Cecal Volvulus in Malrotation at 41years 

 Kabongo Kizito Mulamba Changachanga1, Mbewe Charles2, Lupasha Mwila3,4 

 1. School of Medicine, University of Zambia, Lusaka, Zambia 

2. University Teaching Hospital, Lusaka, Zambia 

3. University Teaching Hospital, Lusaka, Zambia 

4. School of Medicine, University of Zambia, Lusaka, Zambia 

 

Correspondence to: Dr. Kabongo Mulamba Kizito Changachanga; email: kizitomc@yahoo.co.uk 

Received: 23 Mar 2021; Revised: 06 Jul 2021; Accepted: 12 Jun 2021; Available online: 07 Aug 2021

Summary 

Cecal volvulus is rare, and its preoperative diagnosis poses a challenge. Because of its variable clinical features, the ultimate diagnosis of cecal volvulus is determined during surgery. We aim to demonstrate the rarity of cecal volvulus, the challenge in preoperative diagnosis of cecal volvulus, and the use of surgery in both diagnosis and treatment. We herein present a case of ischemic cecal volvulus in a 41-year-old man who presented within 5 hours of onset of symptoms of abdominal pain, vomiting, and lower abdominal distension. He had not passed flatus or opened bowels for a day. The available abdominal radiographs did not reveal preoperative cecal volvulus. An emergency laparotomy was performed, and it showed ischemic anticlockwise cecal volvulus that was managed by right hemicolectomy plus ileo-transverse primary anastomosis and transverse colopexy. The post-operative recovery and follow-up were uneventful. 

Keywords: Cecal volvulus, cecopexy, transverse colopexy 


Ann Afr Surg. 2021 ; 18(4): 252-257 
DOI: http://dx.doi.org/10.4314/aas.v18i4.12 
Conflicts of Interest: None
Funding: None
© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License 

Introduction

Cecal volvulus is relatively uncommon and involves rotation of the cecum, terminal ileum, or ascending colon around its mesenteric axis (1,2). It accounts for <2% of all intestinal obstructions (3) and approximately 10–60% of all colonic volvulus(4). Management of cecal volvulus includes non-operative colonoscopic reduction and operative approach via laparotomy or laparoscopy (1,2). Surgery is commonly performed as an emergency procedure and could involve detorsion plus cecopexy or bowel resection depending on the viability of the intestines (2,5).However, there is paucity of data on transverse colopexy after right hemicolectomy. 

We herein report a case of acute cecal volvulus due to midgut malrotation that was treated with right hemicolectomy and transverse colopexy. With this case, we aimed to highlight the infrequency of cecal volvulus, the challenge in preoperative diagnosis of cecal volvulus, and the role of surgery in both diagnosis and treatment. 


Case presentation

 In February 2020, a 41-year-old man presented to the Surgery Department of the University Teaching Hospitals as a referral from Kafue Gorge Hospital for further management. He presented within 5 hours of onset of symptoms of abdominal pain, vomiting, and lower abdominal distension. He had not passed flatus or opened bowels for a day. He did not have a fever or urinary symptoms. Nine years earlier, he was diagnosed with peptic ulcer disease, which was confirmed via upper endoscopy and managed uneventfully. He had no history of surgery since childhood. On examination, the general condition was good. He was afebrile and hemodynamically stable. The abdomen was soft and mildly tender in the right iliac fossa. It was distended in the suprapubic region and had reduced bowel sounds. There was no evidence of peritonitis. The digital rectal examination revealed stool in the rectum and a tender anterior rectal wall bulge. The hemogram was normal, except for neutrophilia of 82.8%. The kidney and liver tests were essentially normal. The plain abdominal radiographs showed dilated gas-filled loops of the large intestine in the left upper quadrant and center of the abdomen with no air-fluid levels (Fig. 1). 

Click to view Figure 1. Erect abdominal x-ray showing distended loop of large bowel on the left and lower abdomen with no air-fluid levels. 

His urinary bladder was catheterized, and a nasogastric tube was also placed. He was resuscitated with intravenous fluids aside from receiving intravenous antibiotics and analgesia. He underwent an emergency exploratory laparotomy which revealed non-distended small bowels on the right side and large bowels on the left side of the abdomen. The appendix appeared abnormally long. The cecum was dilated, ischemic, and twisted in an anticlockwise fashion in the suprapubic region (Fig. 2).  


Click to view Figure 2: Ischemic and distended cecum.  

The cecum and ascending colon were not in the right gutter and were freely mobile just like the transverse colon (Fig. 3). The duodenum did not cross the midline. There were bands over the duodenum and between the loops of the large bowel. The duodenum and pancreas were abnormally visible, and the stomach appeared elongated (Fig. 4). 

 

Click to view Figure 3. Cecum and ascending colon not fixed in the right gutter. 

Click to view Figure 4. Visibly duodenum and pancreas. 

The Ladd’s bands were divided, and right hemicolectomy (included appendicectomy) plus an end-to-end primary ileo-transverse anastomosis with Vicryl 2-0 in two layers was performed. Counterclockwise detorsion plus transverse colopexy to the right abdominal wall using Vicryl suture was also performed. The post-operative course was uneventful. The patient was discharged home on the fifth day after surgery, and the follow-up at 11 months was uneventful.

Discussion 

Cecal volvulus is an infrequent cause of intestinal obstruction. Although the patient presented with features of intestinal obstruction, it was difficult to make a preoperative conclusive diagnosis of cecal volvulus using the clinical picture and available investigations. Therefore, the ultimate diagnosis of cecal volvulus was made at laparotomy. 

Cecal volvulus accounts for <2% of all intestinal obstructions (3). A review of 60 patients at St. Francis Hospital in Kampala, Uganda, revealed that ileocecal volvulus accounted for 1.6% of all intestinal volvulus (6). For colonic volvulus, cecal volvulus is second to sigmoid volvulus (7). A systematic review of cecal volvulus demonstrated the age range from 14 to 91 years (mean, 51.6 years) (8). It has been reported to be more common in young female patients, but some series show no sex predominance (3). Furthermore, our patient was male and within the age range. There are two major types of cecal volvulus: the classic loop ileocolic volvulus (~90%) and the cecal bascule (~10%) (4). The ileocolic volvulus is further described in terms of rotation of the cecum as clockwise or anticlockwise, which is the most common form. 

Cecal volvulus requires a high index of suspicion, as the clinical features are vastly variable (4) (table 1). In adults, acute abdominal pain is the most common complaint (9,10). Other features include abdominal distension, nausea, vomiting, and obstipation (9,11,12). Adults with a chronic picture present with chronic intermittent abdominal pain, nausea, and vomiting over several days or months (5,10). The cecum spontaneously twists and untwists, making it difficult to establish a preoperative diagnosis of cecal volvulus. Patients with nonspecific clinical features and suspected to have cecal volvulus should undergo investigations such as colonoscopy, barium enema, abdominal computed tomography (CT) scan, or surgery (2,13).