A pediatric case of cecal volvulus with literature review
Article information
Abstract
Cecal volvulus is a rare condition, particularly in the pediatric population, and is associated with serious complications such as ischemia, gangrene, or perforation. Its clinical presentation is often vague and variable, which may delay diagnosis. We present a case of a 10-year-old female who presented to the emergency department with an acute abdomen. Imaging findings showed bowel obstruction, and she subsequently underwent an emergency laparotomy, which confirmed the presence of cecal volvulus. She recovered well and was discharged in stable condition. This case highlights the importance of early recognition and timely management of cecal volvulus to achieve successful outcomes and is supported by a review of the relevant literature.
Introduction
Cecal volvulus is an uncommon presentation in adults, constituting 1.9% of intestinal obstructions in the United States (1). It is presumed to be even rarer in pediatric patients (2,3). Nonspecific presentation of this condition might delay diagnosis or timely intervention, thereby raising the risk of serious complications such as strangulation, perforation, or peritonitis (4). Due to limited data, we aimed to stratify the surgical management of cecal volvulus and to conclude an integrated management approach.
Case
A 10-year-old girl with poor dietary habits presented to the emergency department with a history of chronic constipation since the age of 2 years, associated with diffuse abdominal pain and bilious vomiting. Upon physical examination, she looked sick and febrile. The initial vital signs were as follows: blood pressure, 105/67 mmHg; heart rate, 105 beats/minute; respiratory rate, 20 breaths/minute; temperature, 38 °C; and oxygen saturation, 99% on room air. The abdomen was diffusely distended and tender with no signs of rigidity. The rectum was full of hard stool during the digital rectal examination.
Laboratory investigations showed a C-reactive protein concentration of 10.9 mg/L, with unremarkable findings of complete blood count, serum electrolytes, blood urea nitrogen, and creatinine. Plain abdominal radiography showed no signs of perforation, but a dilated colon (Figure 1). A high suspicion of intestinal obstruction was raised. A contrast-enhanced computed tomography of the abdomen and pelvis suggested the presence of a high-grade obstruction due to colonic volvulus (Figure 2).
A plain radiograph showing gaseous dilatation (8 cm) at the left upper abdomen (asterisk) and fecal impaction in the rectum and distal colon (arrow).
Computed tomography scans showing the dilated colon with multiple air-fluid levels (A, arrows) and swirl sign at the right paramedian aspect of the mid-abdomen at the superior mesenteric vessels (B, curved arrow).
Given the hemodynamic stability, as well as the absence of signs of peritoneal irritation, ischemia, or perforation, an initial trial of colonoscopic detorsion was considered reasonable. This approach served diagnostic and potentially therapeutic purposes since computed tomography findings did not clearly define which segment of the colon was twisted. The patient was resuscitated with intravenous hydration along with empirical antibiotics. Then she was taken to the operating room for an initial attempt at colonoscopic detorsion under general anesthesia; if unsuccessful, she would proceed to laparotomy. We found the rectum and sigmoid full of stool, failing to decompress the abdomen. At the same setting, since she remained stable intraoperatively, a trial of laparoscopic exploration through an umbilical port was made. However, it was converted to laparotomy as the dilated bowel obscured the underlying pathology. Upon the laparotomy, cecal volvulus was encountered with no signs of ischemia (Figure 3). We proceeded with detorsion of the cecal volvulus, appendectomy, colonic deflation via appendectomy opening, and cecopexy.
Operative findings, demonstrating the dilated cecum and ascending colon with volvulus formation. A point of twisting on the appendix (A, arrow) is seen with no sign of ischemia on the terminal ileum (B, curved arrow) and on the cecum (B, asterisk).
The patient was shifted to the intensive care unit for 48 hours of observation, then was discharged in good condition on day 5. She was followed up in the clinic for several weeks, where lifestyle modifications and referral to a gastroenterologist were recommended to avoid constipation. There was no reported incidence of recurrence after 3 years.
Discussion
This literature review encompassed case reports, case series, and systematic reviews published from 2017 through 2024 on cecal volvulus in patients younger than 18 years (5–14), focusing particularly on risk factors, such as comorbidities, surgical history, and chronic constipation, operative management, and recurrence (Table). Studies were excluded if they involved late operative interventions, such as cases of ischemic or perforated viscus necessitating resection.
Reported pediatric cases of cecal volvulus: patient characteristics, management, and outcomes
Cecal volvulus is more commonly seen in adults than in the pediatric population (15,16). Literature shows different results regarding the most common locations of colonic volvulus. Cecal volvulus was observed in 2 cases in a case series consisting of 7 cases (17), whereas it was seen in only 1 case in a 28-case series (18). In a series of 19 cases, 14 were cecal volvulus (4). This difference likely reflects small sample sizes and heterogeneous study populations of the 3 studies (4,17,18).
Cecal volvulus is thought to be caused by a long redundant cecum due to failure of its fixation to the retroperitoneum (19). Reported risk factors include previous abdominal surgeries, prolonged fecal loading, and dysmotility with associated colonic distention, particularly in patients with neurodevelopmental delay and chronic constipation. In some series, a history of Nissen fundoplication has been noted. Patients can develop postoperative gas bloating, which impairs belching and normal decompression of the small intestine and cecum (2–4,17,20). This may contribute to increased gaseous colonic distention and, eventually, cecal volvulus.
It is crucial to raise the index of clinical suspicion in diagnosing colonic volvulus. Clinical manifestations suggestive of high-grade intestinal obstruction may also overlap with those of other causes of obstruction. Despite early conservative management, the clinical overlap was described in several reports where rapid deterioration occurred, ultimately requiring surgical interventions that revealed an intraoperative finding of ischemic changes mandating resection (5,21). The use of plain radiography is important for visualizing features of obstruction and guiding management although it is more likely to be diagnosed intraoperatively (22).
Surgical resection of the twisted colonic segments remains the therapeutic modality of choice in adults. Still, its role is debatable in pediatric patients where management decisions are largely guided by case reports and personal experience (6,23). In children with uncomplicated conditions, various procedures have been proposed, including release of obstructing bands, detorsion, appendectomy, or cecopexy. Of these, cecopexy is often preferred, as reported by Miura da Costa and Saxena (2) in their systematic review, due to its association with a lower risk of recurrence (P = 0.002). Nevertheless, regardless of age, segmental resection with or without need for stoma is still considered the mainstay in case of complicated volvulus with any evidence of ischemic changes, gangrene, or perforation (19,24).
Colonoscopic detorsion is known to be a bridge to surgery despite its known risk of high recurrence within 6 weeks (7,25,26). Hence, some authors have suggested its use as a temporary measure to optimize low-risk or stable patients in whom no signs of peritonitis are present, before definitive surgical treatment (2,17,27). In this review, 3 cases were approached with nonoperative treatment, including gastric decompression as a conservative treatment for suspected adhesive bowel obstruction on day 4 post-appendectomy, and colonoscopic detorsion with or without rectal tube insertion. Two of the 3 cases required operation with resection and anastomosis, either due to the development of complications such as gangrene, necrosis, or recurrence after conservative therapy (5,7,8).
In conclusion, pediatric cecal volvulus is a rare but potentially life-threatening condition. Early diagnosis and prompt intervention are critical to prevent bowel ischemia and serious complications. The selection of an appropriate surgical management should be individualized, depending on the patient’s stability and the extent of bowel compromise. We recommend resection with or without anastomosis in case of compromised bowel viability or hemodynamic instability. In uncomplicated cases, we prefer detorsion with cecopexy as the addition of cecopexy has more advantages over other techniques in terms of morbidity and recurrence.
Notes
Author contributions
All the work was done by the authors.
Conflicts of interest
No potential conflicts of interest relevant to this article were reported.
Funding sources
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