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Paediatric Gangrenous Caecal Volvulus

Siboe MMW1, Omari RO1, Lakati KC2

  1. AHF Plaza, 3rd Parklands Avenue, Nairobi

  2. Giddo Plaza, Nakuru

Correspondence to: Dr. Mark MW Siboe, P.O Box 73946 - 00200, Nairobi.

Email: marxiboy@gmail.com

Summary

Caecal volvulus though common in adults is rare in children. A 10-year-old boy presented with abdominal pain, distension, vomiting and obstipation of acute onset. An exploratory laparotomy revealed a gangrenous caecal volvulus due to an elongated and mobile right colon. This was treated by a right hemicolectomy and an ileo-transverse anastomosis. He recovered uneventfully. Caecal volvulus should be considered in cases of intestinal obstruction even in the pediatric age group.

 

Keywords: Childhood, Caecal Volvulus, intestinal obstruction, laparotomy

Ann Afr Surg. 2016;13(1):29-31

Introduction

Caecal volvulus is an axial twist of the caecum, ascending colon and terminal ileum around a mesenteric pedicle as originally described by Rokitansky in 1837 (1). Although involvement of colonic caecum in adults represents 20 – 40% of large bowel volvulus, it is so rare in children that its true incidence is unknown (1-4). We report a case of caecal volvulus in a pediatric patient.

 

Case Report

A ten year old boy presented with a one day history of abdominal pain and distension. The pain was generalized and exacerbated by movement. He gave a history of vomiting that was neither blood stained nor bilious. He was obstipated since the onset of the pain. There was no relevant past medical or surgical history.

He was ill-looking, in obvious pain, mildly dehydrated but had no pallor or lymphadenopathy. His pulse was 96 beats per minute, respiratory rate of 28 breaths per minute, blood pressure of 120/80 mmHg and temperature of 36.7°C.

The abdomen was uniformly distended, tender and rigid. Bowel sounds were present albeit diminished. Rectal examination revealed an empty rectum. The rest of his systemic examination was normal. He was investigated for acute intestinal obstruction. Pre-operative workup included an erect abdominal radiograph that revealed four air-fluid levels with associated distended loops of both small and large bowel. An emergency laparotomy revealed a gangrenous caecal volvulus that was lying in the left iliac fossa (Figures 1 and 2). We performed a right hemicolectomy and an end-to-end ileo-transverse anastomosis.

Post operatively, recovery was uneventful and the patient was discharged home after five days.

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Click to view figure 2

 

Discussion

The predominant location of large bowel volvulus in children, as with adults, is the sigmoid colon. Volvulus of the colonic caecum accounts for 20-40% of large bowel volvulus in adults. It is rare in children and its incidence in the pediatric group is unknown (1-4). Among the predisposing factors are: congenital hyper mobility of the caecum (due to complete mal rotation), a common ileo-caecal mesentery or imperfect fixation, adhesions (either congenital or from recent operation), pregnancy, prolonged constipation, and high fiber intake. In children it has been associated with neurological impairment, use of psychotropic drugs, intraperitoneal adhesions and Meckel’s diverticulum (1,2,4). In the case presented, the patient was noted to have hyper mobility of the caecum. In 90% of the cases of caecal volvulus, there is torsion or hyper flexion of an enlarged, poorly fixed and hyper mobile caecum or axial twisting of the caecum, terminal ileum and ascending colon. In the remaining 10% there is anterior in folding of the ascending colon (caecal bascule) (3).

Volvulus results in a closed loop obstruction with torsion of the