Management of Cecal Volvulus
Cecal volvulus requires urgent surgical intervention as the primary treatment, as endoscopic decompression is ineffective and wastes valuable time. 1
Diagnosis
- Clinical presentation typically includes abdominal pain, distention, and obstipation
- Abdominal CT is the gold standard diagnostic tool, showing:
- Dilated cecum and bowel
- Characteristic "whirl sign" representing twisted bowel and mesentery
- Air/fluid levels
Treatment Algorithm
Initial Assessment
- Evaluate for signs of bowel ischemia, perforation, or peritonitis
- Assess hemodynamic stability
- Order abdominal CT scan for confirmation
Surgical Management
- Unlike sigmoid volvulus, endoscopic decompression should NOT be attempted in cecal volvulus as it is ineffective and delays definitive treatment 1
- Immediate surgical intervention is required in all cases
For Viable Bowel:
- Right hemicolectomy with primary anastomosis is the preferred treatment for patients with viable bowel 1
- Alternative options (less preferred):
- Cecopexy (fixation of cecum) - higher recurrence rates
- Cecostomy - higher morbidity
For Non-Viable/Gangrenous Bowel:
- Right hemicolectomy with or without primary anastomosis depending on patient condition 1
- For hemodynamically unstable patients or those with significant comorbidities, consider temporary ileostomy 1
Surgical Approach
- Open surgery is the most common approach for emergency cases
- Laparoscopic approach may be suitable in select cases by experienced surgeons, but has limited role due to technical challenges with the distended cecum 1
Complications and Pitfalls
- Manipulating or detorsing ischemic/necrotic bowel can release endotoxins and bacteria into circulation 1
- Delay in diagnosis increases risk of ischemia, necrosis, and mortality
- Risk factors for poor outcomes:
- Age over 60 years
- Presence of shock on admission
- History of previous episodes of volvulus
Special Considerations
- In patients with concomitant megacolon, consider more extensive resection
- For high-risk patients unfit for surgery, temporary measures may be needed, but definitive surgery should not be delayed if possible
Follow-up
- Close monitoring for signs of recurrence
- Patient education about symptoms of recurrence
- Consider elective repair of predisposing factors (redundant colon)
The management of cecal volvulus differs significantly from sigmoid volvulus. While endoscopic decompression is first-line for sigmoid volvulus, it is contraindicated in cecal volvulus where prompt surgical intervention is essential to prevent complications and reduce mortality 1, 2. The mortality rate ranges from 10-40% depending on bowel viability, highlighting the importance of early diagnosis and treatment 2.