Cecal Volvulus: a Review and Analysis of the Literature and Presentation Of

Cecal volvulus: A review and analysis of the Intestinal obstruction literature and presentation of three cases VIVIAN M. BARSKY, D.O. WARREN H. SWENSON, D.O., FACOS ANTHONY A. MINISSALE, n.o. Philadelphia, Pennsylvania contributes to the rotation of the cecum up- Three women were admitted to the hospital ward and to the left to form a closed loop. Ab- with signs and symptoms of cecal volvulus. normal mobility of the cecum has been re- They all were more than 40 years of age and ported in from 11 to 22 percent of several had adhesions from prior surgery. Two series of cadavers. Hendrick reported that in cases were the acute obstructive type of approximately 22 percent of the male and 28 volvulus in which the rotation involved the percent of the female cadavers studied, the cecum and ascending colon were sufficiently adhesions. In one case the length of the mobile to permit volvulus of 180 degrees. Ab- mesentery and its laxity caused intermittent normal fixation of the ascending colon by a bouts of cecal rotation. Detorsion of the transverse band (Jacksons membrane) or ad- involved bowel segment was done in each hesions from previous surgery may provide instance. The viability of the bowel was the fixed point about which the cecum may ro- assessed and when it was questionable, tate. Chronic distention of the cecum with gas right hemicolectomy was done with an or feces has been found to be a factor. At times, opening made between the ileum and the distal obstruction, such as that due to tumors, transverse colon. Factors important to the diverticulosis or diverticulitis with granuloma successful outcomes were the use of formation, incarceration of a hernia, or steno- antibiotics, vigorous fluid and electrolyte sis of a colostomy, has been implicated. A diet replacement, tube decompression, and early high in roughage has been a factor in a signifi- operation with the procedure appropriate cant number of cases. Cecal volvulus has for each case. occurred after bouts of violent or vigorous peristalsis caused by diarrhea or frequent pur- gation. The enlarging uterus of pregnancy can cause dislocation of the cecum from its normal position and predispose the patient to volvulus. Cecal volvulus, a twisting of the bowel on itself Colonic atony due to postoperative intestinal so as to occlude the lumen, was defined by paralysis, peritonitis, hypokalemia, myxedema, Gatellier and associates. in 1931 as torsion con- or other acute intra-abdominal disease has fined to the terminal portion of the ileum, been a consistent finding. In some series, over- cecum, and a portion of the ascending colon. eating, violent physical activity, and direct abdominal trauma have been directly associated Embryologic and etiologic factors with production of acute cecal volvulus. Hepperlen2 said that normally the cecum and ascending colon are the least mobile portions Epidemiologic aspects of the entire colon. In the infant at birth the From 1960 to 1970 approximately 150 cases of cecum lies superior to the normal position in cecal volvulus were reported in the English the adult; it gradually descends by the end of language literature. Prior to this time most 3 years. Fixation of the cecum and ascending patients were male, but in the period studied, colon is accomplished by fusion of the mesen- approximately 60 percent of patients were fe- tery to the posterior peritoneum. When there male. The average age was from 55 to 60 years is preexisting mobility of the cecum and it has and the average mortality 26.3 percent, with a fixed point around which to rotate, volvulus variation in different series from 10 to 75 per- can occur.3 Distention of the colon and cecum cent. High mortality was attributed to gan- Journal AOA/vol. 72, April 1978 812/83 Cecal volvulus grene or to the delay in diagnosis and subse- den development of pain in the lower right quent treatment. In the United States, cecal quadrant, which lasts from 1 to several hours, volvulus has occurred in less than 1 percent of without signs of peritoneal irritation and re- cases of intestinal obstruction. Hendrick4 solves spontaneously. stated that in western Europe, Great Britain, and the United States it accounts for obstruc- Signs and symptoms tion of the colon and rectum in 10 percent of Sudden generalized colicky pain is present in cases, but that in Russia and the Scandinavian all cases. This is followed by nausea and vomit- and eastern European countries cecal volvulus ing in 50 percent of cases. Rapid progressive is the cause of from 30 to 50 percent of intes- distention of the abdomen may be localized to tinal obstructions. Wilson3 attributed this dif- the umbilical or epigastric area. Half the pa- ference to the high roughage content in the tients report increasing constipation for 2 days diet of eastern Europeans, but Peterson5 said or more. The most common physical finding is that the diet in Scandinavia now is little differ- abdominal distention with tympany. The dis- ent from that in other parts of western Europe tention is often asymmetric, with a gas-filled and the United States. loop or palpable mass in the upper part of the abdomen. Tenderness and guarding are most Pathophysiologic picture and types notable in the lower right quadrant. At the on- The rotation of the cecum usually is clockwise. set of symptoms obstructive bowel sounds are The torsion must be at least 180 degrees to present. When gastric aspiration or enema cause pathologic changes. The severity of the is attempted, the pain and abdominal disten- symptoms observed depends on the rapidity tion are not relieved. As the process pro- and tightness of the twist. Hinshaw and asso- gresses, signs of peritoneal irritation develop, ciates, described two major clinical types of and the abdomen is silent and rigid. When the cecal volvulus. The first is the acute fulminat- cecal volvulus is fulminating, severe pain, ing type, in which the onset is sudden. This re- shock, and signs of peritonitis are present sults from a sudden, tight twisting of the mes- from the beginning, and bowel sounds are di- entery with vascular occlusion, which produces minished or absent. early gangrene of the bowel and signs of peritoneal irritation. In this condition there is Radiologic diagnosis little time for gaseous distention. In general, McGraw and associates 8 have found typical this type resembles other catastrophic abdom- roentgen criteria, including great distention inal emergencies, with early shock and rapid of the cecum, which is ectopically placed and deterioration. frequently located in the upper left quad- The second is the acute obstructive type. In rant; distention of loops of small intestine, this type the process is slower, with luminal which often are located to the right of the obliteration and enormous distention of the cecum; visualization of the gas-outlined ileo- cecum. Signs of peritoneal irritation are not cecal valve to the right of the cecum; mucosal seen in the early stages. As the tension in the folds at the point of obstruction possibly hav- colon increases, ischemic necrosis and gan- ing a spiral contour; considerable dilatation grene develop in an area of wall that is thin of the small bowel, with fluid levels when and atonic. Anaerobic bacteria in the cecum the patient is upright, which suggest small multiply rapidly under anoxic conditions and bowel obstruction; and a single fluid level in increase distention in a closed loop, so that the cecum. There also may be a concavity of perforation and peritonitis result. The distal the "coffee bean" deformity directed toward portion of the ileum is blocked. Presenting the lower right quadrant. Dowling and Gunn- signs and symptoms are those of acute small ing9 described the pathognomonic beaking re- bowel obstruction. vealed by barium enema. Large described a third type, intermittent partial cecal volvulus. This is characterized by Treatment recurrent attacks of localized cramping, sud- Surgical measures are directed initially toward 813/84 detorsion of the involved segment of bowel. Lysis of adhesive bands or needle decompression may be necessary to accomplish this. Then the viability of the involved segment is assessed. The management depends not only on viability but on the patients general condition, since he must be able to tolerate the procedure selected. Exploration for distal obstructing lesions or Fig. 1. Anteroposterior roentgenogram of the abdomen adhesive bands is carried out. The bands are of supine patient (Case 1), showing large dilated loop simply divided. Distal tumors should be re- of colon. moved at a subsequent operation. Prevention of recurrences is the next objec- tive. This may be accomplished by cecopexy or cecostomy when the bowel is viable. These pro- cedures were performed with equal frequency in many of the series reviewed. If there is any question as to the viability of the bowel, right hemicolectomy with creation of an opening between the ileum and transverse colon should be carried out. For the poor-risk patient who is unable to tolerate an extensive procedure, a Mikulicz exteriorization with double-barreled enterostomy is indicated. When cecal volvulus occurs during pregnancy, it should be treated as though the pregnancy is not present, and surgical intervention should not be delayed. Report of cases Case 1 A 56-year-old Caucasian woman was admitted to the hospital with a chief complaint of abdominal distention and constipation. The distention had been gradual and progressive, and constipation had been present for 4 days. The patient had associated nausea and vomiting, and vague abdominal cramping had been present for 3 weeks prior to admission. Her past surgical history included right salpingo- oophorectomy and appendectomy. Fig. 2.

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