The initial abdominal films showed an ectopic cecum in the left
upper quadrant measuring 12.6 cm in diameter (figure 1). Films
taken 36 hours later demonstrated the transverse dimension of the
cecum to have increased to 16 cm; 40 hours following admission the
cecum had reached 20 cm in diameter. Despite a radiological
diagnosis of cecal volvulus, a contrast enema was requested for
confirmation. The cecum could not be filled and findings confirmed
the suspected plain film diagnosis of cecal volvulus (figure 2). No
attempt was made to reduce the volvulus.
At surgery, the cecum was intact but grossly distended with
visually apparent infarction. The cecum was resected, and a right
hemicolectomy was performed with a distal ileal resection and ileal
transverse colonic anastomosis. Pathologic analysis confirmed an
infarcted and gangrenous cecum.
It has been reported that cecal distention of more than 10 to 12 cm
places the patient at high risk for bowl perforation.1
In this case the cecal distention significantly exceeded this
degree of distention and resulted in infarction without
Colonic volvulus represents 10% of cases of large-bowel
obstruction, and cecal volvulus represents approximately 40% of all
such cases.2,3 Cecal volvulus occurs predominantly in
patients with poor right colon fixation and affects approximately
10% to 25% of the population.4 Such poor fixation leads
to excessive cecal mobility and the potential for vascular
compromise, which may occur as a result of intestinal dilation and
vascular torsion. Torsion of the cecum takes place for a number of
reasons: sudden distention of the cecum by trauma, pressure,
constipation, or a distal colonic obstruction.5-7
Cecal volvulus can be diagnosed in 50% of the cases on the basis
of abdominal series alone. If the positive diagnosis is not made on
review of the abdominal series, follow up-films or contrast enema
are required. In this case, the duration of the observation over 40
hours represented a fulminant course which may have accounted for a
lack of frank perforation.
Two types of cecal volvulus have been described. Type I cecal
volvulus, sometimes called cecal bascule, occurs when the cecum
rotates anteriorly to the ascending colon. Type II cecal volvulus
occurs when the cecum abnormally rotates into the left upper
quadrant. Perret and Kunberger1 have described a case of
Type II cecal volvulus. These authors suggest that a cecal diameter
>10 to 12 cm is an ominous sign and may indicate impending
There are two major scenarios in clinical cecal volvulus. The
first, fulminant, with strangulation and the mesenteric torsion
causing arterial and venous obstruction, occurs coincidentally with
the rotation.8 The second form has the prominent feature
of the bowel obstruction with vascular compromise occurring
gradually due to an increased distention and intraluminal pressure
in the cecum that interferes with blood supply to its wall.
Perforation occurs in 65% of cases where there is a mechanical
distention combined with a vascular compromise. Perforation results
in a life-threatening complication associated with a mortality of
20%.7 When associated with cecal gangrene, the
postoperative mortality is reported to be as high as
45%.5 It has been suggested that the duration of the
cecal distention is as significant as the absolute size of the
This patient demonstrated signs of abdominal compartment
syndrome (ACS), which is an organ dysfunction due to increased
abdominal pressure with secondary compromised respiratory functions
and decreased cardiac output. The syndrome is a life-threatening
complication of massive bowel distention.9 It is
important to note that this clinical condition is associated with
decreased cardiac function, poor ventilation and retention of
CO2, as in our patient. That clinical finding can be
seen in a number of conditions, including trauma, hemorrhage,
pancreatitis, liver transplantation, and other insults resulting in
increased pressure in intra-abdominal organs but without the
radiological features of the cecal volvulus. In cases of cecal
volvulus with these clinical findings, surgical intervention is
In summary, our case confirms that rapid cecal distention is a
warning sign of an impending perforation. The radiological findings
of distended cecum and the constellation of associated clinical
findings are critical in planning therapeutic intervention.
- Perret R, Kunberger L: Cecal volvulus. AJR Am
J Roengenol 171:860-861, 1998.
- Nelson TG, Bowers WF: Volvulus of the cecum
and sigmoid colon: An analysis of nine cases. Arch Surg 72:469-478,
- Spiro H: Clinical Gastroenterology, pp
758-759. New York, McMillan, 1983.
- Rogers RL, Harford FJ: Mobile cecum syndrome.
Dis Colon Rect 27:399-402, 1984.
- Tejler G, Jiborn H: Volvulus of the cecum.
Report of 26 cases and review of the literature. Dis Colon Rect
- Smith WR, Goodwin JN: Cecal volvulus. Am J
Surg 126:215-222, 1973.
- Johnson CD, Rice RP, Kelvin FM, et al: The
radiological evaluation of gross cecal distention. Emphasis on
cecal ileus. AJR Am J Roentgenol 145:1211-1217, 1985.
- Hinshaw DB, Carter R, Joergenson EJ: Volvulus
of the cecum or right colon: A study of fourteen cases. Am J Surg
- Eddy V, Nunn C, Morris JA, Jr: Abdominal
compartment syndrome. Surg Clin North Am 77:801-812, 1997.