Cecal Volvulus

Cecal Volvulus

Andrew M. Holloway, MD and Michael T. Langford, MD

Table of Contents

Definition and Classification
Etiology
Presentation and Diagnosis
Management

See Also:
*See Colonic Volvulus

Definition and Classification

Cecal Volvulus: Twisting of the Cecum Around Itself

Causes a Closed Loop Obstruction That Can Cause Vascular Compromise with Ischemia, Necrosis, and Perforation

Second Most Common Colonic Volvulus (35%), After Sigmoid Volvulus

Classification

  • Type I: Axial Twisting Along the Long Axis
    • Most Often from Clockwise Rotation
  • Type II: Twisting of the Cecum and Terminal Ileum
    • Most Often from Counterclockwise Rotation
  • Type III (“Cecal Bascule”): Anterosuperior Folding of the Cecum without Any Axial Twisting
    • Less Common (20%)

Cecal Volvulus 1

Etiology

Congenital Risk Factors

  • Mobile Cecum and Ascending Colon (Congenital Failure of Normal Peritoneal Fixation During Development)
  • Malrotation or Incomplete Intestinal Rotation
  • Congenital Bands or Adhesions

More Common in the 4th-6th Decade of Life (Compared to Sigmoid Volvulus Which is Most Common in the 6th-8th Decade of Life) – Due to Congenital Cecal Mobility Rather than Degenerative Colonic Disease

Additional Risk Factors

  • Adhesions
  • Female Sex
  • Pregnancy
  • Chronic Constipation
  • Colonic Dysmotility
  • High-Fiber Intake
  • Abdominal Masses
  • Prolonged Immobility
  • Colonoscopy

Presentation and Diagnosis

Presentation

  • Abdominal Pain
  • Abdominal Distention
  • Nausea and Vomiting
  • Obstipation

Diagnosis

  • Generally Diagnosed by CT Abdomen/Pelvis
    • Cecum is Dilated and Twisted
    • Ileocecal Valve May Be Directed Laterally
    • “Whirl Sign” with Mesentery Twisted
  • Abdominal Plain Film Can Be Diagnostic But is Neither Sensitive nor Specific
    • Classic “Coffee-Bean Sign” (Dilated Loop of Colon with Apex in the Left Upper Quadrant) is Rarely Seen
    • Suggestive Plain Film Findings Should Be Further Evaluated by CT

Can Be Diagnosed at Surgical Exploration in an Emergent Setting

Cecal Bascule

Management

The Primary Treatment is Surgical Resection (Right Hemicolectomy vs Ileocecectomy)

Avoid Endoscopic Detorsion – Technically Difficult with High Risk for Perforation and Missed Injury

Surgical Intervention

  • Do Not Detorse Ischemic or Necrotic Bowel Prior to Resection – Risk for Reperfusion Bacteremia and Sepsis
  • Detorsion Alone without Resection is Generally Advised Against Due to High Recurrence Rate (Up to 25% or More)
  • Consider End Ileostomy vs Anastomosis with Diverting Loop Ileostomy if High Risk for Anastomotic Leak

May Consider Detorsion and Cecopexy Alone (Without Resection) if Bowel is Viable and the Patient is Hemodynamically Unstable or Unfit for Resection

  • Alternatively May Consider Detorsion with Cecostomy Tube Instead of Cecopexy

References

  1. James B, Kelly B. The abdominal radiograph. Ulster Med J. 2013 Sep;82(3):179-87. (License: CC BY-NC-SA-4.0)