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 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 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 , 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 ab- dominal 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-

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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 , 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 decompres- sion may be necessary to accomplish this. Then the viability of the involved segment is as- sessed. 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 be- tween 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 preg- nancy, it should be treated as though the preg- nancy 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 ab- dominal distention and constipation. The dis- tention 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 pres- ent for 3 weeks prior to admission. Her past surgical history included right salpingo- oophorectomy and appendectomy. Fig. 2. Anteroposterior film of erect patient (Case 1), Physical examination showed her to be showing air-fluid levels in the dilated loop of colon and moderately dehydrated with a blood pressure small intestine. of 130/90 mm. Hg. Pulse rate was 96 beats per minute, respiration rate 20 per minute, and temperature 99.4 F. A well-healed midline su- the upper left quadrant. There was generalized prapubic scar was present. Both lower quad- tympany to percussion, and bowel sounds were rants of the abdomen were tender to palpation absent. The rectum was empty of feces or and showed rebound tenderness. The abdomen masses. was grossly distended, somewhat asymmetri- X-ray survey (Figs. 1-3) at admission cally, with a pronounced area of distention in showed massive dilatation of a loop of bowel

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in the midportion and upper left quadrant of the abdomen. This was considered to be evi- dence of bowel obstruction with the radio- graphic characteristics of cecal volvulus. A barium enema showed the classic "bird of prey" or "hawk beak" deformity (Figs. 4 and 5) at the junction of the ascending colon with the visualized cecal region. To the left of this was an area of air-distended bowel in the epigastrium and upper left quadrant. These observations were consistent with cecal volvu- lus. A complete blood count showed 12.6 gm. hemoglobin per 100 ml. and 38 percent hema- tocrit. The leukocyte count was 2,650/cu. mm., and there were 31 percent polymorphonu- clear cells, 40 percent lymphocytes, 7 percent monocytes, 21 percent band forms, and 1 per- cent metamyelocytes. Determinations of fast- ing blood sugar, blood urea nitrogen, sodium, chloride, potassium, carbon dioxide-combining power, amylase, lipase, prothrombin time, and partial thromboplastin time gave results with- in normal limits. Urinalysis at admission Fig. 4. "Hawk" or "bird beak" sign on bamium enema and dilatation of proximal portion of small intestine (Case 1).

showed occult blood but was otherwise not remarkable. An electrocardiogram revealed low voltage. Intravenous replacement of fluid and elec- trolytes, administration of antibiotics, and Cantor tube decompression were started im- mediately. After several hours of this inten- sive therapy the patient was taken to the operating room. When the peritoneal cavity was opened, 600 ml. of free serosanguineous fluid was found. The cecum was greatly distended. Lo- cated in the midportion and upper left quad- rant of the abdomen, it measured 30 by 20 by 20 cm. The cecal wall was cyanotic and thin. An omental band extended to the right lateral peritoneal wall and supplied the fixed point about which the cecum was rotated 180 degrees Fig. 3. Roentgenogram of abdomen with patient (Case in a clockwise direction. 1) in right lateral decubitus position, again demon- Derotation was accomplished after decom- strating air-fluid levels in the dilated colon loop and small intestine. pression of the cecum with a trocar. After de-

815/86 compression the cecum was replaced in its nor- fourth postoperative day the patient had peri- mal position and observed for 10 minutes. It stalsis and was passing flatus. She was taking remained dusky and cyanotic, and right hemi- a liquid diet at this time. A soft diet was begun colectomy, consisting of excision of the distal on the sixth postoperative day. The hospital 10 cm. of ileum, the cecum, and the proximal course thereafter was uneventful, with pro- ascending colon, was performed. An opening gressive improvement, and the patient was was made between the ileum and ascending discharged on the fifteenth postoperative day. colon by the Connell technique. A tube gas- trostomy also was performed. The immediate Case 2 postoperative condition was fair. A 65-year-old Caucasian woman was admitted On the first postoperative day the leukocyte to the hospital with chief complaints of vomit- count was 6,100/cu, mm., with 34 percent ing, pain in the lower left quadrant, and pro- polymorphonuclear cells, 39 percent lympho- gressive abdominal distention. Symptoms had cytes, 1 percent eosinophils, 25 percent band begun several days prior to admission and had forms, and 1 percent metamyelocytes. progressed since then. The patient said that Serial electrolyte studies were utilized as a she was unable to retain any, solids or liquids. guide to electrolyte replacement, and fluids She had a history of increasing constipation were replaced intravenously. Antibiotics and for 1 month. Her past surgical history included transfusions also were given, and gastric suc- subtotal gastrectomy 3 years prior to admis- tion was done via the tube. By the sion, appendectomy, and total hysterectomy. The patients blood pressure was 154/80 mm. Hg, temperature 98.8 F., pulse rate 80 per minute, and respiration rate 20 per minute. The skin was dry and atrophic. The cardiac rate was 80 per minute and regular, and no murmurs were present. Cardiac sounds were of poor quality and intensity. Breath sounds were decreased bilaterally, with rales in the base of the left lung. The abdomen was generally dis- tended, with three well-healed abdominal scars. Bowel sounds were not perceptible, and the abdomen was tympanitic to percussion in all quadrants. There was generalized tender- ness, with increased tenderness in the lower right quadrant. Rectal examination did not show masses or feces. An immediate abdominal x-ray survey (Figs. 6-8) showed dilatation of a bowel loop in the midportion of the abdomen extending laterally to the right. This was compatible with dilatation of the cecum, and there was dilata- tion of the small bowel proximal to this area and of the remaining portions of the colon ex- tending to the left iliac crest. A barium enema showed evidence of diverticulosis of the sig- moid colon. The cecum did not fill with barium, and the dilated bowel loop was seen to be just proximal to the end of the barium bolus, in the lower right quadrant. These observations were Fig. 5. Close view of eecal area at barium enema, snow- ing "hawk" or "bird beak" sign (Case 1). consistent with bowel obstruction in the lower

Journal AOA/vol. 72, April 1978 816/87 Fig. 6. Anteroposterior film of supine patient (Case Fig. 7. Anteroposterior film of erect patient (Case 2), 2), showing large dilated loop of colon and dilatation showing air-fluid levels of the dilated loop of colon of small intestine. and small intestine.

right quadrant, probably representing partial chlorides per 100 ml. of serum, and the carbon volvulus or intussusception of the cecal region dioxide-combining power was 31 mEq. per or gross dilatation of the small bowel with ob- liter. The alkaline phosphatase level of the se- struction. rum was 3.5 Bodansky units per 100 ml. A complete blood count at admission showed An electrocardiogram was consistent with 11.1 gm. hemoglobin per 100 ml. and 37 per- hypokalemia. cent hematocrit. The leukocyte count was Immediately after admission, intensive fluid 11,900/cu. mm., with 83 percent polymorpho- and electrolyte replacement, Cantor tube de- nuclear cells, 10 percent lymphocytes, 2 per- compression, and antibiotic therapy were be- cent monocytes, and 5 percent band forms. gun. After several hours the patient was The prothrombin time was 56 percent and the thought to be satisfactorily hydrated and was partial prothrombin time was normal. Urinal- prepared for surgery. ysis showed no abnormality except a 4+ reac- When the abdomen was opened, 100 ml. of tion for bacteria. The fasting blood sugar serous fluid was aspirated from the peritoneal level was 119 mg./100 ml. and the blood urea cavity. The cecum was seen to be grossly di- nitrogen value 8 mg./100 ml. There were 107 lated and rotated on itself toward the left, in mg. sodium, 3.3 mg. potassium, and 66 mg. a clockwise direction, approximately 180 de-

817/88 colon. The bowel was observed for 10 minutes. The circulation was seen to be intact, and nor- mal color returned, so resection was not neces- sary. The immediate postoperative condition was satisfactory. Postoperatively, fluid and electrolyte re- placement, Cantor tube decompression, and antibiotic therapy were resumed. Cleansing enemas and a progressively varied diet were given. Initially the electrolyte imbalance was severe and the patient required serial monitor- ing. This imbalance was corrected by the fourth postoperative day, and an index of true hydration was apparent. The hemoglobin and hematocrit levels dropped toward the patients true value. Signs of cerebral confusion devel- oped and were thought to be due to anoxia sec- ondary to the drop in erythrocytes. A transfu- sion of 1 unit of packed red blood cells was given, resolving the symptoms. Bowel peristal- sis began on the sixth postoperative day. The patient showed gradual improvement during the remainder of the hospital stay and was dis- charged on the fourteenth postoperative day.

Case 3 A 44-year-old Caucasian woman was admitted to the hospital with chief complaints of recur- Fig. 8. Roentgenogram made after evacuation of bari- rent attacks of pain in the lower right quad- um enema, showing lack of barium in the cecal area rant of the abdomen and gaseous abdominal (Case 2). distention. The pain occurred in bouts, was crampy, and subsided spontaneously. There were nausea and vomiting when the pain was grees. Multiple omentoperitoneal adhesions in present. The symptoms had been present for this area were the focal point of rotation. The an undetermined period but had increased in ileocecal valve was seen to the right of the frequency and severity. There was a history cecum. of intermittent constipation. Past surgery in- Approximately 10 cm. proximal to the ileoce- cluded a right salpingo-oophorectomy, appen- cal valve, several loops of the distal portion of dectomy, hemorrhoidectomy, and uterine sus- the ileum were seen to be densely adherent to pension. each other and to the anterior abdominal wall. The patients blood pressure was 90/60 mm. The small bowel proximal to this area was Hg, temperature 98.0 F., pulse rate 80 beats massively dilated. The remaining parts of the per minute, and respiration rate 20 per minute. large and small bowel were normal. Multiple The heart and lungs were unremarkable. The adhesive bands were lysed and the cecum de- abdomen showed two well-healed scars, one in rotated and replaced in its normal position. the midline suprapubically and the other near The small bowel loops were released and re- the midline in the lower right quadrant. Some placed in the abdomen. After derotation, the tenderness to deep palpation of the upper and trapped gas and fluid passed rapidly from the lower right quadrants and umbilical areas was cecum through the ascending and transverse present. Otherwise the abdomen was normal.

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A barium enema did not show gross abnor- biotics, and tube decompression followed by mality of the colon. An intravenous urogram, early surgical intervention contributed to the oral cholecystogram, and x-ray studies of the successful outcomes. The surgical procedures upper part of the gastrointestinal tract and were tailored to the condition of the patients. small bowel showed no abnormality. Because the symptoms persisted, intermit-

tent cecal volvulus was suspected, and an ex- 1. Gatellier, J., Moutier, F., and Porcher, P.: Les volvulus du ploratory operation was done. caecum. Arch Fr Mal App Dig 21:20-94, Jan 81 2. Hepperlen, H.M.: Volwlus of the cecum. Case report. Nebr State The patient was found to have a dense ad- Med J 54:373, Jun 69 hesion from the omentum to the anterior peri- 3. Wilson. R.: Volvulus of the cecum. Can J Surg 8:363-8. Oct 65 4. Hendrick, J.W.: Treatment of volvulus of the cecum and right toneal wall just to the right of the umbilicus. colon. A report of six acute and thirteen recurrent case.. Arch This coincided with an area of tenderness Surg 88:364-73, Mar 64 5. Peterson, H.: Volvulus of the cecum. Ann Surg 166:296-9, Aug found on physical examination. The cecum was 67 brought into the incision, and the mesentery 6. Hinshaw, D.B., Carter, R., and Joergenson, E.J.: Volvulus of the cecum or right colon. A study of fourteen cases. Am J Surg was measured. It was found to extend 23 98:175-83. Aug 59 inches from the skin level to the cecum. The 7. Large, A.M.: Partial intermittent volvulus of the cecum. Ann Surg 167:609-11, Apr 68 cecum was extremely mobile, slightly dis- 8. McGraw, J.P., Kremen, A.J., and Bigler, L.G.: The roentgen tended, and filled with intestinal contents. The diagnosis of volvulus of the cecum. Surgery 24:793-804, Nov 48 9. Dowling, B.L., and Gunning, A.J.: Caeca! volvulus. Br J Surg remaining portions of small and large bowel 56:124-8, Feb 69 were normal. It was thought that the patient 10. Donhauser, J.L., and Atwell, S.: Volvulus of the cecum, with a review of one hundred cases in the literature and a report of was having intermittent bouts of cecal rotation six new cases. Arch Surg 58:129-48, Feb 49 Balasingham, K.: Volvulus of the caecum, ascending and trans- caused by the length and laxity of the mesen- verse colon. Ceylon Med J 12:122-4, Jun 67 tery, and right hemicolectomy was performed. Weinstein. E.C., Hiebert. B., and Clark, P.L. III: Volvulus of the cecum. Am Surg 33:21-4, Jan 67 Postoperatively the patient was treated with Wolf, R.Y., and Wilson. H.: Emergency operation for volvulus of fluids, electrolytes, and antibiotics. The diet the cecum. Review of 22 cases. Am Surg 32:96-102. Feb 66 was gradually broadened. The convalescence was uneventful, and the patient was dis- charged on the eighth postoperative day.

Comment Of the three cases of cecal volvulus presented here, the condition was of acute obstructive type in the first two and intermittent in the last. All patients were women past 40 who had had previous surgery, and adhesions were present. In the two cases of acute obstruction the adhesions were the focal point for rotation Dr. Barsky, left, submitted this paper in the 1971 Awards for Scientific Literary Achievement sponsored by Geigy Phar- of the cecum. In the case of intermittent ob- maceuticals through the American College of Osteopathic Surgeons. She is currently chief resident in general surgery struction the length and laxity of the cecal at Parkview Hospital. Philadelphia. Dr. Swenson, center, is mesentery were contributory factors. chairman of the Department of Surgery at Parkview Hospital and associate professor of surgery at Philadelphia College of Donhauser and Atwelln reported mortality Osteopathic Medicine. Dr. Minissale, right, is attending surgeon at Parkview Hospital and clinical instructor of sur- of 42 percent in 100 cases. However, none of gery at PCOM. our patients died. Vigorous replacement of Dr. Barsky, 1216 Englewood St., Philadelphia 19111. fluids and electrolytes, administration of anti-

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