S1786 A Rare Case of Bowel Obstruction: Cecal Bascule After Colonoscopy

Abstract

Introduction: 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 partial obstruction. The following vignette highlights a case of cecal bascule following two unsuccessful colonoscopy attempts. Case Description/Methods: A 68-year-old male with history of advanced adenoma and no prior abdominal surgery was admitted for surveillance colonoscopy after inability to intubate the cecum on outpatient colonoscopy. Repeat double balloon assisted colonoscopy attempt failed to intubate the cecum , raising concern for cecal volvulus. While admitted, the patient complained of abdominal distention and discomfort despite ability to pass gas and stool. Abdominal x-ray showed a significantly dilated colon to 12 centimeters (Figure 1A). Computed tomography (CT) revealed upside down rotated cecum with ileocecal valve pointing laterally, dilatation of ascending colon to 10 centimeters without evidence of perforation, compatible with cecal volvulus (Figure 1B). A multi-disciplinary 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. He underwent a right hemicolectomy with ileal colonic anastomosis. The patient did well post-surgery without significant sequelae. Discussion: Cecal volvulus, a rare clinical entity, accounts for 1-2% of all large bowel obstructions. 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. It occurs secondary to congenital or acquired adhesions fixing the anterior wall of the cecum to that of the ascending colon. In our patient, the increased motility related to the colonoscopy preparation may have initiated the rotation of the cecum. The signs and symptoms of a cecal bascule are similar to that of a cecal volvulus. Plain X-ray usually reveals a distended cecum. CT of abdomen confirms the diagnosis in 90% of patients showing upward folding of the cecum, as in our patient. Treatment is primarily surgical. Due to high recurrence after simple reduction, cecopexy or resection and anastomosis are preferred approaches. In patients with recurrent or persistent abdominal pain and distension, cecal bascule should be considered in the differential diagnosis.Figure 1.: Abdominal X-ray and exploratory laparotomy findings.