[Cecal volvulus: one case and literature review]

BACKGROUND

Cecal volvulus is a rare disease that causes intestinal obstruction. It has various congenital and acquired risk factors. It is frequently associated with abnormal cecal fixation, and it is caused by torsion of the cecum in one of its three axes. It is not different from other causes of intestinal obstruction, but a delay in its diagnosis can lead to ischemia, necrosis and colon perforation. Its management depends on the viability of the tissues, ranging from untwisting and cecopexy to hemicolectomy with or without anastomosis. We present a case of caecal volvulus (caecal bascule) and review the literature as well.

CLINICAL CASE

43-year-old female, who was admitted to an emergency department with data of intestinal obstruction. A simple tomography of the abdomen was performed, where a dilated colon and an image that resembles an inverted coffee bean were identified. An exploratory laparotomy was performed, identifying a bascule-type cecal volvulus, without vascular compromise. Devolvulation, decompression through appendectomy, and caecopexy were performed. After the surgical event, the patient recovered without incident and was discharged with adequate controls by external consultation.

CONCLUSIONS

Cecal volvulus is a cause of intestinal obstruction with a low incidence, which is why early recognition and treatment are key to avoiding the complications that its evolution entails. This type of disease should be among our differential diagnoses, since treatment is surgical and delay leads to a high mortality rate.

Midgut malrotation presenting with hyperemesis gravidarum: A case report

RATIONALE

Midgut malrotation is a rare congenital abnormality resulting from failure of complete intestinal rotation and subsequent fixation during early fetal development. There appeared to be no obvious symptoms in most patients, and a few patients may exhibit symptoms similar to hyperemesis gravidarum, such as nausea and vomiting. Here, we present a case of midgut malrotation presenting as hyperemesis gravidarum.

PATIENT CONCERNS

A 27-year-old woman with an intrauterine pregnancy of 27 + 6 weeks complained of severe nausea and vomiting for 2 weeks.

DIAGNOSIS

Magnetic resonance imaging showed obvious dilatation in the proximal part of the duodenum and gastric cavity and the absence of a duodenal path dorsal to the superior mesenteric artery, which was diagnosed as midgut malrotation.

INTERVENTIONS

Considering that the patient's vital signs were stable, without manifestation of peritonitis or the risks of surgery to the fetus, conservative treatment was adopted. Unfortunately, the fetus developed severe hydrocephalus at 32 weeks. The patient and her family decided to abandon the fetus, and a mid-trimester-induced abortion was performed.

OUTCOMES

The related symptoms completely disappeared after delivery, and the relevant examination after discharge also confirmed the presence of midgut malrotation without gastrointestinal discomfort within 1 year after delivery.

LESSONS

Midgut malrotation can be considered as a differential diagnosis of hyperemesis gravidarum. Conservative treatment under close monitoring is desirable in pregnant women diagnosed with midgut malrotation.

Case Report: Caecal volvulus management from diagnosis to treatment in a young patient

Caecal volvulus (CV) is a rare cause of intestinal obstruction, defined by an axial torsion of the caecum, ascending colon, and terminal ileum around the mesenteric vascular pedicles, leading to ischemia and bowel necrosis. A 20-year-old woman, with no significant medical history, was admitted for generalized abdominal pain evolving for three days, along with constipation and abdominal distension, but with no vomiting. Physical examination showed a generalized abdominal tenderness with no rigidity or rebound tenderness, associated with abdominal distension and tympanic upon percussion. Laboratory findings were within normal limits. An abdominal computed tomography scan revealed distension of a loop of the large bowel with its long axis extending from the right lower quadrant to the epigastrium or left upper quadrant. Colonic haustral pattern was absent. An abdominal computed tomography scan showed a rounded focal collection of air-distended bowel with haustral creases in the upper left quadrant. In addition, spiraled loops of the collapsed cecum (giving a whirl sign) were noted, along with low-attenuating fatty mesentery from the twisted bowel. The patient underwent an emergency laparotomy and caecectomy using GEA 80 charges. The patient had no complaints post-operation. CV is a rare cause of bowel obstruction, mainly caused by an exceedingly mobile caecum. Despite its rareness, CV represents the second most common cause of large bowel volvulus, behind sigmoid volvulus. For acute obstruction by CV, it is hard to differentiate it clinically from obstruction of the small bowel; therefore, radiological exams are needed. Surgery is the gold standard treatment for CV. We report a rare case of CV to highlight the rarity of this pathology, specify its diagnostic and therapeutic means, and its clinical and biological evolution.

Management of sigmoid volvulus during labor : a challenging situation

Acute intestinal obstruction is rare during pregnancy. Its diagnosis is difficult because the symptoms can be minimal and mimic signs of a regular pregnancy. Sigmoid volvulus is a common cause of these obstructions. The management is challenging because it depends on many factors, and affects maternal-fetal outcomes. We report a case of a 32-year-old woman with sigmoid volvulus associated with fetal demise that came during labor and we discuss the management options.

Uncommon presentation of Meckel's diverticulum in a child with decompensated hypovolemic shock

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract and may cause serious complications such as intestinal obstruction, gastrointestinal hemorrhage, or inflammation with/without perforation, which can present with non-spe-cific symptoms and signs. We report on the case of a 2.5-year-old boy admitted to our emergency department in poor condition, with compatible signs of decompensated hypovolemic shock. This case finally resulted in intestinal volvulus and internal hernia, a very rare combination of two complications of MD, as determined in the operating room.

Caecal volvulus in a foramen of Winslow hernia

Caecal herniation through the foramen of Winslow is an uncommon presentation of internal hernia with an estimated overall incidence of 0.02%. Even rarer still is a caecal volvulus strangulated in the lesser sac, a surgical emergency seldom described in the literature. A woman in her 70s presented with a 1-day history of acute-onset right upper quadrant and epigastric pain associated with nausea and vomiting. Prompt CT imaging revealed caecal volvulus within a foramen of Winslow hernia. The diagnosis was confirmed by laparotomy. A right hemicolectomy was performed and the foraminal defect was closed. We identified eight case reports of this rare entity published within the last 30 years. Our patient was managed in a similar manner and recovered without complication, providing further guidance for the operative management of caecal volvulus in the foramen of Winslow.

Diagnosis and management of intestinal rotational abnormalities with or without volvulus in the pediatric population

Intestinal malrotation is a congenital anomaly that can be associated with midgut volvulus, requiring an emergent operation in order to maintain blood supply to the compromised intestine. It results from an abnormal rotation of the intestines, leading to three types of malrotation. Non-rotation is complete failure of the intestines to rotate, while the most common configuration is associated with the cecum in the mid-upper abdomen, close to a malpositioned duodenal-jejunal (DJ) flexure. This configuration has a narrow mesentery that has a high risk of volvulus. The final form of malrotation is incomplete rotation, where the DJ flexure and cecum are malpositioned, but the mesentery is not narrowed. The benefits of performing a Ladd's procedure for these individuals is controversial. Workup for malrotation should be considered in all patients who present with abdominal pain/distention and bilious emesis. An upper gastrointestinal contrast study is 93-100% sensitive and will show a corkscrew appearance when a volvulus is present. While the basic tenets of the Ladd's procedure have not changed and include detorsion of a volvulus, adhesiolysis of Ladd's bands and broadening of the mesentery, how this is accomplished and in whom are controversial. Laparoscopic Ladd's is associated with shorter hospital stays but also has a higher incidence of recurrent volvulus compared to an open approach. Patients with heterotaxy syndrome also represent a controversial group with some studies showing no difference in post-operative complications despite a higher mortality due to underlying cardiac disease, while other studies show a low incidence of volvulus and question the need for Ladd's in those who are asymptomatic. This review highlights the major aspects of diagnosing and treating malrotation, including the pathophysiology, workup, surgical options and areas of controversy.

A rare case of an iatrogenic superior mesenteric arteriovenous fistula following surgery for a midgut volvulus

Superior mesenteric arteriovenous fistula is an extremely rare vascular malformation with most cases occurring following abdominal trauma or surgery. They are often asymptomatic or present with various abdominal symptoms with or without features of portal hypertension. A 30-year-old man developed fistulising of the superior mesenteric artery into the superior mesenteric vein following bowel resection surgery for an acquired midgut volvulus. Although endovascular management remains the treatment of choice in such cases due to increased morbidity of a repeat abdominal surgery, definite risks remain, such as coil migration, which happened in this case. The open surgical approach remains the only option in such instances.

Dilemma of sigmoid volvulus management

INTRODUCTION

Patients with sigmoid volvulus (SV) are at a high risk of recurrence with increased morbidity and mortality. This study aims to review whether patients with SV underwent definitive surgical treatment after initial endoscopic reduction according to the guidelines, and to compare mortality rate between surgical and conservative management.

METHODS

Retrospective study conducted at East Kent Hospitals University NHS Foundation Trust, included all patients with SV between 2016 and 2018. The primary outcome was 30-day mortality following the initial management of the acute attack. Secondary outcomes were recurrence rate and overall mortality. The median follow-up period was 3 years.

RESULTS

A total of 40 patients were identified with a median age of 82 years; 27 (67%) were males. Of these 40 patients, 6 (15%) had emergency surgery, 26 (65%) received endoscopic decompression only, and 8 (20%) had planned definitive resection; 32 patients (80%) had recurrence and the median interval between any two episodes was 86 days. The mortality rate among patients with ASA grade 3 or 4 in the three groups, elective surgery, emergency surgery and decompression only, was 0%, 25% and 70% respectively, whereas it was 0%, 50% and 33% in those with ASA grade 2. The mortality rate among patients with similar ASA who had a planned surgery was significantly lower compared with those who did not undergo surgery (p=0.003).

CONCLUSIONS

In patients with sigmoid volvulus, regardless of ASA grade, performing early definitive surgery following initial endoscopic decompression resulted in a statistically significant lower mortality rate.

Non-invasive treatment of sigmoid volvulus in a child. The role of the endoscopist

Sigmoid volvulus (SV) is a rare cause of intestinal obstruction in children. Its varied presentation and rapid progression engender a high risk of morbidity and mortality. We report two cases of SV in teenage boys. Patient 1 is 16 years old and patient 2 is 17. Both presented to our institution with recent-onset abdominal pain, constipation, and nausea and vomiting, and both had previous episodes of SV. Patient 1 had been surgically treated with manual derotation, and patient 2, who had redundant colon, had two past episodes of endoscopically-treated SV. Both patients were in poor condition and had distended but treatable abdomens, with no peritoneal signs. After computed tomography (CT) confirmation of the clinical impression of no ischemia or perforation, we decided to attempt detorsion of the SV and decompression of proximal dilated colon by flexible endoscopy, and planned for elective surgery shortly after the endoscopic procedure. Because sigmoid volvulus is so rare in children, operative and technical details of endoscopic management are gleaned from the larger adult experience. In patients without signs of complication, initial endoscopic reduction is the gold standard, and elective sigmoid resection with primary anastomosis is often required to prevent recurrence. KEY WORDS: Case report, Children, Endoscopy, Endoscopic treatment, Sigmoid volvulus, Volvulus.

Evaluation of the predictability of clinical and radiological findings in the diagnosis of malrotation

BACKGROUND

To evaluate the predictability of clinical and radiological findings in the diagnosis of malrotation.

METHODS

Between 2010 and 2020, children with presumptive diagnosis of malrotation were included. The demographic features, clinical and radiological findings, operative findings and outcome were recorded. The upper gastrointestinal series (UGIS) were evaluated by two radiologists. All parameters were correlated with surgical findings to evaluate the predictability.

RESULTS

Seventy patients were included. The presenting symptom was bilious vomiting in 29 cases (41.4%), and atypical symptoms (non-bilious vomiting, food refusal, etc.) in 40 cases (57%). One of the cases (1.6%) was asymptomatic and diagnosed incidentally during UGIS. 52 cases had abdominal X-ray and 14 (26.9%) of them were normal. Doppler ultrasonography (US) (n=20) revealed evidence of malrotation in 13 cases (65%). The location of duodenojejunal junction (DJJ) in UGIS was compatible with malrotation in 33 cases. 48 (61%) cases underwent surgical exploration; 35 cases had malrotation and seven cases had midgut volvulus. Median followup time was one year (0.5-7 years). Volvulus has recurred in one case and another case operated for volvulus died because of short bowel syndrome. The statistical analysis for predictability revealed that bilious vomiting (sensitivity: 57.1%, specificity: 82.1%), Doppler US (sensitivity: 92.3%, specificity: 75%) and right-sided DJJ in UGIS (sensitivity: 96.8%, specificity: 75%) have highest predictability.

CONCLUSIONS

The bilious vomiting, Doppler US findings and right-sided DJJ have the highest predictability to confirm the diagnosis. However, presenting with atypical symptoms and having atypical or normal findings in UGIS do not rule out malrotation.

[Internal herniationand ileus caused by intestinal malrotation and Ladd's band in an adult]

Midgut malrotation and internal herniation due to Ladd's band in adults is sparsely described. Due to the low incidence and the uncharacteristic symptoms, the diagnosis and treatment is often delayed causing increased morbidity. In this case report, a 68-year-old man was hospitalised with severe abdominal pain. A computed tomography showed abnormal placement of the small bowel loops and torsion of the small bowel mesentery. He underwent a laparoscopic procedure which revealed internal herniation due to a Ladd's band. He recovered uneventfully, and an elective Ladd's procedure was scheduled.

Five Hundred Patients With Gut Malrotation: Thirty Years of Experience With the Introduction of a New Surgical Procedure

OBJECTIVES

Define clinical spectrum and long-term outcomes of gut malrotation. With new insights, an innovative procedure was introduced and predictive models were established.

METHODS

Over 30-years, 500 patients were managed at 2 institutions. Of these, 274 (55%) were children at time of diagnosis. At referral, 204 (41%) patients suffered midgut-loss and the remaining 296 (59%) had intact gut with a wide range of digestive symptoms. With midgut-loss, 189 (93%) patients underwent surgery with gut transplantation in 174 (92%) including 16 of 31 (16%) who had autologous gut reconstruction. Ladd's procedure was documented in 192 (38%) patients with recurrent or de novo volvulus in 41 (21%). For 80 patients with disabling gastrointestinal symptoms, gut malrotation correction (GMC) surgery "Kareem's procedure" was offered with completion of the 270° embryonic counterclockwise-rotation, reversal of vascular-inversion, and fixation of mesenteric-attachments. Concomitant colonic dysmotility was observed in 25 (31%) patients.

RESULTS

The cumulative risk of midgut-loss increased with volvulus, prematurity, gastroschisis, and intestinal atresia whereas reduced with Ladd's and increasing age. Transplant cumulative survival was 63% at 10-years and 54% at 20-years with best outcome among infants and liver-containing allografts. Autologous gut reconstruction achieved 78% and GMC had 100% 10-year survival. Ladd's was associated with 21% recurrent/de novo volvulus and worsening (P > 0.05) of the preoperative National Institute of Health patient-reported outcomes measurement information system gastrointestinal symptom scales. GMC significantly (P ≤ 0.001) improved all of the symptomatology domains with no technical complications or development of volvulus. GMC improved quality of life with restored nutritional autonomy (P < 0.0001) and daily activities (P < 0.0001).

CONCLUSIONS

Gut malrotation is a clinicopathologic syndrome affecting all ages. The introduced herein definitive correction procedure is safe, effective, and easy to perform. Accordingly, the current standard of care practice should be redefined in this orphan population.

Initial Computed Tomography Findings of Long and Distended Colon Are Risk Factors for the Recurrence of Sigmoid Volvulus

BACKGROUND

Sigmoid volvulus is a common condition in elderly patients with elongated colons. Although endoscopic de-torsion is effective as the primary treatment of sigmoid volvulus, elective surgery is recommended because of the high risk of recurrence and high mortality rate.

AIM

The aim of this study was to determine the risk factors for the recurrence of sigmoid volvulus.

METHODS

Clinical records of patients treated at Shimane Prefectural Central Hospital were reviewed retrospectively. Among 41 sigmoid volvulus patients who were successfully treated by endoscopic de-torsion and followed up, 30 were observed over 1 year. Among the 30 patients, eight (26.7%) did not experience recurrence, while 22 (73.3%) did. Initial computed tomography (CT) findings indicating the sigmoid colon extending to the diaphragm or ventral to the liver were defined as "extension findings." Extension findings and sigmoid diameter were evaluated in relation to sigmoid volvulus recurrence.

RESULTS

Extension findings were significantly more frequent in the recurrent group (77.3%) than in the nonrecurrent group (25.0%) (P = 0.009). Distended sigmoid colon diameter was significantly larger in the recurrent group (11.7 ± 3.8 cm) than in the nonrecurrent group (7.1 ± 1.1 cm) (P = 0.044). Receiver operating characteristic curve analysis demonstrated that the performance threshold was greater than 8.9 cm. Kaplan-Meier analysis showed the significantly high sigmoid volvulus recurrence rate in the patients with extension findings and a distended sigmoid colon greater than 8.9 cm.

CONCLUSIONS

CT findings of a long and distended sigmoid colon in initial sigmoid volvulus are risk factors for the recurrence of sigmoid volvulus.

Rare case of rectosigmoid stricture causing transverse colon volvulus

A 60-year-old woman with remote history of sleeve gastrectomy presented with altered mental status after an unwitnessed fall. She was found to be hypothermic with lactic acidaemia, leucocytosis, positive urinalysis, and dilated ascending and transverse colon on cross-sectional imaging, initially thought to be secondary to faecal loading. She was admitted to the medical intensive care unit for resuscitation and broad-spectrum antibiotics for presumed urinary sepsis. She became acutely altered and underwent urgent flexible sigmoidoscopy by gastroenterology to evaluate for ischaemic colitis. During the procedure, there was concern for iatrogenic colon injury given the friability of the colonic mucosa, so the patient was taken urgently for exploratory laparotomy. Intraoperatively, she was found to have a transverse colon volvulus with large areas of patchy, gangrenous bowel without evidence of gross perforation. A rectosigmoid stricture with associated serosal tear, but no full-thickness injury was identified. An extended left hemicolectomy and end transverse colostomy was performed resulting in improvement in the patient's clinical status and eventual discharge to subacute rehab.

Cecal Volvulus Resolved Spontaneously

Cecal volvulus is an uncommon cause of colonic obstruction. First-line treatment for cecal volvulus is surgery, as nonoperative management is rarely achievable. We herein report an extremely rare case of a patient with spontaneously resolved cecal volvulus; no recurrence occurred without elective surgery. A 47-year-old woman presented with acute lower abdominal pain. She was misdiagnosed with small bowel obstruction and treated conservatively. A few hours later, she was correctly diagnosed with cecal volvulus. Subsequently, her symptoms and computed tomography findings of cecal volvulus completely disappeared. She refused elective surgery, but no recurrence occurred during five months of follow-up.

Caecal volvulus: untwisting the mystery

Caecal volvulus is an infrequent cause of acute surgical abdomen, where an abnormally mobile cecum twists on its own axis. It can lead to the development of closed-loop obstruction, small bowel ischaemia and perforation. Early recognition and prompt treatment is key; however, due to the rarity of this pathology, it is seldom listed as a differential diagnosis. Here, we present a single-centre case series of two patients presenting with caecal volvulus to an Emergency Surgery Unit at a University Hospital.

Redundant mesocolonic mesentery in a Shire colt

An unusual condition in a 3-month-old Shire colt presented for colic unresponsive to medical therapy is documented in this report. A redundant mesocolonic mesentery resulting in intestinal displacement and volvulus was diagnosed during exploratory celiotomy. The finding was presumed to be congenital, resulting in a loose anatomic configuration that predisposed the intestine to displacement, torsion, volvulus, and entrapment. Key clinical message: This case demonstrates that congenial anatomical anomalies should be included in the differential of younger animals presented for recurrent conditions and highlights the use of exploratory celiotomy to reach a definitive diagnosis.