What is the difference between caecal (cecal) volvulus and sigmoid volvulus in terms of diagnosis, management, and patient outcomes, particularly in different age demographics?

Differences Between Cecal and Sigmoid Volvulus

Cecal volvulus requires immediate surgical intervention with right hemicolectomy as the only definitive treatment, whereas sigmoid volvulus should be managed with endoscopic decompression followed by elective resection during the same admission if there are no signs of ischemia or perforation. 1

Demographics and Patient Population

Age and Gender Distribution:

• Sigmoid volvulus predominantly affects elderly males (age >70 in Western countries, mean age 56-77 years) 2
• Cecal volvulus typically presents in younger patients (age ≤60), more commonly in females 2, 3, 4
• Cecal volvulus can occur in very young patients, including those in their 20s 4

Risk Factors:

• Sigmoid volvulus is strongly associated with chronic constipation, frequent laxative use, dolicho-sigmoid (elongated sigmoid colon), and neuropsychiatric conditions with chronic psychotropic medication use 2, 1
• Cecal volvulus is caused by an exceedingly mobile cecum, often triggered by constipation, high-fiber diets, laxative use, history of abdominal surgery, pregnancy, and prior colonoscopy 3, 4

Clinical Presentation

Sigmoid Volvulus:

• Classic triad: abdominal pain, constipation, and abdominal distension (more common in endemic cases at 88% vs sporadic cases at 33%) 2
• Vomiting appears as a late sign 2
• Empty rectum on digital examination is characteristic 2
• Previous episodes of abdominal distention reported in 30-41% of cases 2
• Symptom duration typically 3-4 days in Western countries 2

Cecal Volvulus:

• Presents with generalized abdominal pain, constipation, and abdominal distension 4
• Clinically difficult to differentiate from small bowel obstruction 4
• Less likely to have previous episodes compared to sigmoid volvulus 2

Diagnostic Imaging

Plain Radiography:

• Sigmoid volvulus: Classic "coffee bean sign" or "omega loop" (inverted-U sigmoid) 2, 5
• Cecal volvulus: Rounded focal collection of air-distended bowel in the upper left quadrant 4

CT Findings (Gold Standard for Both):

• Sigmoid volvulus: Dilated colon with air/fluid level and "whirl sign" representing twisted colon and mesentery 2, 5
• Cecal volvulus: Distended loop of large bowel extending from right lower quadrant to epigastrium or left upper quadrant, absent colonic haustral pattern, and whirl sign of spiraled collapsed cecum 4

Management Approach

Sigmoid Volvulus Management Algorithm:

Step 1: Assess for Complications

• If septic shock, bowel ischemia, or perforation present → immediate surgical intervention (Hartmann's procedure or sigmoid resection with primary anastomosis) 2, 6
• Emergency surgery mortality: 12-20% 6

Step 2: Uncomplicated Cases

• First-line treatment: endoscopic decompression (success rate 70-91%, complication rate 2-4.7%) 6, 1
• Mandatory definitive sigmoid resection during the same hospital admission after successful decompression 6, 1
• Elective sigmoid resection mortality: 5.9% vs 40% for emergency surgery 6

Step 3: Recurrence Prevention

• Without resection, recurrence rates are extremely high (45-71%) 2, 6, 1
• Each recurrence increases risk of ischemia, perforation, and mortality 1

Cecal Volvulus Management:

Immediate surgical intervention is mandatory 1

• Endoscopy has no role in cecal volvulus management 1, 3
• Right hemicolectomy is the only definitive treatment 1
• Alternative: ileocecal resection if intestinal ischemia is present 3
• Cecopexy may be considered if blood flow is intact (confirmed with ICG fluorescence imaging) 3
• Emergency surgery is necessary due to low success rate of endoscopic treatment 3

Critical Pitfalls and Caveats

Sigmoid Volvulus:

• Absence of peritoneal signs does not rule out bowel ischemia 2
• History may be unreliable in patients with neuropsychiatric issues 2
• If infarcted bowel present, resection should be performed without detorsion and with minimal manipulation to prevent release of endotoxin, potassium, and bacteria 6

Cecal Volvulus:

• Can be misdiagnosed as fecal impaction on plain films 5
• Mortality rate >50% when bowel gangrene develops 5
• Colonoscopic treatment should not be attempted as first-line therapy due to risk of intestinal strangulation 3

High-Risk Features for Mortality (Both Types):

• Age over 60 years 6, 1
• Presence of shock on admission 6, 1
• History of previous volvulus episodes 6, 1