An Unusual Cause of a Cecal “Seesaw” and Pneumatosis Intestinalis

Abstract

Question: A 66-year-old woman with history of stroke, previous hernia surgery with mesh placement, and obstructive cholestasis due to choledocholithiasis presented with 3 days of right-sided abdominal pain, 15-lb weight loss over 1 month, and 3 weeks of constipation with thin stools. Colonoscopy was normal a few months prior. Her prior episode of choledocholithiasis in 2017 led to endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and placement of a double pig-tail stent. She was recently admitted 1 month ago for jaundice and right upper quadrant (RUQ) pain at which time magnetic resonance cholangiopancreatography showed severe intrahepatic and extrahepatic biliary duct dilation but no liver or pancreatic lesions. The cecum was nonspecifically distended and fluid filled. Esophagogastroduodenoscopy revealed a benign-appearing intrinsic duodenal stricture felt to be related to scar tissue from the previous hernia mesh surgery. ERCP revealed an occluded biliary stent that had migrated to the major papilla and a severe burden of choledocholithiasis. The occluded stent was removed, and partial removal of stones was achieved via basket extraction. A new biliary stent was placed with a plan to follow up in 4 weeks for repeat ERCP for further stone extraction and stent removal. Before this appointment she was readmitted for worsening RUQ pain. A computed tomography scan revealed dilated loops of distal small bowel and a dilated cecum that had folded anteriorly and superiorly with extensive pneumatosis. The ascending colon was also dilated up to a decompressed hepatic flexure, where nonspecific bowel wall thickening was visualized, suggesting a transition point. No obvious mass or lesion was noted at the hepatic flexure (Figure A). Despite clinical improvement with conservative management, a lower gastrointestinal series performed a few days later showed persistent severe obstruction at the hepatic flexure with bird-beak appearance (Figure B). What is the most likely explanation for these imaging findings and how should it be managed? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. The patient’s imaging findings are consistent with cecal bascule (type III cecal volvulus). Cecal bascules are the rarest variant of cecal volvulus that involve upward folding of the cecum, without axial twisting or sigmoid involvement.1Rabinovici R. Simansky D.A. Kaplan O. et al.Cecal volvulus. Dis Colon Rectum. 1990; 33: 765-769Crossref PubMed Scopus (119) Google Scholar Bascule in French means “seesaw,” describing the pathophysiology of the cecal presentation. Surgical management was indicated given the persistent and severe hepatic flexure stricture seen on lower gastrointestinal series. Exploratory laparotomy revealed numerous omental nodules and a mass was discovered in the RUQ involving the gallbladder and liver that was causing extrinsic compression of the hepatic flexure. The largest nodule was excised and confirmed a diagnosis of metastatic cholangiocarcinoma. A distal loop ileostomy was created to decompress the colon and prevent ongoing colonic obstruction. No colonic resection was necessary. The patient began cancer staging and treatment planning, but unfortunately passed 1 month after diagnosis. This is a unique case of an extrinsic malignant obstruction causing cecal bascule. The development of a cecal bascule is usually attributed to an abnormally mobile cecum due to improper development and insufficient fixation of the mesentery to the posterior parietal peritoneum. A mobile cecum may also be acquired in pregnancy due to enlargement of the uterus or after abdominal surgery, such as open appendectomies, which require extensive division of peritoneal attachments to the cecum. Clinical presentation varies with abdominal pain, distention, and nausea being the most common symptoms but can progress to an acute abdomen and perforation.2Lung B.E. Yelika S.B. Murthy A.S. et al.Cecal bascule: a systematic review of the literature.Tech Coloproctol. 2018; 22: 75-80Crossref PubMed Scopus (14) Google Scholar Diagnosis of type III cecal volvulus requires computed tomography imaging confirming a distended cecum lying anterior to ascending colon. Treatment generally involves surgical resection of the affected bowel because colonoscopic detorsion may lead to recurrence.3Le C.K. Nahirniak P. Qaja E. Cecal volvulus. StatPearls Publishing. StatPearls Website, 2021Google Scholar