What is Cecal Volvulus?

Volvulus is a condition where parts of the intestine twist around an anatomical structure called the mesenteric axis. This can disrupt the blood supply or cause a full or partial blockage of the intestinal opening, most commonly in the colon. Colonic volvulus is quite rare in the United States, accounting for about 4% of large intestine blockages, after cancer and a condition called diverticulitis. However, in parts of the Middle East, India, South America, Africa, and Russia, colonic volvulus is responsible for about 50% of all colon blockages. These areas are often referred to as the “volvulus belt.” Among types of volvulus, the sigmoid volvulus, which affects a specific part of the colon, occurs more often than cecal volvulus, which affects another section.

What Causes Cecal Volvulus?

This condition happens when an excess and loose part of the mesentery, which is tissue in the abdomen, twists around an axis. Speaking of a cecal volvulus, this includes the last part of the small intestine and the right side of the colon. When the cecal volvulus involves only the cecum, which is the start of the large intestine, it’s also known as a cecal bascule. This happens when the cecum, which is highly mobile, moves from a downward direction to an upward direction.

Risk Factors and Frequency for Cecal Volvulus

In the United States, colonic volvulus is one of the causes of large bowel obstruction, after cancer and diverticulitis.

  • Colonic volvulus contributes to around 5% of all cases of intestinal obstruction.
  • It represents 10% to 15% of all cases of large bowel obstruction.
  • The most affected part of the large bowel is the sigmoid colon (80%), followed by the cecum (15%), the transverse colon (3%), and the splenic flexure (2%).

In Africa and the Middle East, almost 50% of large bowel obstructions are due to colonic volvulus, mostly affecting the sigmoid colon. Cecal volvulus, another type, is less common, affecting up to 15% of all cases.

  • Cecal volvulus often impacts women in their sixties.

Signs and Symptoms of Cecal Volvulus

Colonic volvulus is a condition where a person may experience an intestinal blockage that often resembles the symptoms of colon cancers. Common signs of this condition include sudden severe abdominal pain, difficulty with bowel movement (constipation or inability to pass gas), nausea, and vomiting. Generally, an unusually bloated abdomen can be noticed, which often gives a hollow sound when tapped (tympanitic). In some situations, due to too much stretching of the bowel, deprived blood supply (ischemia) may occur, especially in cases of cecal volvulus, a type of colonic volvulus. This ischemia can also result from the twisting of the blood supply to the abdomen’s tissue layer (mesentery). The person’s condition may become alarming when they present with a rapid heart rate (tachycardia), extreme tenderness in the abdomen that increases when pressure is released (rebound tenderness) and severe abdominal pain that doesn’t improve with standard medical care.

  • Sudden severe abdominal pain
  • Constipation or inability to pass gas
  • Nausea
  • Vomiting
  • Unusually bloated and hollow-sounding abdomen (tympanitic)
  • Potential for deprived blood supply (ischemia)
  • Rapid heart rate (tachycardia)
  • Extreme tenderness in the abdomen that increases when pressure is released (rebound tenderness)
  • Severe abdominal pain that doesn’t subside with standard medical care

Testing for Cecal Volvulus

If your doctor thinks you may have a colonic volvulus – which is a type of stomach twist – they will order blood tests, including a complete blood count, and checks for electrolyte levels and lactic acid in your bloodstream. These tests can provide useful information but they can’t confirm the diagnosis on their own. If your white blood cell count is high, or you have a left shift (also known as a ‘pandemic’) or metabolic acidosis, it can be a sign of sepsis (a dangerous infection), damage to the bowel tissue, or a serious abdominal infection. Changes in your electrolyte levels can indicate bowel obstruction and vomiting.

Imaging techniques can further help identify whether you have a sigmoid or cecal volvulus, and distinguish it from other possible abdominal conditions. If you have a cecal volvulus, an abdominal x-ray will show a dramatic swelling of the bowel, which originates in the lower right side of the abdomen and moves upwards towards the left upper side. Typically, patients with a cecal volvulus present with obstructions of both the small and large bowels, a collapse of the distal large bowel, and excessive dilation of the higher parts of the small bowel. One tell-tale sign of a cecal volvulus is the displacement of the appendix upwards along with a blockage of the large bowel. In contrast, a sigmoid volvulus shows an ‘inner tube’ appearance with the twist of the volvulus located in the upper left side of the abdomen.

Regular abdominal x-rays are usually enough to confirm a sigmoid volvulus, but they might not be as helpful for diagnosing a cecal volvulus. In such cases, a CT scan can provide a more accurate picture of the location of the twist. An abdominopelvic CT scan can diagnose a cecal volvulus in around 90% of patients. A ‘whirl sign’ observed on a CT scan, which indicates a twist in the tissues around the ileocolic vessels, is considered a definitive sign of a cecal volvulus. Around 10% of patients are diagnosed with a cecal volvulus during a surgical procedure.

Treatment Options for Cecal Volvulus

Cecal volvulus, a condition where the cecum (the beginning of the large intestine or colon) twists upon itself disrupting the flow of materials, is generally treated through surgery. Although there are non-surgical techniques like a barium enema or colonoscopy that can alleviate the condition, they are rarely successful and carry a high risk of injuring the colon. Additionally, these non-surgical procedures may miss signs of death of colon tissue up to 25% of the time. The exact method of surgical treatment depends on the patient’s condition and what the surgeon finds during the operation.

There are different surgical treatment options based on the patient’s status and whether the bowel is compromised or viable:

1. If patients are stable with no compromised bowels, procedures such as ileocolic resection (removal of a portion of the small and large intestine) or right hemicolectomy (removal of the right side of the colon) are recommended. Followed by the ileocolic resection, an additional procedure called colopexy needs to be performed to attach the remaining right colon to the back of the abdominal wall in order to reduce the chance of volvulus recurrence.

2. For patients who are unstable but the bowel is not compromised, a procedure called cecopexy (attaching the cecum to the abdominal wall) is done in conjunction with a cecostomy tube placement (surgical creation of an opening into the cecum). In some cases, cecopexy may be done alone.

3. If patients are stable and there’s bowel compromise, the surgeon should opt for a right hemicolectomy or ileocolic resection, followed by an ileocolic anastomosis (joining the remaining sections of the intestines).

4. Unstable patients with compromised bowels should undergo a right hemicolectomy or ileocolic resection, with an ileostomy creation (creation of a stoma or opening in the ileum, part of the small intestine). Later, once the patient’s condition stabilizes, the ileostomy can be reversed.

When a doctor is trying to diagnose a condition called cecal volvulus, which is a twisting of the bowel, there are several other conditions they’ll need to rule out. These might look similar to cecal volvulus, but they are different illnesses that need different treatments:

  • Hernias in the stomach
  • Acute mesenteric ischemia, which is a sudden loss of blood flow to the intestines
  • Appendicitis, or inflammation of the appendix
  • A blockage in the bowel
  • Iliosigmoid knot, which is a rare condition where two parts of the bowel – the ileum and the sigmoid colon – become twisted together
  • Pseudo obstruction – a condition that mimics a true blockage in the bowel, but isn’t one
  • Severe constipation
  • Sigmoid diverticular disease, which causes small pockets to form in the wall of the intestine
  • Megacolon, a severe dilation of the colon
  • Rectal cancer

The doctor will consider these conditions carefully and use the right tests to make sure they’re diagnosing the right condition.

What to expect with Cecal Volvulus

Cecal volvulus, a medical condition involving the twisting of the cecum, is serious and not to be taken lightly. If treatment is not administered promptly, the mortality rate could rise above 30%. Research generally suggests that treatment should occur within 24 to 72 hours after the condition has been diagnosed. This time frame allows for proper hydration and necessary medical investigations.

However, it’s important to note that even with treatment, patients still face significant health risks due to cecal volvulus. These include a prolonged case of ileus (a disruption in the normal movement of the digestive tract), wound infection, respiratory failure, and bowel obstruction.

Possible Complications When Diagnosed with Cecal Volvulus

After undergoing treatment for cecal volvulus, which is a twisting of the lower bowels, there can be some common complications. These include:

  • Wound infection, which is when the surgical wound gets infected
  • Sepsis, a severe reaction to an infection that can cause serious illness
  • Anastomotic leak, a leak in the area of the intestine that was stitched back together
  • Colocutaneous fistula, an abnormal passage that forms between the colon and the skin
  • Pelvic or abdominal abscess, an infected area filled with pus

Recovery from Cecal Volvulus

Patients usually need to stay in the hospital for an extended period, especially those who are older and weaker. If their ileus, or intestinal blockage, lasts for a long time, they typically need to be given fluids directly into their veins for a few days. It’s also recommended to use procedures that help prevent deep vein thrombosis (DVT), a condition where blood clots form in deep veins, and physical therapy.

Frequently asked questions

Cecal volvulus is a type of volvulus that affects a specific section of the colon.

Cecal volvulus affects up to 15% of all cases.

Signs and symptoms of Cecal Volvulus include: - Sudden severe abdominal pain - Constipation or inability to pass gas - Nausea - Vomiting - Unusually bloated and hollow-sounding abdomen (tympanitic) - Potential for deprived blood supply (ischemia) - Rapid heart rate (tachycardia) - Extreme tenderness in the abdomen that increases when pressure is released (rebound tenderness) - Severe abdominal pain that doesn't subside with standard medical care

Cecal volvulus occurs when the cecum, which is the start of the large intestine, moves from a downward direction to an upward direction.

The other conditions that a doctor needs to rule out when diagnosing Cecal Volvulus are: - Hernias in the stomach - Acute mesenteric ischemia - Appendicitis - A blockage in the bowel - Iliosigmoid knot - Pseudo obstruction - Severe constipation - Sigmoid diverticular disease - Megacolon - Rectal cancer

The types of tests needed for Cecal Volvulus include: - Blood tests, such as a complete blood count, to check for signs of infection or damage to the bowel tissue. - Checks for electrolyte levels and lactic acid in the bloodstream, which can indicate bowel obstruction and vomiting. - Abdominal x-rays to confirm a sigmoid volvulus and show a dramatic swelling of the bowel. - CT scan to provide a more accurate picture of the location of the twist, especially for diagnosing a cecal volvulus. - In some cases, a surgical procedure may be necessary to diagnose a cecal volvulus.

Cecal volvulus is generally treated through surgery. The exact method of surgical treatment depends on the patient's condition and what the surgeon finds during the operation. There are different surgical treatment options based on the patient's status and whether the bowel is compromised or viable. These options include procedures such as ileocolic resection, right hemicolectomy, colopexy, cecopexy, cecostomy tube placement, and ileostomy creation. The specific procedure chosen will depend on the stability of the patient and the condition of the bowel.

The side effects when treating Cecal Volvulus include: - Wound infection, which is when the surgical wound gets infected - Sepsis, a severe reaction to an infection that can cause serious illness - Anastomotic leak, a leak in the area of the intestine that was stitched back together - Colocutaneous fistula, an abnormal passage that forms between the colon and the skin - Pelvic or abdominal abscess, an infected area filled with pus

The prognosis for Cecal Volvulus can be serious, with a mortality rate that could rise above 30% if treatment is not administered promptly. Even with treatment, patients still face significant health risks, including a prolonged case of ileus, wound infection, respiratory failure, and bowel obstruction.

A gastroenterologist or a general surgeon.

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