What is the primary concern in a patient with acute abdominal pain, vomiting, constipation, and imaging consistent with caecal (cecal) volvulus?

Primary Concern in Cecal Volvulus

In a patient with acute abdominal pain, vomiting, constipation, and imaging consistent with cecal volvulus, the primary concern is gangrene (ischemia) of the bowel. 1

Pathophysiology and Primary Concern

Cecal volvulus occurs when an abnormally mobile cecum twists on its own axis, leading to:

• Twisting of mesenteric vessels causing impaired blood supply
• Increasing intraluminal pressure impairing capillary perfusion
• Ischemic injury beginning in the mucosa and progressing to other layers 1
• A competent ileocecal valve converting the proximal colon into a "closed loop" 1

This pathophysiological process makes gangrene (ischemia) the most urgent concern because:

• Mortality rates increase dramatically once ischemia develops, with rates as high as 25% 1
• Early diagnosis and prompt intervention are essential to avoid complications of ischemia and gangrene 2
• The condition leads to axial torsion around mesenteric vascular pedicles, directly causing ischemia and bowel necrosis 3

Clinical Presentation and Diagnostic Features

The clinical presentation typically includes:

• Acute abdominal pain, vomiting, and constipation
• Abdominal distension with tympanic percussion
• Generalized abdominal tenderness 3

Imaging findings that suggest cecal volvulus:

• Plain abdominal radiographs showing a "coffee bean sign" or "comma-shaped" dilated cecum 1, 4
• CT scan revealing:
  • Dilated cecum with air/fluid level
  • "Whirl sign" representing twisted bowel and mesentery
  • Signs of ischemia: abnormal bowel wall enhancement, intramural hyperdensity, bowel wall thickening, mesenteric edema 1, 3

Important Clinical Pitfalls

• The absence of peritonitis on examination does not rule out bowel ischemia 1
• Relying solely on clinical examination is insufficient to determine the presence of ischemia 1
• Physical examination and laboratory tests are neither sufficiently sensitive nor specific for detecting ischemia 1
• Waiting for peritoneal signs is not recommended 1
• Diagnostic difficulties may arise in patients with peritonitis and when there is gross small bowel dilatation 4

Management Implications

The primary concern of gangrene (ischemia) directly dictates management:

• Without ischemia, endoscopic decompression may be attempted
• With ischemia, immediate surgical intervention is necessary without delay 1
• Surgical options include:
  • Detorsion and caecopexy if bowel is viable
  • Resection of infarcted tissue if ischemia is present 1, 5

While obstruction is certainly present in cecal volvulus, and pain and potential perforation are complications, gangrene (ischemia) represents the most immediate life-threatening concern that requires urgent intervention to prevent mortality.