Caecal Volvulus in Pregnancy: Is Delay in Diagnosis Avoidable?

Cecal volvulus in rural Kenya: delayed presentation contributes to high mortality

Background

Cecal volvulus, which is a torsion involving the cecum, terminal ileum, and ascending colon around its own mesentery, results in a closed-loop obstruction. It is a rare reported cause of adult intestinal obstruction. This study aimed to review the clinical presentation, management, and outcomes at a rural, resource-limited referral center.

Methods

We performed a retrospective review of all patients with a diagnosis of cecal volvulus between January 1st, 2009 and December 31st, 2019 at Tenwek Hospital in Bomet, Kenya. The outcome of survival was compared by the time to presentation. Mortality was also compared with prior reports of intestinal obstruction at our institution.

Results

Thirteen patients were identified with a mean age of 52 years and a mean symptom duration of 5 days. All patients presented with abdominal pain and distension. Seven patients (54%) presented with perforation, gangrene, or gross peritoneal contamination. Identified risk factors were Ladds bands with malrotation, adhesions, and a sigmoid tumor. Procedures included primary resection and anastomosis (7), damage control (3) with anastomosis on second-look in 2 of these, simple surgical detorsion (1), and surgical detorsion and cecopexy (2). There were four mortalities (31%), of which all had delayed presentation with perforation and fecal contamination. Delays to presentation were associated with mortality (p = 0.03). Cecal volvulus resulted in increased perioperative mortality compared to all intestinal obstructions presenting to the institution (p < 0.0001).

Conclusions

Cecal volvulus carries a high risk of mortality. A high index of suspicion and early consideration in the differential diagnosis of intestinal obstruction should be considered to reduce the mortality associated with the delay in preoperative diagnosis.

Atypical presentation of ileocecal volvulus in a postpartum woman: a case report

Volvulus appears with unusual symptoms in pregnancy and postpartum, and if the clinicians do not consider it, the patient becomes complicated quickly. It seems that volvulus may cause obstetrics complications such as preterm delivery.

Vólvulo del ciego, una entidad infrecuente como causa de abdomen agudo en embarazadas: Reporte de caso clínico y revisión de la literatura

Introducción. El vólvulo cecal en el embarazo es una patología infrecuente a nivel mundial, con un espectro clínico variado y limitación en estudios diagnósticos, lo que puede resultar en un desenlace ominoso. Caso clínico. Se presenta el caso de una gestante en segundo trimestre del embarazo quien presenta abdomen agudo secundario a vólvulo cecal y sufrimiento fetal. La paciente fue llevada a cesárea de urgencia, donde además se practicó cecectomía y anastomosis íleo transversa, con mortalidad fetal. Discusión. El vólvulo cecal forma parte de los diagnósticos diferenciales en caso de abdomen agudo durante el embarazo. Tiene un pronóstico reservado, en donde pueden presentarse desenlaces maternos y perinatales adversos, con mortalidad maternofetal.

Mid-gut volvulus and mesenteric vessel thrombosis in pregnancy: case report and literature review

BACKGROUND

Mid-gut volvulus is a rare complication of pregnancy, where torsion of the small bowel around its mesentery can result in extensive bowel infarction. To our knowledge, there has been no previous reported case of mid-gut volvulus and mesenteric vessel thrombosis managed without bowel resection.

CASE

A 25-year-old woman presented at 35 + 3 weeks gestation with constant abdominal pain. There was no past medical history of abdominal surgery. The patient later developed feculent vomiting. Exploratory laparotomy revealed a mid-gut volvulus causing small bowel ischaemia, which extended from the duodenojejunal (DJ) flexure to the terminal ileum. There was also mesenteric arterial and venous thrombosis. A healthy baby girl was delivered by caesarean section and the mid-gut volvulus was reduced. Further, two re-look laparotomies confirmed viable bowel following detorsion. The mesenteric vessel thrombosis was treated with intravenous heparin. The patient went on to make a full recovery.

CONCLUSIONS

As shown in this case, the volvulus and mesenteric vessel thrombosis may occur during pregnancy even in patients without previous history of coagulopathies and abdominal surgery. It is difficult to make a clinical diagnosis, as the symptoms, physical signs and laboratory findings can be misleading. Therefore, a high index of suspicion is necessary for the early diagnosis of these conditions, as prompt treatment can prevent bowel resection and improve maternal and foetal outcomes.

Cecal volvulus in a multiple-gestation pregnancy

BACKGROUND

Intestinal obstruction during pregnancy is rare, with volvulus being responsible for about 25% of cases.

CASE

We present a case in which a woman in the 12th week of a twin gestation presented with abdominal pain and distension. She was initially diagnosed with an ileus, and radiological studies at the time were deferred. The patient's symptoms worsened, and eventually she was taken to surgery for a diagnostic laparoscopy, which revealed a cecal volvulus with ischemic changes. A right hemicolectomy with primary anastomosis was performed.

CONCLUSION

Volvulus in pregnancy carries a high mortality rate, often because diagnosis is delayed due to avoidance of radiography and because of similarity of symptoms to other clinical entities. A high index of suspicion for volvulus must be maintained when a pregnant patient presents with obstructive symptoms. Abdominal radiographs may be justified in aiding the diagnosis, and diagnostic laparoscopy is a viable alternative when the patient has an acute abdomen.

Volvulus in Pregnancy: A Diagnostic Dilemma

In this case report, we describe a pregnant female patient at 27 weeks' gestation with a rare complication of volvulus. Her initial symptom was acute cramping pain of the lower right abdomen. Surgical intervention was performed under the impression of peritonitis. Pathologic diagnosis revealed volvulus of the mid ileum. The remainder of her pregnancy was uneventful. The physiologic changes of pregnancy may predispose the parturient to bowel obstruction due to compression of the gravid uterus against the intestine. If volvulus is suspected, then emergent surgery should be performed. Delays in treatment may result in septic shock and even death. We present this case to remind obstetricians of such rare causes of acute abdomen during pregnancy.