What are the implications of a dilated cecum following a cesarean (C-section)?

From the Guidelines

A dilated cecum after cesarean section is a concerning finding that requires prompt evaluation and management, with an initial approach including bowel rest, intravenous fluid resuscitation, nasogastric tube decompression, and close monitoring of vital signs, as recommended by the Enhanced Recovery After Surgery Society 1. The initial management should focus on preventing further complications and assessing the degree of cecal dilation.

• Abdominal X-rays or CT imaging should be obtained to assess the degree of cecal dilation, with a cecal diameter greater than 9-12 cm indicating high risk for perforation.
• If the patient is stable without signs of peritonitis, conservative management can be attempted for 24-48 hours, including frequent position changes, ambulation if possible, and rectal tube placement, as part of an enhanced recovery protocol 1.
• The use of regional anesthesia is recommended as part of an enhanced recovery protocol, which may help reduce the risk of postoperative ileus and cecal dilation 1.
• Perioperative and intraoperative euvolemia are important factors in patient perioperative care and appear to lead to improved maternal and neonatal outcomes after cesarean delivery, which may also help reduce the risk of cecal dilation 1. If conservative measures fail or if the patient shows signs of clinical deterioration (increasing pain, fever, leukocytosis), surgical intervention is necessary, with options including cecostomy, cecal plication, or right hemicolectomy depending on bowel viability.
• The prevention of intraoperative hypothermia is also crucial, as it can contribute to postoperative ileus and cecal dilation, and can be achieved through the use of forced air warming, intravenous fluid warming, and increasing operating room temperature 1. This condition likely results from a combination of factors including decreased bowel motility from anesthesia, narcotic pain medications, and manipulation of the bowel during surgery.
• Postoperative ileus is common after cesarean delivery, but cecal dilation specifically requires vigilant monitoring due to the risk of perforation and subsequent peritonitis, which carries significant morbidity and mortality, highlighting the importance of prompt evaluation and management 1.

From the Research

Causes of Dilated Cecum after Cesarean

• A dilated cecum after cesarean can be caused by cecal bascule, a rare form of cecal volvulus characterized by an anterior and superiorly displaced cecum, which can result in a large bowel obstruction 2.
• Other risk factors for cecal bascule include recent surgery, previous abdominal surgery, ileus, chronic constipation, and distal colonic obstruction, as well as an association with pregnancy or the postpartum abdomen 2.
• Cecal perforation can also occur due to paralytic ileus following primary cesarean section, often as a result of an antecedent bowel obstruction 3.

Diagnosis and Treatment

• Clinical diagnosis, prompt imaging, and surgery are important to avoid bowel ischemia and perforation in cases of cecal bascule 2.
• Computed tomography (CT) scan of the abdomen and pelvis with oral and IV contrast and laboratory testing can be used to diagnose colonic ischemia, which can be a complication of a dilated cecum 4.
• Treatment of ischemic colitis is supportive in less severe cases, with intravenous fluids and bowel rest, while surgical consultation should be obtained in cases of severe disease, pancolonic ischemia, and isolated right colonic ischemia 4.
• In cases of bowel obstruction, identifying signs of ischemia is important in the management of the patient, as it enables patients at higher risk of poor outcomes after conservation treatment to benefit from early surgical intervention 5.

Clinical Presentation

• Patients with a dilated cecum after cesarean may present with severe abdominal pain, vomiting, and peritonitis, as well as symptoms of bowel obstruction such as abdominal pain, bowel urgency, and passage of bloody diarrhea 2, 4.
• A high index of suspicion is required to diagnose cecal bascule, particularly in postpartum patients, and clinical presentation, radiologic findings, and treatment should be carefully evaluated 2.