Cecal Volvulus in a Teenaged Patient

Abstract

A previously healthy 16-year-old female patient presented to the emergency department for the fifth time in a month with complaints of recurrent abdominal pain and vomiting. Pain was described as sudden in onset, severe in degree, generalized in location, and associated with nonbilious/nonbloody vomiting. She reported having no bowel movements for the previous 5 days; and had experienced multiple similar episodes of generalized abdominal pain and vomiting, lasting a variable amount of time and then spontaneously resolving. Previous imaging included ultrasonography of the abdomen and computed tomography (CT) scans, which were nondiagnostic. On this visit, a repeat CT scan performed of the abdomen showed a markedly distended cecum displaced to the left upper quadrant and diffusely distended small bowel consistent with obstruction (Figure). A diagnosis of cecal volvulus was made, and the patient emergently taken to surgery. Laparotomy revealed a hypermobile cecum lacking normal right upper quadrant (RLQ) attachments, localized in the left upper quadrant, volvulized in a counter-clockwise direction around its mesentery (type 2 cecal volvulus) with mottled appearance. Surgeons manually detorsed the volvulus and fixed the cecum to the RLQ peritoneum, without need for bowel resection. A cecal volvulus is the torsion of a mobile cecum and ascending colon, occurring when a redundant and loosely applied mesentery twists around an axis. Most commonly, it involves the cecum, terminal ileum, and proximal ascending colon. It is rare, with an estimated incidence of 2.8-7.1 cases per million people/year (the pediatric incidence is undefined),1Consorti E. Liu T. Diagnosis and treatment of caecal volvulus.Postgrad Med J. 2005; 81: 772-776https://doi.org/10.1136/pgmj.2005.035311Crossref PubMed Scopus (105) Google Scholar accounting for 1%-5% of all adult intestinal obstructions, and 40% of colonic volvuli. The clinical presentation is highly variable, ranging from intermittent, self-limited abdominal pain to acute severe abdominal pain associated with intestinal ischemia, necrosis, and sepsis. As with any intestinal volvulus, pain can be intermittent, associated with vomiting (sometimes bilious), and often spontaneously resolves. This recurrent intermittent pattern of cecal volvulus (also called “mobile cecum syndrome”) occurs in nearly one-half of all patients before the onset of acute volvulus.1Consorti E. Liu T. Diagnosis and treatment of caecal volvulus.Postgrad Med J. 2005; 81: 772-776https://doi.org/10.1136/pgmj.2005.035311Crossref PubMed Scopus (105) Google Scholar It often is confused with more common intra-abdominal conditions causing intermittent acute abdominal pain, including constipation, ovarian torsion or uterine fibroids in female patients, cholecystitis, inflammatory bowel disease, urolithiasis, and appendicitis. Early diagnosis is essential to reduce mortality risk (rate up to 30%1Consorti E. Liu T. Diagnosis and treatment of caecal volvulus.Postgrad Med J. 2005; 81: 772-776https://doi.org/10.1136/pgmj.2005.035311Crossref PubMed Scopus (105) Google Scholar) associated with this condition, which can lead to vascular compromise with gangrene and perforation. Patients with severe recurrent episodes of abdominal pain, especially associated with bilious vomiting, should be clinically suspect for mechanical bowel obstruction and consideration given to performing advanced imaging to define bowel anatomy. A CT scan of the abdomen is the preferred diagnostic modality for cecal volvulus; false negatives can theoretically occur if the volvulus untwists and the cecum relocates to the RLQ at the time of imaging. Ultrasonography of the abdomen, a frequently favored imaging modality to avoid ionizing radiation exposure in children, is often nondiagnostic for this condition.