Caecal bascule: a rare complication following emergency caesarean section

Cecal bascule in pregnancy: a case report and review of the literature

A 36-year-old female at 36 weeks' gestation presented with right upper quadrant abdominal pain. She had no prior surgeries. Her pregnancy had been uncomplicated up until her presentation. Abdominal ultrasound was negative for cholecystitis or cholelithiasis, and the appendix was not visualized. During the second day of her hospital course, an abdominal magnetic resonance imaging (MRI) was performed revealing dilated small intestine with air-fluid levels and an inverted-appearing, prominent cecum. She was urgently taken to the operating room for cesarean section followed by abdominal exploration. After delivery of the child, a cecal bascule was found, with a severely distended cecum. To our knowledge, this is the first report of a cecal bascule diagnosed by MRI, and the first diagnosis of cecal bascule in a pregnant patient requiring surgical intervention. We discuss the pathophysiology, diagnosis and treatment of cecal bascule and review the current literature of reported cases.

Caecal bascule - A variant of caecal volvulus: Review of diagnostic challenges and approaches

Caecal volvulus is a rare cause of intestinal obstruction, of which the caecal bascule is the most uncommonly encountered subtype. Definitive radiological diagnosis of a caecal bascule can be challenging. Lack of familiarity with this rare condition can contribute to delayed diagnosis and treatment, which may result in unnecessary morbidity. This article highlights the case of a patient who presented with a diagnostic challenge, and also discusses the pathogenesis and diagnostic features of caecal bascules. Various options in the surgical management of caecal bascules are reviewed, including the feasibility of laparoscopic-assisted approaches in the emergency setting.

Cecal bascule - A rare cause of cecal volvulus after cesarean section

Introduction and importance

Cecal bascule is a rare form of a cecal volvulus characterized by an anterior and superiorly displaced cecum in turn causing compression of the ascending colon that can result in a large bowel obstruction. We report a case of cecal bascule in a newly postpartum patient, with emphasis on clinical presentation, radiologic findings and treatment.

Case presentation

A 37-year-old female who underwent an uncomplicated c-section and bilateral salpingectomy developed severe abdominal pain, vomiting, and peritonitis 12 h after surgery. A computerized tomography of the abdomen and pelvis revealed a dilated and superiorly displaced cecum. The diagnosis of cecal bascule was confirmed intraoperatively and a right hemicolectomy was performed. The patient recovered appropriately and was discharged on postoperative day six.

Discussion

Cecal bascule is the rarest form of cecal volvulus. In the context of obstetrics and gynecology, it has mostly been mentioned perioperatively after cesarean, but was also reported in an antepartum patient. It usually occurs in patients with redundant or mobile cecum, which is a result of incomplete fixation of the cecum to the retroperitoneum during embryogenesis. Other risk factors include recent surgery, previous abdominal surgery, ileus, chronic constipation, and distal colonic obstruction. An association has also been shown with pregnancy or the postpartum abdomen and is hypothesized to be due to mass effect.

Conclusion

Cecal bascule is a serious entity requiring a high index of suspicion and warranting greater awareness in the post-natal patient. Clinical diagnosis, prompt imaging, and surgery are important to avoid bowel ischemia and perforation.

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Any patient with a redundant cecum who undergoes delivery could potentially be at risk of developing a cecal bascule.

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The importance of clinical diagnosis as well as prompt imaging in the post-natal patient with obstructive symptoms.

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A right hemicolectomy is the gold standard in the treatment, whereas a cecopexy or cecostomy tube can be used in unstable patients.

Caecal bascule: a case series and literature review

BACKGROUND

Caecal bascule is a rare condition characterized by the inferior pole of the caecum folding on a horizontal axis antero-superiorly towards the ascending colon, potentially causing obstruction. An unusual variant of volvulus, diagnosis is challenging due to its obscurity. We present the experience of an Australian tertiary-referral hospital with the diagnosis/management of caecal bascule, and review cases reported in the literature to raise awareness of this uncommon diagnosis.

METHODS

Medical records of patients diagnosed with caecal bascule during 2001-2016 were reviewed. Data relating to their presentation, investigations, management and outcomes were obtained. A literature search was conducted through PubMed and Medline databases.

RESULTS

Caecal bascule was diagnosed in four patients (median age: 60.5 (range: 48-75) years, two females). Patients presented with abdominal pain (4/4), distension (3/4), vomiting (3/4) and confusion (1/4) over a 1- to 4-day period. Computed tomography identified caecal displacement in three cases, and bascule was diagnosed at laparotomy in all cases. All patients underwent right hemicolectomy, with primary ileo-colic anastomosis in three cases and formation of Abcarian stoma in one case. Median length of stay was 15.5 days (range: 10-24), with no mortality. Fifteen cases of caecal bascule have been reported in the literature to date, with authors suggesting resection as definitive treatment.

CONCLUSION

Correct diagnosis of caecal bascule requires a high index of suspicion and avoids delay of appropriate management. Recent operation, particularly laparoscopic cholecystectomy, may be contributing factors. Resection is recommended, a sentiment echoed by reported cases in the literature.