Bowel Obstruction: Cecal Bascule After Colonoscopy.

Abstract

CASE REPORT Cecal bascule is an exceedingly rare type of cecal volvulus in which a mobile cecum folds anteriorly and superiorly on to the ascending colon, causing obstruction. The following vignette highlights a case of cecal bascule after double-balloon-assisted colonoscopy. A 68-year-old man with a history of advanced adenoma and no prior abdominal surgery was admitted for surveillance colonoscopy after inability to intubate the cecum on outpatient colonoscopy. Repeat attempt using double-balloon-assisted colonoscopy on the next day failed to intubate the cecum, raising concern for cecal volvulus. During medical observation, the patient complained of abdominal distention, discomfort, and inability to pass flatus. Abdominal x-ray showed a significantly dilated ascending colon to 12 cm in diameter (Figure 1). Computed tomography revealed upside-down rotated cecum with the ileocecal valve pointing laterally and dilatation of ascending colon to 10 cm without evidence of perforation, compatible with cecal volvulus. A multidisciplinary discussion between gastroenterology, radiology, and surgery resulted in exploratory laparotomy with right hemicolectomy and end ileostomy. Intraoperatively, a redundant colon was observed with severely dilated cecum and cecal bascule with pathology showing distended cecum and part of the right colon with vascular congestion, suggestive of mild acute ischemic colitis (Figure 1). On follow-up, the patient complained of abdominal pain without signs of obstruction.Figure 1.: Abdominal x-ray and exploratory laparotomy findings. (A) Abdominal x-ray showed a significantly dilated colon. (B) Exploratory laparotomy revealed a rotated cecum with a severely dilated colon.Cecal volvulus is a rare clinical entity, which accounts for 1%–2% of all large bowel obstructions.1 Cecal bascule, where the distended cecum folds anteriorly on the ascending colon without torsion, is the rarest type of cecal volvulus, accounting for 5%–20% of all cases.2 It occurs secondary to congenital or acquired adhesions fixing the anterior wall of the cecum to the ascending colon. In our patient, the increased motility of the cecal volvulus combined with the insertion of double-balloon-assisted colonoscopy with air insufflation may have initiated the rotation of the cecum. The signs and symptoms of a cecal bascule are similar to cecal volvulus. Plain x-ray usually reveals a distended cecum. Abdominal computed tomography confirms the diagnosis in 90% of patients showing upward folding of the cecum, as in our patient. Treatment is primarily surgical. Owing to high recurrence after simple reduction, cecopexy or resection and anastomosis are preferred approaches.3 In patients with recurrent or persistent abdominal pain and distension, cecal bascule should be considered in the differential diagnosis. DISCLOSURES Author contributions: T. Li wrote, edited, and approved the article. Y. Myat wrote and approved the article. ST Nguyen revised the article for intellectual content. W. Zhao provided the endoscopy images. P. Patel provided the pathology images. M. Martinez approved the final article and is the article guarantor. Financial disclosures: None to report. Previous presentation: This case was presented at the American College of Gastroenterology Annual Scientific Meeting; October 22–27, 2021; Las Vegas, NV. Informed consent could not be obtained for this case report. All identifying information has been removed.