow CB. The pathogenesis and etiology of colonic volvulus. Semin Colon Rectal Surg. 1999;10:129-138.
  5. Madiba TE, Thomson SR. The management of cecal volvulus. Dis Colon Rectum. 2002;45:264-67.
  6. Dibra A, Rulli F, Kaçi M, Çeliku E, Draçini X. Acute right intrathoracic gastric volvulus. A rare surgical emergency. Ann Ital Chir. 2013;84:205-07.
  7. Carter R, Brewer LA 3rd, Hinshaw DB. Acute gastric volvulus. A study of 25 cases. Am J Surg. Jul 1980;140(1):99-106.
  8. Janardhanan R, Bowman D, Brodmerkel GJ Jr, Agrawal RM, Gregory DH, Ashok PS. Cecal volvulus: decompression and detorsion with a colonoscopically placed drainage tube. Am J Gastroenterol. September 1987;82(9):912-14.
  9. Tejler G, Jiborn H. Volvulus of the cecum. Report of 26 cases and review of the literature. Dis Colon Rect. 1988;31:445-49.