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

The primary concern in a patient with acute abdominal pain, vomiting, constipation, and imaging consistent with cecal volvulus is ischemia (gangrene) of the bowel, which requires immediate surgical intervention. 1

Pathophysiology and Primary Concerns

Cecal volvulus occurs when an abnormally mobile cecum twists on its own axis, leading to a cascade of serious complications:

• Ischemia (Gangrene): The twisting of mesenteric vessels causes impaired blood supply, while increasing intraluminal pressure impairs capillary perfusion 1

  • Ischemic injury begins in the mucosa and progresses to other layers
  • A competent ileocecal valve converts the proximal colon into a "closed loop," worsening the ischemia
  • Mortality rates increase dramatically to as high as 25% once ischemia develops 1

• Secondary Concerns:

  • Obstruction: While obstruction is present (manifesting as vomiting and constipation), it is a consequence rather than the primary concern
  • Perforation: This is a late complication that occurs after gangrene develops
  • Pain: While significant, pain is a symptom rather than the primary pathological concern

Clinical Presentation and Diagnosis

The clinical presentation includes:

• Acute abdominal pain
• Vomiting
• Constipation
• Abdominal distension 2

Diagnostic findings:

• Plain abdominal radiographs may show a "coffee bean sign" or "comma-shaped" dilated cecum 1, 3
• CT is the gold standard for diagnosis, showing:
  • 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

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, as physical examination and laboratory tests are neither sufficiently sensitive nor specific 1
• Waiting for peritoneal signs is dangerous and not recommended 1
• Diagnostic difficulties may arise in patients with peritonitis and when there is gross small bowel dilatation 3

Management Approach

1. Immediate surgical consultation upon diagnosis of cecal volvulus
2. Assess for ischemia through clinical and radiological evaluation
3. Surgical intervention:
   • Without ischemia: Endoscopic decompression may be attempted
   • With ischemia: Immediate surgical intervention without delay 1
   • Surgical options include:
     • Detorsion and caecopexy if bowel is viable
     • Resection of infarcted tissue if ischemia is present 1, 4

Early detection and prompt intervention are essential to avoid complications of ischemia and gangrene 5. Accurate diagnosis is vital as delay in surgical treatment may lead to an increased incidence of gangrene of the cecum and higher mortality 3.