Volvulus of the transverse colon in an octogenarian veteran

Transverse colon volvulus and the wandering liver

INTRODUCTION AND IMPORTANCE

Transverse colon volvulus is a rare cause of colonic obstruction accounting for 1-3 % of colonic volvuli due to the short mesentery and hepatic and splenic attachments. Previous mobilisation of the flexures and conditions resulting in chronic dilatation of the colon predispose to the condition. The risk of mortality is high, ranging from 11 to 20 % highlighting the need for early diagnosis and intervention.

CASE PRESENTATION

We present a case of a 90-year-old male who was referred with a large bowel obstruction with a transition at the splenic flexure and the liver rotated to the left upper quadrant. The patient was taken to the theatre and an emergency laparotomy was performed with findings of a transverse colon volvulus. The liver was initially found in the left upper quadrant and was freely mobile in the upper abdomen consistent with an absence of the hepatic ligament. A subtotal colectomy was performed. Unfortunately, the postoperative course was complicated by a cardiac event and the patient died on postoperative day six.

CLINICAL DISCUSSION

Absence of hepatic ligaments is a rare cause of transverse colon volvulus which has only been described in one previous case report. Diagnosis of transverse colon volvulus can be challenging and early operative intervention with colectomy is required to minimise mortality.

CONCLUSION

This case illustrates an unusual cause of transverse colon volvulus secondary to the absence of the hepatic ligaments and stresses the need for early diagnosis and intervention due to the high mortality associated with this condition.

Cecal perforations due to descending colon obstruction (closed loop): a case report and review of the literature

BACKGROUND

Cases of large bowel closed-loop phenomenon with cecal perforation are extremely rare, especially when extracolonic epiploic appendage and peritoneal bands are the cause. However, sporadic cases exist in the literature with various presentations, but very few occur in patients in the abdomen without a previous scar.

CASE PRESENTATION

An 89-year-old Sudanese farmer was admitted to the emergency department with 9-day history of generalized colicky abdominal pain, abdominal distension, anorexia, persistent vomiting, and constipation. Given his clinical presentation and assessment, he was diagnosed with peritonitis due to a perforated viscus in a virgin abdomen. Operative exploration revealed an extraluminal left-sided omento-epiploic band that resulted in closed-loop colonic obstruction with secondary multiple cecal perforations. Standard right hemicolectomy with adhesiolysis was done. Postoperative wound infection and hypoalbuminemia were treated, and the patient was discharged on postoperative day 9 on a regular oral diet.

CONCLUSIONS

Although this condition is rare, it can be extremely dangerous, requiring prompt investigation and surgical intervention. It usually occurs secondary to raised intraluminal pressure with subsequent ischemia of the cecal wall. Through this case report, we aim to reflect on this rare experience, shedding light on the benign, extracolonic pathologies that can be life threatening or even fatal.