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Diagnosis and Treatment of Caecal Volvulus E T Consorti, T H Liu

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Diagnosis and Treatment of Caecal Volvulus E T Consorti, T H Liu 772 Postgrad Med J: first published as 10.1136/pgmj.2005.035311 on 12 December 2005. Downloaded from REVIEW Diagnosis and treatment of caecal volvulus E T Consorti, T H Liu ............................................................................................................................... Postgrad Med J 2005;81:772–776. doi: 10.1136/pgmj.2005.035311 Caecal volvulus is an infrequently encountered clinical The nearly 40-fold difference between the incidence of mobile caecum and occurrence of condition and an uncommon cause of intestinal caecal volvulus suggests that factors other than obstruction. Patients with this condition may present with anatomical susceptibility are involved in volvulus highly variable clinical presentations ranging from development. Clinical series have reported that 23%–53% of patients presenting with caecal intermittent, self limiting abdominal pain to acute volvulus have a history of prior abdominal abdominal pain associated with intestinal strangulation surgery,1 6–8 and based on this association, pre- and sepsis. Lack of familiarity with this condition is a factor vious abdominal surgery has been identified as an important contributor in caecal volvulus contributing to diagnostic and treatment delays. The formation. It is postulated that postoperative objective of this review is to promote clinicians’ awareness adhesions contribute to the formation of fixation of this disease through patient case illustration, discussion points and fulcrum of rotation for the mobile right colon, whereby promoting volvulus devel- of disease pathogenesis, clinical features, and opment.1 management strategies. Additional conditions such as those seen 910 6 ........................................................................... during late term pregnancy, high fibre intake, adynamic ileus, chronic constipation, and distant colon obstruction11 12 have also been implicated aecal volvulus is characterised anatomi- in caecal volvulus formation in anatomically cally by the axial twisting that occurs susceptible people, presumably through caecal involving the caecum, terminal ileum, displacement, hyperperistalsis, and colonic dis- C 12 and ascending colon. Caecal bascule is a tension. variant of this condition associated with the upward and anterior folding of the ascending CLINICAL FEATURES colon and accounts for about 10% of all caecal The clinical findings and laboratory abnormal- volvulus cases2 (figs 1 and 2). Although anato- ities associated with caecal volvulus are predo- mically distinct, caecal volvulus and caecal minantly determined by the pattern, severity, bascule share many similar clinical features, and duration of the intestinal obstruction (box including the potential for intestinal obstruction 1). The patterns of clinical presentation are and strangulation.12 broadly categorised as recurrent intermittent, http://pmj.bmj.com/ The incidence of caecal volvulus is reported to acute obstruction, and acute fulminant pat- range from 2.8 to 7.1 per million people per year, terns.13 and the process is responsible for 1%–1.5% of all the adult intestinal obstructions and 25%–40% of Recurrent intermittent pattern all volvulus involving the colon. Patients’ ages at The recurrent intermittent pattern has also been presentation are presumably affected by cultural referred to as the mobile caecum syndrome.14 15 and dietary influences and their effects on This clinical presentation has been reported to intestinal motility, resulting in highly variable occur in nearly 50% of patients before the onset on September 28, 2021 by guest. Protected copyright. peak ages of presentation from various geogra- of acute volvulus.51415 Typically, the patients phical regions, where the average age of patients have recurrent symptoms consisting of general- reported in India is 33 years as compared with 53 ised or localised right lower quadrant abdominal years in reports from Western countries.1 pain, abdominal distension, and pain resolution after the passage of flatus. The physical findings in patients during symptomatic episodes may ANATOMY AND PATHOGENESIS include high pitched bowel sounds and right Intestinal development during embryogenesis is lower quadrant abdominal tenderness; however, a complex and sequential process, where during these abnormal physical findings generally dis- the final stages, the caecum rotates counter appear as the patients’ symptoms resolve.14 15 See end of article for clockwise from the left side of the abdomen to authors’ affiliations ....................... its final position in the right lower abdomen. Acute obstructive and acute fulminant Simultaneous with the final rotational process is patterns Correspondence to: fixation of the right colon mesentery to retro- Patients with acute volvulus and obstruction Dr T H Liu, UCSF-East Bay. 1411 East 31st Street, peritoneal structures. People with incomplete typically exhibit a clinical picture that is indis- Oakland, CA 94602- intestinal rotation generally develop inadequate tinguishable from acute, uncomplicated small 1018, USA; LiuT@surgery. right colon fixation associated with the potential bowel obstruction. Depending on the patients’ ucsf.edu for caecal volvulus formation. Based on reports body habitus, tender and dilated caecum may or Submitted 22 March 2005 from necropsy reviews, sufficient caecal mobility may not be palpable and may help to differenti- Accepted 23 April 2005 for volvulus and bascule formation is found in ate caecal volvulus from other forms of small ....................... 11% and 25% of adults, respectively.45 bowel obstruction. For patients without this www.postgradmedj.com Caecal volulus management 773 Postgrad Med J: first published as 10.1136/pgmj.2005.035311 on 12 December 2005. Downloaded from Figure 2 Schematic diagram of caecal bascule showing anterior Figure 1 Schematic diagram of caecal volvulus showing axial twisting folding of the caecum resulting in closed loop obstruction of the caecum. of the ascending colon and terminal ileum resulting in closed loop obstruction of the caecum. chemistry abnormalities are not useful for diagnosis but reflect the fluid, electrolyte deficiencies, and inflammatory or characteristic physical finding, differentiation between small infectious changes related to the obstructive process. bowel obstruction and caecal volvulus on clinical basis may be problematic; therefore, it is recommended that these patients undergo early radiological evaluation. DIAGNOSTIC IMAGING Patients with untreated acute volvulus may progress to As most patients with acute caecal volvulus present with develop intestinal strangulation and perforation leading to clinical pictures suggestive of intestinal obstruction, abdom- the acute fulminant presentation. With this clinical presenta- inal radiography is frequently obtained as the initial tion, patients typically exhibit severe abdominal pain, diagnostic imaging. It has been reported that radiolgical http://pmj.bmj.com/ peritoneal irritation, dehydration, and haemodynamic abnormalities are identifiable in nearly all patients with acute instability. caecal volvulus, with caecal dilatation (98%–100%), single PRESENTATIONS IN PATIENTS WITH CONCURRENT ILLNESSES Box 1 Clinical syndromes associated with There is an apparent increased propensity for acute caecal abnormal caecal mobility and volvulus volvulus presentation during periods of concurrent acute medical illnesses, as 12%–28% of the reported patients with Mobile caecum syndrome on September 28, 2021 by guest. Protected copyright. acute volvulus are already hospitalised for a variety of Chronic intermittent abdominal pain with spontaneous medical illnesses at the time of diagnosis.7813 In these resolution after the passage of flatus. Physical examination hospitalised patients, caecal volvulus development is believed may show mild right sided abdominal tenderness or no to be associated with the increased occurrence of colon abnormalities. This clinical presentation is generally not distension and intestinal dysmotility. associated with bowel necrosis however may be an Recognition of acute caecal volvulus in the hospitalised identifiable predecessor in 50% of patients presenting with patient population can be difficult because of alternative acute volvulus causes of abdominal distension in many of these patients. Acute obstruction Moreover, symptoms and findings related to acute voluvulus Cramping abdominal pain and vomiting that do not resolve may be more easily overlooked in patients presenting with spontaneously. The physical findings generally include serious concurrent medical illnesses. Therefore, prompt tenderness of the abdomen, with or without a palpable diagnosis in this setting requires heightened clinical suspi- abdominal mass, and high pitched bowel sounds. With cion and timely acquisition of diagnostic imaging studies. recognition and timely treatment, this presentation is associated with comparatively low incidence of bowel LABORATORY EVALUATIONS necrosis Laboratory evaluations are neither sensitive nor specific for Acute fulminant the diagnosis of caecal volvulus, as the laboratory values are Patients generally have toxic appearance with abdominal often unremarkable in patients with intermittent symptoms tenderness associated with peritonitis. Patients with this and early acute obstruction. Whereas, in patients with presentation frequently have bowel necrosis advanced obstruction, the white blood cell count and serum www.postgradmedj.com 774 Consorti, Liu Postgrad Med J: first published
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