Rare Pediatric Cecal Anomalies: A Lesson in Pediatric Surgery

BACKGROUND

Rare incidence cases are part of the routine work of pediatric surgeons. Cecal anomalies in children are an example of such cases. Objectives: To describe the presentation, workup, management and outcome of rare cecal anomalies in children and to analyze the skills needed for their successful treatment.

METHODS

A retrospective chart review was conducted of all cases of cecal anomalies managed by the pediatric surgical service at a tertiary hospital from June 2017 to January 2020. Data regarding demographics, clinical presentation, radiological studies, surgical treatment, pathology, complications, and outcome were collected.

RESULTS

Five cases of cecal anomalies were encountered over a period of 32 months, including a cecal volvulus, cecal duplication, cecal intussusception, and two cecal masses (one ulcerated lipoma and one polyp). All patients, except the patient with cecal duplication, presented acutely and were managed surgically. Long-term follow-up of 17-24 months was unremarkable in all cases.

CONCLUSIONS

A wide knowledge base, careful judgment, and creativity enable pediatric surgeons to successfully treat rare conditions such as rare cecal anomalies. These skills should be part of the education of pediatric surgery trainees.

Fryns anophthalmia-plus syndrome: two rare cases

Fryns anophthalmia-plus syndrome is a rare syndrome with clinical diversity primarily including anophthalmia/microphthalmia, facial clefts, cleft lip/palate, ear and nasal deformities. Here we present two different cases of APS with anopthalmia/microphthalmia, cleft palate, low set ears, ventriculomegaly and one of which had intestinal non-fixation anomaly not described in the literature before.

Caecal duplication cyst mimicking intussusception

Cystic caecal duplication is a rare congenital anomaly. We report a case of an infant, who presented with bilious vomiting and abdominal distension. On ultrasonography, intussusception with a cyst as a lead point was present in the right iliac fossa. On exploration, there was no evidence of intussusception, only caecal duplication cyst was found. To date, only three cases of caecal duplication which mimicked intussusception have been reported in the English literature.

Different clinical presentations, diagnostic difficulties, and management of cecal duplication

BACKGROUND

Cecal duplications (CDs) are very rare, representing 0.4% of all gastrointestinal duplications. This study evaluates the variable clinical presentations, imaging workup, and surgical management of CDs.

METHODS

The records of 7 patients who underwent surgery between April 2001 and December 2011 for CD were retrospectively reviewed. Sex, age, duration of complaints, diagnostic studies, surgical intervention, and pathologic findings were recorded.

RESULTS

The median age was 8 months, and mean age was 1.65 ± 2.88 years. Complaints were abdominal pain, rectal bleeding, vomiting, cough and dyspnea, and a prenatally detected cystic mass. The patients were referred with the diagnosis of appendicular abscess, necrotizing enterocolitis, gastrointestinal lymphoma, and intraabdominal cystic mass. Abdominal distention, signs of peritonitis, substernal retraction, fullness at right lower quadrant, and normal findings were detected on physical examination. Diagnostic imaging included plain abdominal radiography (7), ultrasonography (7), computed tomography (3), and magnetic resonance imaging (2). A cystic mass was reported on radiologic studies in 6 patients and appendicular abscess in 1. Cyst and cecum were resected, ileocolostomy was performed in 6 patients, and cyst excision was performed in 1. The diagnosis of duplication cyst was made by pathologic examination in all patients.

CONCLUSIONS

Cecal duplications may be detected incidentally; however, they may mimic appendicular abscess, a tumor mass, or necrotizing enterocolitis. Whether cystic lesions are symptomatic, they should be excised when detected because of possible complications.

FGF9-Pitx2-FGF10 signaling controls cecal formation in mice

Fibroblast growth factor (FGF) signaling to the epithelium and mesenchyme mediated by FGF10 and FGF9, respectively, controls cecal formation during embryonic development. In particular, mesenchymal FGF10 signals to the epithelium via FGFR2b to induce epithelial cecal progenitor cell proliferation. Yet the precise upstream mechanisms controlling mesenchymal FGF10 signaling are unknown. Complete deletion of Fgf9 as well as of Pitx2, a gene encoding a homeobox transcription factor, both lead to cecal agenesis. Herein, we used mouse genetic approaches to determine the precise contribution of the epithelium and/or mesenchyme tissue compartments in this process. Using tissue compartment specific Fgf9 versus Pitx2 loss of function approaches in the gut epithelium and/or mesenchyme, we determined that FGF9 signals to the mesenchyme via Pitx2 to induce mesenchymal Fgf10 expression, which in turn leads to epithelial cecal bud formation.

Adenocarcinoma arising in a duplication of the cecum

Intestinal duplications are rare developmental abnormalities that may occur anywhere in the gastrointestinal tract. The possibility of a malignant change occurring in these duplications is very low. We present a case of adenocarcinoma arising in a duplication of the cecum. A 41-year-old male patient was admitted because of a palpable abdominal mass. Abdominal computed tomography revealed a 6-cm, peripheral wall-enhanced, round, cystic mass in the cecal area. Excision of the mesenteric mass and a right hemicolectomy was performed. Upon histologic examination, the patient was diagnosed with adenocarcinoma arising in a duplication of the cecum.

Cecum duplication in a 14-year-old female. Case report

BACKGROUND

Duplications of the alimentary tract are a group of rare malformations occurring in about 1/5,000 live births. These may be either spherical or tubular and may communicate with the intestinal tract. Duplications of the cecum are very uncommon.

CLINICAL CASE

A 14-year-old female was admitted to the emergency department with a 1-day history of abdominal pain, vomiting, constipation and abdominal distension. Abdominal examination revealed distension and tenderness around the umbilicus. Plain abdominal radiography showed dilated colon. The patient underwent surgical management with diagnosis of sigmoid volvulus. Laparotomy revealed spherical duplication from the cecum. Hemicolectomy was done and alimentary continuity was restored by end-to-end anastomosis. Pathological report was a spherical communicated duplication from the cecum (22 × 32 cm).

CONCLUSIONS

Duplication of the cecum is extremely rare and is seen in 0.4% of duplications of the alimentary tract. The majority of cases (85%) are diagnosed before age 2 years. It is rare at 14 years of age. Diagnosis is difficult and volvulus, intussusception or appendicitis should be considered in the differential diagnosis. Ultrasonography and tomography are the imaging studies of choice. Plain abdominal x-ray is not specific. Resection of the duplication with restoration of alimentary continuity is the treatment of choice.

[Abdominal pain caused by mobile caecum with strangulation]

An 84-year-old woman was admitted to the emergency department of the St. Elisabeth Hospital in Curaçao for acute diffuse abdominal pain. Her medical history revealed an 'irritable bowel syndrome' with symptoms of chronic progressive abdominal pain. Plain abdominal radiography and computed tomography showed a substantially dilated bowel with torsion of the organ structures and suspected strangulation of the colon. Perioperative examination revealed a distended mobile caecum and right hemicolon. There was also strangulation and herniation of both structures through the foramen of Winslow around the hepatoduodenal ligament, protruding through the minor omentum. After destrangulation and closure of the herniation a caecopexy with an additional appendectomy was performed. Mobile caecum is defined as a failure of the right colon to fuse to the posterior parietal peritoneum. The symptoms of chronic abdominal pain may have been the result of the pre-existing mobile caecum.

Cecal volvulus in situs inversus totalis accompanied with pancreatic malrotation

Situs inversus totalis is a rare anomaly that is characterized by mirror image anatomy of the abdominal and thoracic organs. This anomaly is often discovered incidentally in adults during an emergent surgical procedure or by radiologic investigations performed for other medical reasons. Cecal volvulus is a surgical emergency requiring urgent laparotomy. Coexistence of these two abnormalities poses a challenge in establishing a definitive diagnosis because of the alteration of normal anatomy; this may cause a delay in emergent surgical intervention. We present a case of situs inversus totalis complicated by cecal volvulus. In our case, a different type of pancreatic malrotation, which we called "folded", also accompanied these abnormalities. To our knowledge, this is the first case in the literature involving situs inversus totalis, cecal volvulus, and a "folded" type of pancreatic malrotation.

Papillary adenocarcinoma arising in a duplication of the cecum

Malignant carcinomatous change is a rare complication in an enteric duplication cyst, and papillary adenocarcinoma is especially unusual. We describe a papillary adenocarcinoma, arising from a duplication of the colon, seen as a cyst with an enhancing papillary projection nodule located adjacent to the wall of the ascending colon and cecum on computed tomography.

A case of split notochord syndrome with congenital ileal atresia, the total absence of a colon, and a dorsal enteric cyst communicating to the retroperitoneal isolated ceca with a vesical fistula

Split notochord syndrome (SNS) is an extremely rare anomaly. This report presents the case of a male infant with SNS associated with congenital ileal atresia and a dorsal enteric cyst communicating to the retroperitoneal isolated ceca with a vesical fistula. Dorsal fistulography and vesicography were useful and essential for the detailed study of the topology in this patient. The embryological mechanism and etiologic theories are discussed with a review of 19 cases reported in the literature.

The ileocaecal knot

Variations in intestinal knot syndromes have been described in the past, including ileoileal knots, ileosigmoid knots and appendico-ileal knots. We report a new type of intestinal knot syndrome, an ileocaecal knot, which, to our knowledge, has not been reported before in the world literature. Features on CT that may raise suspicion of an ileal knot syndrome are described.

Intussusception due to a cecal duplication cyst: a rare cause of acute abdomen. Case report

Duplications of the alimentary tract are rare congenital anomalies. The ileum is the most common site, whereas rectal, duodenal, gastric and cecal duplications are extremely rare. Duplication cysts of the cecum, in a neonate, are even rarer, with only 19 cases reported in medical literature to date. We report a case of intestinal intussusception due to a cecal duplication cyst.

Spectrum of normal and abnormal CT appearances of the ileocecal valve and cecum with endoscopic and surgical correlation

Because of advances in imaging technology, evaluation of the gastrointestinal tract is increasingly being performed with cross-sectional imaging (eg, computed tomographic [CT] colonography, CT enterography). However, the diagnosis of disease involving the ileocecal valve (ICV), cecum, and appendix with CT can be challenging. The normal ICV can have many different appearances, depending on cecal distention and mobility, whether the valve is open or closed, and inherent variable morphologic characteristics. In addition, flat cecal lesions are difficult to detect, and larger masses are sometimes mistaken for the ICV or residual stool. Familiarity with the typical appearances of the normal anatomy and various pathologic conditions of the gastrointestinal tract on two- and three-dimensional cross-sectional images is useful in making the correct diagnosis.

Unusual hindgut malrotation and associated mesenteric vascular abnormality presenting as large bowel obstruction in an adult

We report an unusual and not previously described congenital hindgut malrotation presenting as large bowel obstruction in an adult.

[Anatomo-clinical comparison: caecal duplication cyst]

Enteric duplication cysts, and particularly caecal duplication cysts, are rare and generally benign congenital anomalies for which a diagnosis is difficult to make because they mimic other surgical diseases. A surgical management is the treatment of choice. The diagnosis can then be made or confirmed by histopathologic analysis.

A case with undescended testis, left pelvic kidney and gut malrotation

We describe here an autopsy case presenting bilateral cryptorchidism, left pelvic kidney and intestinal malrotation, evoking a "reverse rotation" with hypoplasia of the cecum. Furthermore, the colon showed alternate bands of stenosis and dilatation. This association has not yet been described, and is discussed in the light of the embryological events of kidney, gut and gonad development. Two hypotheses can explain gut stenoses (vascular consequences of the malrotation and type Hirschprung aganglionic segments).

[Intestinal barotrauma after diving--mechanical ileus in incarceration of the last loop of the small intestine between a mobile cecum and sigmoid]

A few hours after a self-contained underwater breathing apparatus (SCUBA) dive at 30 meters depth, a 49 years-old man complained of diffuse abdominal pain with nausea and vomitus. A laparotomy was performed 36 hours after a conservative treatment because of persistent mechanical small bowel obstruction. The last ileal loop was strangulated between a mobile ceacum and a long sigmoid loop. The man never had previous abdominal surgery. In absence of intestinal necrosis, a caecopexy was done and there was no post-operative complications. The gas distension during the ascension following the Boyle-Mariotte law and its distribution induced in this man with a special anatomy a mechanical small bowel obstruction. The treatment of mobile caecum and the literature of abdominal barotrauma is reviewed.

Unusual case of Morgagni hernia associated with malrotation

Morgagni herniae are rare congenital diaphragmatic hernia, which normally present late in adult life with minimal symptoms. They are always associated with a peritoneal hernial sac, and often contain transverse colon or stomach. We present an unusual case of a Morgagni hernia containing caecum in an 81-year-old woman, post ruptured aortic aneurysm repair.

Prenatal sonographic findings of congenital duplication of the cecum

BACKGROUND

Alimentary tract duplications are rare congenital lesions that may arise at any location throughout the gastrointestinal tract. The most common site of enteric duplications is the ileum, with only 13% of cases occurring in the colon.

CASE

Prenatal sonography at 39 weeks' gestation showed a cystic structure with thick walls exhibiting clear peristaltic movements in the right lower fetal abdomen. Inner walls of the cystic structure had small folds suggestive of colonic haustra. The sonographic findings and location of the finding were consistent with duplication of the colon and, possibly, the cecum. Congenital duplication of the cecum was proven at neonatal laparotomy. Ileocecal resection with ileocolonic anatomosis was performed and congenital duplication of the cecum confirmed by pathology examination of the resected specimen.

CONCLUSION

Unusual sites of alimentary tract duplications detected by prenatal ultrasound include the cecum.

[Experience in examining the small bowel with the agent Enteroview]

The paper presents data of small bowel X-ray study in 20 patients by using the contrast agent Enteroview. Thirteen patients were found to have changes typical of chronic enteritis (n = 9); atypical location of the cecum and inflammatory ileocecal lesion (n = 2); Peutz-Jeghers syndrome (n = 10); Crohn's disease (n = 1). The X-ray semiotics of the normal and abnormally changed small bowel is given. The advantages of Interview during X-ray study are shown.

Massive lower gastrointestinal bleeding due to Dieulafoy lesion of colon

A 25-year-old man with massive lower gastrointestinal bleeding underwent emergency mesenteric angiography. An actively bleeding lesion was found in the cecum. Right hemicolectomy was performed. Histology revealed a Dieulafoy lesion of the cecum. This is an extremely rare lesion responsible for massive lower GI bleeding.

Meconium thorax: A case of Bochdalek hernia and cecal perforation in a neonate with Job's syndrome

Meconium peritonitis most often is associated with congenital intestinal obstruction and meconium ileus. Uncommonly, other etiologies are identified. Hyperimmunoglobulin E syndrome (Job's syndrome) is a rare genetic disorder that is characterized by recurrent staphylococcal respiratory and skin infections in addition to elevated serum IgE levels. There have been 2 previously reported cases of intestinal complications associated with Job's syndrome. The current case is the third such case and is the first report of meconium peritonitis in a patient with hyperimmunoglobulin E syndrome. The patient presented with a meconium thorax as a result of a concurrent congenital diaphragmatic hernia.

Four-legged broiler chicken with two cloacae and three ceca

This case report examines an Arbor Acres female x Peterson male crossbred 6-wk-old female broiler chicken with four legs, two cloacae, and three ceca. The intestines occupied the caudodorsal portion of the abdominal cavity with three ceca attached to the terminal end of the ileum. The left lateral cecum was larger and had a divided distal end that terminated into 2-cm-long blind sacs. The rectum was dilated and divided into two cloacae that each opened on the dorsolateral aspect of both the right and left cloacal elevator muscles. The two extra legs were attached to the pygostyle by cartilage and skin tissue. Both femoral heads of the extraneous legs were fused together. The extra legs were smaller in size (approximately 17 cm in length) compared with the normal legs (approximately 22 cm). The femoral heads of the two normal legs were disarticulated from the acetabulum.

Cecal duplication causing a disappearing abdominal mass in an infant

Duplications of the alimentary tract are rare malformations. A case of a 2-year-old girl with an intestinal intussusception caused by a cystic duplication of the cecum is presented. This case report is justified by its clinical features and the difficult diagnosis, which was only confirmed during surgery. Ultrasonography had documented an abdominal mass that then disappeared and later reappeared, leading to surgical indication. During surgery, the intussusception within the abdomen was reduced, and right hemicolectomy was performed around the mass in the interior part of the cecum and appendix, with ileocolic anastomosis. On resecting the cecum, a cystic duplication measuring 4 x 3 cm was observed, with a granular mucous layer, an ulcerated hole in its interior, and inflammatory reaction. The patient had an uneventful recovery and was discharged on the fourth postoperative day.

Unusual duplication of appendix and cecum: extension of the Cave-Wallbridge classification

Duplicated appendix has, to date, been classified into 3 types. The authors present a type of duplicated appendix not previously described. Surgical exploration was done in a 14-year-old girl who had an acute abdomen. Surgical exploration showed a duplicated appendix that arose from the normal appendix and ended in a thick-walled, inflamed, perforated muscular pouch. Duplicated appendix is a treatable condition that rarely occurs with colonic duplication and which should be considered in the differential diagnosis of lower abdominal pain.

Cornelia de Lange syndrome associated with cecal volvulus: report of a case

Cornelia de Lange syndrome is known to be occasionally associated with gastrointestinal malformation. However, the occurrence of cecal volvulus in such anomalies is very rare. We report a 15-y-old Japanese boy with Cornelia de Lange syndrome associated with a cecal volvulus secondary to non-fixation of the cecum and ascending colon. The patient was admitted to our hospital because of abdominal pain and bilious vomiting. At emergent laparotomy, cecal volvulus with non-fixation of the ascending colon and cecum was diagnosed. Release of the cecal volvulus and the fixation of the cecum and ascending colon to the right retroperitonium were performed. The postoperative course was uneventful, except for sepsis caused by aspiration pneumonia soon after the operation.

CONCLUSION

Clinicians treating patients with this syndrome should be aware that such patients may be at risk for developing severe gastrointestinal anomalies, including cecal volvulus.

Cystic duplication of the cecum with segmental dilatation of the ileum: report of a case

Duplication cyst and segmental dilatation are rare congenital anomalies of the gastrointestinal tract, both of which are known to result in intestinal obstruction. We describe herein a case of intestinal obstruction in a neonate, caused by a duplication cyst in the cecum. A small dilated segment of ileum was also present at the site where Meckel's diverticulum would be expected, which was not causing obstruction to the luminal contents. Although it is well known that either of these conditions may coexist with a number of congenital malformations, their concurrent occurrence has never been reported before.

Carcinoid tumour in a caecal duplication cyst

Intestinal duplication cysts are rare congenital anomalies that may occasionally undergo neoplastic change. We report the case of a 30-year-old woman who was diagnosed to have a caecal duplication cyst. The cyst was excised and histology revealed the presence of a 10 mm diameter carcinoid tumour within the cyst wall. There was no evidence of metastatic spread and the patient remains well after 2 years follow-up. The 3 previously reported cases of carcinoid tumour arising within duplication cysts are reviewed.

Waugh's syndrome: a report of six patients

Waugh's syndrome (WS) is the association of intussusception and intestinal malrotation. The association has not been widely reported in the literature. In the only prospective study, Brereton et al. reported a high frequency of the association, which suggests non-random association. Six patients with this association presented to our unit over a 4-month period. The clinical findings and management are presented and discussed. We suggest that malrotation by its very nature is associated with a mobile right colon, which may be a prerequisite for intussusception.

[Cecal duplication: unusual cause of acute abdomen in children. Report of a case]

The Authors describe a rare cause of cecal duplication cyst in children: because of the inflammatory clinical finding, an emergency operative intervention is made. Ultrasonic preoperative diagnosis is evaluated.

Misexpression of the pancreatic homeodomain protein IDX-1 by the Hoxa-4 promoter associated with agenesis of the cecum

BACKGROUND & AIMS

The endoderm-specific homeodomain transcription factor IDX-1 is critical for pancreas development and for the regulation of islet cell-specific genes. During development, IDX-1 is expressed in the epithelial cells of the endoderm in the pancreatic anlage of the foregut. The aim of this study was to determine whether IDX-1 may have potential properties of a master homeotic determinant of pancreas and/or gut development.

METHODS

Transgenic mice were generated in which the expression of IDX-1 was misdirected by a promoter of the mesoderm-specific homeodomain protein Hoxa-4 known to express in the stomach and hindgut during development. The expectation was the formation of ectopic pancreatic tissue or alterations of gut patterning or morphology.

RESULTS

Although no ectopic induction of pancreatic markers was found in these transgenic mice, they manifested an altered midgut-hindgut union and agenesis of the cecum. Further, IDX-1 binds to the gut-specific homeodomain protein Cdx-2 and inhibits transactivation of the sucrase-isomaltase promoter by Cdx-2.

CONCLUSIONS

These findings further support the emerging understanding that interactions among different classes of homeodomain proteins, expressed in a spatially and temporally restricted manner during development, determine the pattern of organogenesis. A possible mechanism for the dysmorphogenesis of the proximal colon may be an inhibition of Cdx-2 actions by IDX-1.

Congenital short bowel syndrome associated with appendiceal agenesis and functional intestinal obstruction

Congenital short bowel with functional intestinal obstruction and absence of appendix vermiformis is a very rare condition with poor prognosis. Seventeen cases of congenital short bowel have been reported previously in the literature. The etiology is unknown. In this report, a case of congenital short bowel, combined with functional intestinal obstruction, mal-rotation, and absence of the appendix vermiformis, is presented and the pathogenesis discussed.

Broiler chicken with a duplicated lower intestinal tract

A case is described of a duplicated lower intestinal tract in a broiler chicken. The ileum branched to form two lower intestinal tracts. The ileum of the malformed branch was swollen and attached to paired ceca that were grossly enlarged, and the rectum was a swollen blind sac, disconnected from the exterior of the bird.

Intestinal rotation abnormalities without volvulus: the role of laparoscopy

BACKGROUND

Intestinal rotation disorders may be discovered during investigation for abdominal symptoms. Two questions are raised in this setting: are the patient's symptoms from the rotation abnormality, and is the base of the small bowel mesentery so narrow that it places the patient at risk for midgut volvulus? Previously, laparotomy was necessary to answer these questions, and then it was necessary to do a Ladd procedure and appendectomy if necessary.

STUDY DESIGN

We used laparoscopic surgery to evaluate seven patients, ages 4 days to 23 years of age (median age 7 years), when upper gastrointestinal series revealed intestinal rotation abnormalities without volvulus.

RESULTS

Two patients had nonrotation. One had Ladd's bands across the duodenum that were divided, and the appendix was removed. The other had diffuse peritoneal soilage from a ruptured appendix; irrigation and appendectomy were performed. Three patients had duodenal malrotation and underwent laparoscopic Ladd procedure and appendectomy. Two patients had combined duodenal and cecal malrotation. One of these patients had a previous appendectomy for what in retrospect was primary peritonitis; malrotation was confirmed radiologically after the operation. She underwent a laparoscopic Ladd procedure 3 months later. The other patient was believed to have combined duodenal and cecal malrotation based on radiographic studies performed during workup for gastroesophageal reflux. At laparoscopy the small bowel mesentery was believed to have a broad enough base to prevent midgut volvulus, and an appendectomy was done. No patient required conversion to an open procedure. The sole complication was intra-abdominal abscess in the child with ruptured appendicitis that required prolonged hospitalization and operative abscess drainage. Operative times ranged from 1.25-3.25 hours (median 2 hours). Time to a regular diet was 1-20 days (median 2 days). Resolution of symptoms was seen in 5 of the 7 patients, with a median followup of 15 months.

CONCLUSIONS

Laparoscopy is an excellent technique for the evaluation and definitive management of patients without midgut volvulus with intestinal rotation abnormalities.

The diagnosis of malrotation during air enema procedure

This paper describes the correct diagnosis of cecal malposition, suggesting midgut malrotation, during air enema examination in seven patients. It is possible to diagnose cecal malposition by air enema, even in the presence of a reducible intussusception.

A caecal diaphragm in cystic fibrosis

A right iliac fossa mass may be a difficult diagnostic problem in a patient with cystic fibrosis. We present a patient with such a mass who was thought to have a non-obstructing intussusception on clinical and radiological grounds. However, at laparotomy she was found to have a pathology not previously described in cystic fibrosis. She had a partial diaphragm almost blocking the lumen to her appendix. The differential diagnosis of a right iliac fossa mass is considered and the cause of her pathology discussed.