What is a cecal bascule?

Cecal Bascule: Definition and Clinical Significance

A cecal bascule is a rare type of cecal volvulus in which the cecum folds anteriorly and superiorly over the ascending colon without axial rotation, creating a flap valve mechanism that can cause large bowel obstruction.

Pathophysiology and Mechanism

• Unlike typical cecal volvulus which involves axial rotation of the bowel, cecal bascule consists of an anterior and superior folding of the cecum over itself 1
• The folded cecum creates a flap valve mechanism that impairs cecal emptying, leading to progressive distention 2
• Predisposing factors include:
  • Incomplete fixation of the cecum to the retroperitoneum during embryogenesis (mobile cecum) 3
  • Recent surgery, particularly laparoscopic procedures 4
  • Pregnancy or postpartum state 3
  • Chronic constipation and distal colonic obstruction 3

Clinical Presentation

• Patients typically present with:
  • Abdominal pain (often sudden onset and progressive) 1, 4
  • Abdominal distention 4
  • Nausea and vomiting 2
  • Constipation 2

Diagnostic Approach

• Computed tomography (CT) is the primary diagnostic modality, showing:

  • Dilated and superiorly displaced cecum 3
  • Absence of the typical "whirl sign" seen in classic cecal volvulus 1
  • Possible small bowel dilation proximal to the obstruction 2

• In pregnant patients with suspected cecal bascule, CT may be required despite radiation concerns if the diagnosis is uncertain and surgical intervention is being considered 5

Management Options

• Surgical management is the definitive treatment for cecal bascule 1, 6

• Treatment options include:

  1. Anatomic resection (right hemicolectomy) - preferred for cases with bowel ischemia or necrosis 1, 4
  2. Cecopexy - fixation of the cecum to the abdominal wall, appropriate for viable bowel without ischemia 1, 6

• Endoscopic decompression may provide temporary relief in select cases but is not definitive 2

Clinical Considerations and Pitfalls

• Unlike cecal volvulus, ischemia in cecal bascule typically occurs only from:

  • Intraluminal tension from severe distention
  • Extraluminal compression (e.g., from the borders of foramen of Winslow in cases of internal herniation) 1

• Cecal bascule can present as an internal hernia in rare cases, with the folded cecum herniating through anatomical openings like the foramen of Winslow 1, 6

• Delay in diagnosis can lead to serious complications including:

  • Bowel ischemia
  • Perforation
  • Peritonitis 3

• A high index of suspicion is needed, particularly in postoperative patients with unexplained abdominal pain, distention, and vomiting 4

Unique Considerations

• Cecal bascule is the rarest form of cecal volvulus 3
• Recent surgery, particularly cesarean section, has been associated with cecal bascule development 3
• Prompt surgical intervention is critical to prevent bowel ischemia and perforation 3

In summary, cecal bascule represents an uncommon but clinically significant cause of large bowel obstruction that requires prompt recognition and surgical management to prevent serious complications.