An Unusual Pathology of Cecal Dilation

Abstract

Purpose: A 64-year-old male with a history of rheumatoid arthritis and alcohol abuse was started on plaquenil for the treatment of rheumatoid arthritis as an outpatient. Seven days after treatment initiation, papular eruption developed on his chest and progressed to diffuse erythematous eruption with symptoms of burning. He presented to the emergency room with these complaints, and was noted to have tachycardia and a prominent leukocytosis of 32,000 per microliter. He was subsequently admitted to the ICU, and developed mental status changes attributed to alcohol withdrawal. On day one, patient was noted to have significant abdominal distention, and an abdominal X-ray was obtained, which showed an isolated cecal dilation of 15 cm, with the cecum rotated centrally toward the midline and no evidence of any small bowel dilation. Conservative measures failed to improve his continued dilation. Gastroenterology consult service was then consulted, and after discussion with radiology and general surgery, it was felt that there was low probability of cecal volvulus, and the decision was made to attempt a colonic decompression. Colonoscopy showed stool in the ascending colon, and there was difficulty in intubating the cecum. A follow up X-ray showed a continued cecal dilation of 12 cm. Six hours later, and on follow up imaging, it was noted to be 16 cm, and at this time the patient was taken to the operating room. Intra-operatively a cecal bascule was noted. Cecal bascule is a rare type of intestinal obstruction that occurs when a mobile cecum folds upward over the ascending colon and obstructs the ascending colon. It is a rare diagnosis, and it is estimated that 0.2% of all intestinal obstructions are cecal bascules. Over the last 20 years, only a handful of cases have been reported (less than 10). It is frequently confused with cecal volvulus on x-rays, and plain films will frequently demonstrate a massively dilated cecum with or without evidence of small bowel obstruction. Computed tomography scan is much more sensitive and can clearly define the large bowel anatomy. Cecal bascule is defined as type 3 cecal volvulus, and is a rare diagnosis that should be considered in all patients who present with findings of cecal dilation and if there is concern for volvulus.Figure