Cecal volvulus: a rare complication of colonoscopy

Abstract

Dear Editor: Cecal volvulus after colonoscopy is exceedingly rare. In fact, only four such cases are reported in English medical literature, to the best of the authors’ knowledge. We report the case of a 40-year-old female who underwent right hemicolectomy for cecal volvulus precipitated by colonoscopy. This condition accounts for approximately 40% of colonic torsion cases and requires a mobile cecum which allows twisting of the organ along its axis or anteromedial folding on the ascending colon. Inadequate fixation of cecum and ascending colon to the posterior parietal peritoneum is a prerequisite. Even though cadaver studies have demonstrated this predisposing factor in 11% to 25% of the population, cecal volvulus accounts for only 1% of all large bowel obstructions. A 40-year-old woman with no significant past medical history was referred to the colorectal surgery clinic with complaints of recurrent intermittent right lower quadrant pain. She reported associated nausea without vomiting and occasional passage of bright red blood per rectum. On physical examination, abdomen was soft without tenderness or palpable mass. The patient was scheduled for diagnostic colonoscopy and anoscopy. The colonoscope was advanced to the cecum where mucosa was noted to be inflamed without frank ulceration presenting an impression of segmental colitis. Two cold biopsies were obtained. The remainder of the examination revealed minimal sigmoid diverticulosis and two small internal hemorrhoids estimated to be first to second degree in severity. In the recovery room, the patient reported persistent right lower quadrant pain prompting radiologic imaging to rule out perforation, although that was considered unlikely. She had no radiologic evidence of free air or clinical findings suggesting peritoneal inflammation. Her pain gradually improved, and she was discharged home. Eight hours later, she returned to the emergency department with recurrent right lower quadrant pain. She was afebrile, abdomen was soft with localized tenderness in the same area. CT scan showed markedly distended cecum with an abrupt change in diameter at the junction with the ascending colon and location of terminal ileum to the right of the cecum suggesting cecal volvulus. A water soluble contrast enema revealed flow of contrast to the ascending colon where slight hold up responded to change in position with eventual filling of dilated cecum. The patient was taken to the operating room for exploratory laparotomy where a 180° counterclockwise torsion of the cecum was confirmed. The cecum measured 15 cm in longest diameter with no frank perforation but several areas of discoloration and thinning of the wall. Detorsion and right hemicolectomy with primary ileal–transverse colon anastomosis was performed. The patient had an uneventful recovery and was discharged home on postoperative day 5. Pathologic examination confirmed ulceration with focal transmural inflammation and hemorrhage in the cecum. During normal fetal development, the midgut follows an orderly sequence of growth, elongation, herniation into the base of umbilical cord, reduction into the intracoelomic M. Agko : B. Gociman :A. Mukherjee Department of Surgery, University of Toledo Medical Center, Toledo, OH, USA