Prepared by Dr. Anna K. Henisz of the Department of
Radiology, Dr. Dwight Miller, of the Department of Pathology,
and Dr. Peter Reyelt, of the Department of Surgery of the
Sharon Hospital, Sharon, CT; and Paul M. Silverman of the MD
Anderson Cancer Center in Houston, TX.
An 83-year-old woman was admitted to the hospital because of
vomiting and abdominal pain. Her medical history included abdominal
surgery with cecoplasty in 1987. She had no subsequent abdominal
complaints. The patient had a respiratory rate of 20/min, blood pH
of 42%, p0
of 56% and 0
saturation 84% on 4 liters 0
per minute. These findings are all indicative of decreased
cardiopulmonary function, poor oxygenation, and retention of CO
. Systolic blood pressure was 70 mm Hg. An abdominal study was
performed and a series of abdominal films failed to demonstrate
free air. A hypaque enema was then performed. The patient was seen
immediately following the procedure by a surgeon and transferred to
an operating room for emergency exploratory laparatomy.
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.
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
Cecal volvulus occurs predominantly in patients with poor right
colon fixation and affects approximately 10% to 25% of the
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.
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 Kunberger
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 perforation.
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 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%.
When associated with cecal gangrene, the postoperative mortality is
reported to be as high as 45%.
It has been suggested that the duration of the cecal distention is
as significant as the absolute size of the cecum.
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.
It is important to note that this clinical condition is associated
with decreased cardiac function, poor ventilation and retention of
, 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 warranted.
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.
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