The colonoscope in cecal volvulus: report of three cases

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

[Elective laparoscopic right colectomy for caecal volvulus: case report and literature review]

BACKGROUND

Caecal volvulus is an uncommon cause of intestinal obstruction. Its clinical presentation is non-specific, with the diagnosis usually confirmed by barium enema and abdominal computed tomography. Treatment depends on many factors, and minimally invasive approaches are becoming the treatment of choice.

CLINIC CASE

A 54 years old female, admitted to the Emergency Department with clinical symptoms of intestinal obstruction. On physical examination she had a palpable, firm, and tympanitic mass in the right abdomen, with peritoneal irritation. The radiographs of the abdomen, barium enema and abdominal computed tomography showed caecal volvulus. As she showed a full remission after the barium enema, with no clinical or biochemical data of systemic inflammatory response syndrome or peritoneal irritation, she was discharged to her home. Two weeks later, a laparoscopic right hemicolectomy was performed with an ileo-transverse extracorporeal anastomosis. Her progress was satisfactory, and she was discharged 4 days after surgery due to improvement.

CONCLUSION

Caecal volvulus is a rare cause of intestinal obstruction, with high mortality rates, and is caused by excessive mobility of the caecum. Its incidence is increasing. Treatment depends on many factors. Early non-surgical untwisting, followed by an elective laparoscopic surgical procedure offers several advantages and reduces mortality.

Caecal volvulus: a consequence of acute cholecystitis

Caecal volvulus is an uncommon cause of closed loop intestinal obstruction which can lead to caecal gangrene and high mortality. Delay in diagnosis is one of the causes of this high mortality. Caecal volvulus is reported to be associated with previous abdominal surgery in most cases. We present the first reported case of caecal volvulus following/associated with acute cholecystitis.

Diagnosis and treatment of caecal volvulus

Caecal volvulus is an infrequently encountered clinical condition and an uncommon cause of intestinal obstruction. Patients with this condition may present with highly variable clinical presentations ranging from intermittent, self limiting abdominal pain to acute abdominal pain associated with intestinal strangulation and sepsis. Lack of familiarity with this condition is a factor contributing to diagnostic and treatment delays. The objective of this review is to promote clinicians' awareness of this disease through patient case illustration, discussion of disease pathogenesis, clinical features, and management strategies.

Le volvulus du cæcum chez l'enfant : à propos d'un cas

Volvulus of the caecum is a rare entity in childhood. We report on a case of caecal volvulus in a 6-year-old child, admitted with clinical symptoms of gut occlusion and shock. Outcome was favourable after surgical treatment. The epidemiological, clinical, radiological aspects and therapy are discussed in light of data of the literature.

Cecal volvulus causing postoperative intestinal obstruction: report of a case

Cecal volvulus is a rare cause of intestinal obstruction after major abdominal surgery. A case of cecal volvulus occurring in the early postoperative period after left colon resection for malignancy is presented. Clinical evaluation and plain abdominal radiographs suggesting cecal volvulus prompted laparotomy and correction. Delay in diagnosis results in high mortality, and treatment depends largely on the viability of the involved intestine. This report describes the second case of cecal volvulus complicating a left colectomy. It was treated by detorsion and reperitonealization cecopexy.

Management and causes of acute large-bowel obstruction

Acute LBO has many possible causes. In the United States, the most common cause is colorectal carcinoma. Mechanical obstruction should be differentiated from pseudo-obstruction by contrast enema or colonoscopy because the treatments differ. The high postoperative mortality and morbidity of LBO compared with elective resection are explained by the multiple associated pathophysiologic changes of obstruction. Management of this condition requires careful assessment, awareness, and expertise in the current modalities of treatment. Gangrene and perforation should be avoided because they limit treatment options and are associated with an increase in mortality. We prefer, in most instances, to perform a single-stage procedure, which has the advantages of reduced hospital stay (and cost) and avoidance of a stoma. However, the appropriate treatment needs to be tailored to the individual situation. Recent developments in nonoperative decompressing procedures may demonstrate advantages in the future.

True and false large bowel obstruction

Acute large bowel obstruction can be the result of mechanical causes (such as colorectal cancer) or motility disturbances, the latter being termed colonic pseudo-obstruction. Whatever the aetiology, the pathophysiology of large bowel obstruction has clinical significance. Changes in motility augmented by increased colonic blood flow may play a role in dissemination of tumour cells and/or bacteria. Intravascular fluid depletion, especially shortly after intestinal decompression, has important haemodynamic implications. The diagnosis is often confirmed on plain abdominal X-ray, but water-soluble contrast studies are important in distinguishing a mechanical obstruction (which almost always requires an operation) from a pseudo-obstruction (which can usually be managed without surgery). Mortality and morbidity may be reduced by optimization of the patient's condition both before and after the operation using intensive care facilities and by careful timing of surgery. The surgical management of malignant large bowel obstruction is best directed by a senior surgeon. For tumours up to and including the splenic flexure, an extended right hemicolectomy is advisable since it offers adequate removal of the tumour and allows an immediate safe ileocolic anastomosis. More distal tumours should be resected if possible, and there is much to recommend on-table irrigation and immediate anastomosis, although a colostomy with a mucous fistula or Hartmann's procedure still have a place. Endoscopic diagnosis and decompression enables definitive surgery to be undertaken electively and several techniques are being evaluated. Non-operative reduction of sigmoid volvulus by rigid or flexible endoscopy is achieved with high success rates, but is not recommended for caecal volvulus. Resection is usually necessary in both to prevent recurrence. Mortality of colonic volvulus is closely related to bowel viability. Uncomplicated colonic pseudo-obstruction may be managed medically or by endoscopic decompression. It often occurs in association with systemic medical conditions, which need to be treated vigorously. Surgery is indicated if there are signs of impending or frank perforation, or if non-operative measures fail.

Cecal volvulus

A review of 561 cases of cecal volvulus that were published between 1959 and 1989 along with 7 new cases, was performed to characterize the clinical and laboratory profile and to evaluate the various surgical options in treating this life-threatening condition. The age and sex distribution of these patients have changed over the years and shifted toward older patients (mean, 53 years) and female predominance (female:male ratio, 1.4:1). The clinical presentation was usually of distal closed-loop small bowel obstruction. Forty-six percent of the plain abdominal radiographs were suspected for cecal volvulus, but only 17 percent were diagnostic. Barium enema had a high rate of accuracy (88 percent) and was associated with minimal complications. True volvulus was 6 times more common than bascule, and gangrenous cecum was found in 20 percent of cases. Detorsion alone and cecopexy had almost similar complications, mortality, and recurrence rates (15, 10, and 13 percent, respectively), whereas, resection, which was performed primarily for gangrenous cecum, had higher rates. However, the highest rates of complications (52 percent), mortality (22 percent), and recurrence (14 percent) were noticed after cecostomy. These data suggest that resection should be reserved for patients with necrotic cecum and that detorsion is sufficient for patients with viable cecum. Cecostomy should be abandoned.

Colonoscopic decompression of pseudo-obstruction and volvulus

Flexible fiberoptic endoscopy has an integral role in the management of colonic pseudo-obstruction and volvulus. Colonoscopic decompression is the primary method for diagnosis and treatment of colonic pseudo-obstruction. Some patients require repeat endoscopic decompression, but few require tube cecostomy. In the case of sigmoid volvulus, endoscopic examination is useful as a temporizing measure to allow preparation of the colon and patient for elective definitive operative treatment.

Experience with colonic volvulus

Fifty-eight cases of colonic volvulus were reviewed including 30 cases of sigmoid volvulus, 27 cases of cecal volvulus, and 1 of transverse colon volvulus. Decompression procedures were attempted in 31 instances of sigmoid volvulus in 27 patients and were successful 25 times (81 percent). Seven patients with sigmoid volvulus did not undergo surgery and of those, two died of unrelated causes, one was lost to follow-up, one was well, and three had recurrent volvulus. Twenty-four operations were performed on 23 patients and there were three deaths (13 percent mortality). There was one recurrence in two patients who underwent simple detorsion. Chronic large-bowel motility disturbances were a persistent problem in 9 of 20 (45 percent) surgical survivors. Among 27 instances of cecal volvulus, one was reduced by contrast enema and ten endoscopic attempts at decompression were unsuccessful. Twenty-six operations were done and there were four operative deaths (15 percent mortality). There were no recurrences. Large-bowel motility disorders were noted in follow-up in 3 of 22 patients (14 percent). Overall there were 10 deaths in 58 patients for a 17 percent mortality rate. These data support the importance of endoscopic decompression for sigmoid volvulus but not for cecal volvulus. Definitive treatment of both forms of volvulus should include assessment of colonic motility.

Endoscopy in colonic volvulus

Flexible fiberoptic gastrointestinal endoscopy has greatly simplified the diagnosis and treatment of colonic volvulus. The management of 39 patients with colonic volvulus treated over 9 years was reviewed. Five per cent were treated with rectal tube decompression alone, 23% were treated with either sigmoidoscopic or colonoscopic reduction, and 26% were treated exclusively with operation. Endoscopic reduction was attempted in nearly half of the patients in preparation for operation. Recurrent volvulus occurred in 57% of patients initially treated with endoscopic reduction alone. Sigmoidoscopic examination did not confirm the diagnosis in 24% of instances in which it was used, although colonoscopy was always diagnostic. The overall mortality rate was 8%, but increased to 25% in patients with gangrene of the colon. Three patients who later proved to have gangrene of the colon had a normal initial sigmoidoscopic examination. Two of these patients died of intra-abdominal sepsis from a perforated colon. In five patients an accurate endoscopic diagnosis of gangrene prompted immediate exploration. None of these patients died. Endoscopy is a safe and effective diagnostic tool for the initial evaluation of patients with suspected colon volvulus. In addition, endoscopy may result in therapeutic decompression and may provide visual assessment of the viability of the bowel mucosa, thus assisting in the timing of appropriate operative treatment.

Volvulus of the colon. Incidence and mortality

Between 1960 and 1980, 137 patients with colonic volvulus (52% cecal, 3% transverse colon, 2% splenic flexure, and 43% sigmoid) were seen at the Mayo Clinic. Among the 59 patients with sigmoid volvulus, four (7%) had colonic infarction. Total mortality with sigmoid volvulus was seven per cent. There were 71 patients with cecal volvulus. Colonoscopic decompression was accomplished in two of these patients; in 15 (21%), gangrenous colon developed and mortality was 33%. Total mortality for cecal volvulus patients was 17%. Mortality for all forms of volvulus in patients with viable colons was 11%. Mortality for all patients with volvulus was 14%.

Volvulus of the transverse colon. Reports of cases and review of the literature

Volvulus of the transverse colon is rare. Sixty-six cases have been reported in the English medical literature, and three new cases are presented herein. The causative factors, classical clinical presentation, radiologic findings, and management have been addressed. It is believed that colonoscopy will have an increasing role in the diagnosis and treatment of this condition in the future.

Cecal volvulus: A diagnostic and therapeutic challenge

Cecal volvulus is a malrotational abnormality of the intestine that causes obstruction. Diagnosis is difficult and, if delayed, the results may be intestinal ischemia, perforation, sepsis, and even death. Cecal ischemia or gangrene cannot always be determined from physical and laboratory findings. Although not always conclusive, contrast radiography may be helpful; however, laparotomy is often required for definitive diagnosis and therapy. If vascular compromise of the cecum is found, right hemicolectomy is the treatment of choice. In the absence of ischemia, decompressive tube cecostomy, simple detorsion, and cecopexy have all been recommended, but the optimal treatment is a matter of controversy.

Colon volvulus and the geriatric patient

One is tempted to believe that volvulus in elderly patients on many occasions may be preceded by inactivity and pseudomegacolon. Owing to psychiatric problems, chronic illness, or institutionalization, the patient is more likely to be subjected to treatment with sedatives and psychotropic drugs, causing decreased neuromuscular function of the gut. The basic principles in treating the volvulus are releasing the volvulus, deciding whether a nonoperative or an operative procedure should be employed, and treating complications. As far as surgical management is concerned, several techniques have been suggested, some of which are still controversial. Colonoscopy appears to have become an important method of treatment for volvulus with clearly established indications. Oddly enough, already hospitalized patients are occasionally subjected to delayed attention for volvulus. Therefore, physicians responsible for the care of geriatric patients should be alerted by even fairly mild symptoms of distention, abdominal pain, vomiting, and constipation. Clinical evaluation, including routine films of the abdomen, may avert a major catastrophe.

The colonoscope in volvulus of the transverse colon

A case of volvulus of the transverse colon in a patient with dystrophia myotonica is reported in which the volvulus was reduced during colonoscopy. Indications for colonoscopy in patients with volvulus of the transverse colon are discussed, and it is suggested that colonoscopic reduction of volvulus of the transverse colon might have a place as emergency treatment in patients with other severe complications.

Volvulus of the transverse colon: report of case and review of the literature

A case of transverse colon volvulus is reported, bringing the total number of collected cases in the English language medical literature to 45. Although this type of volvulus is rare, a definite pattern can be appreciated. Patients tend to be young, female, and give a history of chronic or recurrent difficulty in having bowel movements. A triad of underlying factors predisposes to the development of the volvulus: a distal impediment (either organic or functional) to the evacuation of the bowel, a redundant bowel and mesocolon and a fixed point around which the bowel can twist. The best treatment is resection with either anastomosis or exteriorization, depending on bowel viability.