Chief Complaint

Abdominal Pain

HPI

47-year-old female presenting to the emergency department with approximately 2 hours of right upper quadrant pain described as sharp, constant, worse with movement, and associated with nausea. Patient self-induced emesis x1. She has never had this before. It did not change with 2 tablets of Tylenol at home.

EMS gave 50 mcg of fentanyl.

Pertinent Exam Findings

General Appearance: Moderate distress secondary to pain.
Gastrointestinal: Abdomen is soft, tender to palpation over entire right side, but maximally in right upper quadrant, negative Murphy’s, negative McBurney’s, and no rebound is present.

Data Interpretation

CBC: There is no acute leukocytosis, unstable anemia, or significant platelet abnormality.
LFT: LFTs are not consistent with clinically significant abnormality.
Lipase: Lipase is not consistent with acute pancreatitis.
BMP: There is no acute renal dysfunction or significant electrolyte abnormality.
CT abdomen without contrast:

IMPRESSION: 1. Cecal volvulus with associated mildly dilated distal ileum extending past area of twisting in the right lower quadrant. An internal hernia cannot be excluded. Mild to moderate ascites but no free intraperitoneal gas seen. 2. Mild periportal edema.

ED Course

Fentanyl 50mcg x 2 with no change in pain

Dilaudid given and pain still not controlled

Discussed CT results showing cecal volvulus and need for surgery. Patient still reports being in significant pain, written for an additional 1 mg of Dilaudid.

Discussed case with general surgery, plan to admit for surgery

Operative note for ex lap, cecectomy:

FINDINGS: Twisted cecum/terminal ileum on pedicle. Ischemic, grossly distended.

Hospital Course

Patient presented with severe abdominal pain, distension, and CT findings of cecal volvulus. Taken emergently to OR for ex lap, ileocecectomy. Patient did well thereafter, with expected postoperative ileus which resolved by postoperative day 3 with bowel movements, good bowel sounds, and tolerance of regular diet. Pain was well controlled.

DISCUSSION

Background

Large bowel obstruction occurs when there is rotation or torsion of the large bowel and represents approximately 25% of all intestinal obstructions. Cecal volvulus, or twisting of the cecum and ascending colon, comprises about 1 to 3% of all large bowel obstructions. It is a rare condition that is very dangerous as it can progress to tissue necrosis and possibly perforation of the bowel. Mortality rates are as high as 30% if this condition is not recognized quickly and treatment is delayed more than 24-72 hours after diagnosis. Associated risk factors for all types of colonic volvulus, including cecal volvulus, are a diet high in fiber, advanced age, and chronic constipation. Uniquely, cecal volvulus typically arises in the second or third decade of life and more frequently occurs in females. Maintaining a broad differential when working up obstructive-like symptoms and quick recognition of cecal volvulus in the emergency department is imperative to prevent the significant morbidity and mortality associated with this condition.

Diagnosis

Workup of cecal volvulus begins with a thorough history and physical. Patients typically present with symptoms of nausea, vomiting, constipation, obstipation, and acute-onset abdominal pain. On exam, the patient may present with a tender, distended abdomen that may be tympanitic to percussion. Signs such as tachycardia, hypotension, and rebound tenderness may indicate the patient has ischemic bowel or peritonitis as a result of cecal volvulus. Laboratory studies are not necessary for diagnosis of cecal volvulus, but may show metabolic acidosis and leukocytosis if the volvulus has progressed. Upright plain films should be obtained to assess for possible pneumoperitoneum or obstruction. If films are indicative of a perforation, consult surgery immediately. If cecal volvulus is suspected on xray, a CT of the abdomen and pelvis can be ordered for further confirmation. A contrast enema may be performed, so long as there are no signs of peritonitis on exam, if clinical suspicion is high, but imaging is non-diagnostic. Surgical exploration is a last resort option when imaging is non-confirmatory and the patient’s condition is worsening.

Management in ED

Once cecal volvulus is highly suspected or confirmed on CT, the next steps in management is emergent surgical consultation for intraoperative resection or detorsion of the volvulus. Endoscopic reduction of the cecal volvulus is not recommended due to increased risk of bowel perforation and a 20-25% chance of missing colonic necrosis. While awaiting surgical consultation, keep the patient NPO, give intravenous hydration, and attempt to manage their pain. If bowel perforation or gangrene is suspected, appropriate antibiotics such as ceftriaxone plus metronidazole should be given as soon as possible to cover for gram negative and anaerobic organisms.

Prognosis

One large retrospective study found the overall mortality rate in the study for patients with cecal volvulus who underwent a resection was 6.7%. The strongest predictors of mortality for patients with cecal volvulus undergoing resection were the presence of a coagulopathy and the patient being older than 60 years of age. Bowel gangrene and peritonitis also significantly increased mortality in patients with cecal volvulus. The most common complications following surgery were ileus/bowel obstruction, anastomotic leaks, acute renal failure, and respiratory failure. The predictive factors discussed above reiterate the importance of prompt management once cecal volvulus is suspected or diagnosed.

Differential Diagnoses

• • Incarcerated or strangulated hernia
  • Small bowel obstruction
  • Appendicitis
  • Acute mesenteric ischemia
  • Severe constipation
  • Gastroenteritis
  • Perforated viscus
  • Peritonitis
  • Large bowel obstruction
  • Diverticulitis

Clinical Pearls

• • Cecal volvulus, a type of large bowel occlusion, is a rare condition with high morbidity and mortality if not recognized.
  • If untreated, cecal volvulus may progress to colonic ischemia or perforation
  • Diagnosis is best with CT imaging
  • If bowel perforation or gangrene suspected, ceftriaxone/metronidazole provide gram negative and anaerobic coverage

References

1. Alavi K, Poylin V, Davids JS, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction. Dis Colon Rectum. 2021;64(9):1046-1057. doi:10.1097/DCR.0000000000002159
2. Ballantyne GH, Brandner MD, Beart RW Jr, Ilstrup DM. Volvulus of the colon. Incidence and mortality. Ann Surg. 1985;202(1):83-92. doi:10.1097/00000658-198507000-00014
3. Delabrousse E, Sarliève P, Sailley N, Aubry S, Kastler BA. Cecal volvulus: CT findings and correlation with pathophysiology. Emerg Radiol. 2007;14(6):411-415. doi:10.1007/s10140-007-0647-4
   
4. Gomes CA, Soares C Jr, Catena F, et al. Laparoscopic Management of Mobile Cecum. JSLS. 2016;20(4):e2016.00076. doi:10.4293/JSLS.2016.00076
5. Halabi WJ, Jafari MD, Kang CY, et al. Colonic volvulus in the United States: trends, outcomes, and predictors of mortality. Ann Surg. 2014;259(2):293-301. doi:10.1097/SLA.0b013e31828c88ac.
6. Le CK, Nahirniak P, Qaja E. Cecal Volvulus. [Updated 2021 Sep 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan
7. Lee SY, Bhaduri M. Cecal volvulus. CMAJ. 2013;185(8):684. doi:10.1503/cmaj.120651
8. Peterson CM, Anderson JS, Hara AK, Carenza JW, Menias CO. Volvulus of the gastrointestinal tract: appearances at multimodality imaging. Radiographics. 2009;29(5):1281-1293. doi:10.1148/rg.295095011

Authors

Aaron Wolfe, DO, FACEP, Director of Education for Emergency Medical Minute and Clinical Associate Faculty for Rocky Vista University College of Osteopathic Medicine

Jack Spartz MSIV

Peter Haskins MSIV

Josh Wahba MSIV