Cecal Volvulus at an Unusual Age

For the past 2 hours, a 19-year-old man had lower abdominal pain accompanied by nausea and vomiting. He had no fever and no diarrhea. Direct tenderness was mainly in the right lower quadrant, radiating slightly to the left lower quadrant. There was no significant rebound tenderness. The patient refused rectal examination.

Results of complete blood cell count and urinalysis were normal. A plain abdominal film, which is seen here, showed a large dilated loop of large bowel in the lower midsection. Results of an intravenous pyelogram were normal.

Surgery confirmed the diagnosis of cecal volvulus; the greatly dilated cecum had rotated approximately 180 degrees around its mesenteric attachment, as seen in the intraoperative photo. Peritoneal bands were released, cecostomy and cecopexy were performed, and the cecum was decompressed by insertion of a Foley catheter that remained for 1 week. The postoperative course was uneventful, and the patient recovered completely.

Cecal volvulus can occur only when the right colon is incompletely fused with the posterior parietal peritoneum, an embryonic variant present in 10% to 37% of normal adults.¹ It is less common than sigmoid volvulus and accounts for 2% to 3% of all colonic obstructions and about one third of all cases of colonic volvulus.¹

Symptoms of cecal volvulus can be confused with those of ileus or acute pseudoobstruction of the colon. The small bowel is usually dilated with a variable amount of gas. Plain films characteristically reveal a dilated, air-filled cecum in an ectopic location, usually with the cecal apex in the left upper quadrant.² The medially placed ileocecal valve may produce soft-tissue indentation, so that the gas-filled cecum has the appearance of a coffee bean or a kidney. In most cases, little gas is seen distally in the colon. If the ileocecal valve is incompetent, refluxed gas in the small bowel may erroneously suggest a small-bowel obstruction and obscure the diagnosis. A contrast enema shows typical “beaking” at the point of the volvulus in the mid-ascending colon.²

Drs Abbas Chamsuddin and Edgard Victoria of Mobile, Ala, and Luverne, Ala, respectively, comment that this case is unusual because of the patient's age. Cecal volvulus occurs most often either early or late in life.

REFERENCES:
1. Ballantyne GH, Brandner MD, Beart RW JR, wt al. Volvulus of the colon: incidence and mortality. Ann Surg. 1985;202:83-91.
2. Young WS. Further radiological observations in cecal volvulus. Clin Radiol. 1980;31:479-483.