An Overview of Cecal Volvulus

An abnormal twisting (torsion) of the bowel

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Cecal volvulus is a type of intestinal malrotation that occurs in the lower part of the bowel. It can involve the cecum, terminal ileum, or colon. Cecal volvulus is not as common as other types of intestinal torsion, but all can lead to potentially serious bowel obstructions. Sometimes, people have recurrent, chronic symptoms before an acute torsion occurs. An acute blockage or twist in the bowel is a medical emergency that usually requires surgery.

Symptoms

During the very last phase of fetal development, one of the most important changes that takes place in the embryo happens in the intestines. During this time, the intestines are anchored to the abdominal wall by the mesentery. The intestines move to digest food (peristalsis), but it's this crucial connection that keeps them from wiggling and twisting or folding in ways that could damage the bowel.

In some cases, the lower portion of the cecum does not firmly attach (or attach at all) during this period of fetal development. This allows the cecum to move freely (mobile cecum syndrome). Sometimes the condition is diagnosed during surgery or on a radiology film.

Many people would never realize they had a moveable cecum because they don't experience any symptoms or problems.

Some circumstances or conditions can make it more likely a person who is predisposed will experience a problem related to mobile cecum, such as becoming pregnant, undergoing abdominal surgery, or getting an infection. Other factors, such as a high-fiber diet, may also play a role.

If a person does have symptoms of cecal volvulus, at first they may be intermittent, recurrent, and chronic. Eventually, they can culminate with an acute—and potentially serious—bowel obstruction. Most people develop an acute obstruction without having symptoms suggestive of a partial obstruction beforehand, and about 60 to 70 percent of cecal volvulus cases are acute.

The symptoms resemble many other gastrointestinal conditions, which can make diagnosis difficult. Doctors don't see cases of cecal volvulus very often, especially compared to another type of intestinal torsion that affects the sigmoid colon (sigmoid volvulus). Therefore, a diagnosis of cecal volvulus may be missed or delayed.

When part of the intestine becomes twisted, the portion above the section continues to function. As food, fluid, gas, and stool moves through the bowel and reaches the folded or twisted part, a person will begin to feel unwell.

Symptoms of cecal volvulus include:

  • Abdominal pain. When the condition is chronic/recurrent, the pain may be vague and intermittent and a person will generally start to feel better once they are able to pass gas or have a bowel movement. When the pain is severe and constant, this usually indicates the condition is acute or complications, such as gangrene, have occurred.
  • Distention of the abdomen
  • High-pitched bowel sounds
  • Inability to pass gas or have a bowel movement
  • Nausea and lack of appetite
  • Vomiting
  • Black, tarry, stools
  • Chronic constipation and/or diarrhea

When the torsion has not lead to a complete bowel obstruction, people may feel relief once they are able to pass gass—an indication that the volvulus has resolved on its own. When the obstruction cannot resolve itself, or complications have occurred, the pain and other symptoms will worsen.

If a person continues to experience recurrent episodes of cecal volvulus, complications can result even if an acute obstruction does not occur. When the bowel twists, its blood supply is cut off. Over time, repeated interruptions of normal blood flow to the same part of the intestine can cause the bowel to stop working.

Untreated cecal volvulus can also lead to potentially life-threatening infections, such as sepsis or gangrene, as the tissue dies (necrosis). As the pattern continues, symptoms may slowly get worse as the bowel loses its ability to function correctly. People may also experience worsening health related to malnutrition and malabsorption.

While cecal volvulus is not frequently seen in children, they are more likely to present with general symptoms such as fatigue, low energy, reluctance to eat, and vague belly pain.

Intestinal malrotation can also present in newborns—usually within the first month after birth. In these cases, male infants are more likely to show symptoms (which may at first be confused for colic). Cases that occur later in life seem to occur equally between males and females.

Causes

Cecal volvulus is quite rare, but there are certain conditions that can make a person more likely to develop it. As mentioned above, having a mobile cecum is a known predisposing factor in some cases. Around 10 percent of the population is estimated to have a cecum that is not properly attached—though this number may be low.

Many people never have symptoms and the condition is only noticed incidentally, if at all, during their lifetime. In fact, many cases are only noticed after a person has died and an autopsy is performed.

Other diseases and conditions that can lead to intestinal torsion include:

  • Chronic constipation
  • Lesions caused by conditions such as diverticulitis
  • Masses or tumor in the pelvis or abdomen
  • Hirschsprung's disease and other diseases of the bowel (especially those that cause enlargement of the colon)
  • Adhesions in the bowel from surgery, inflammation, infection, or injury
  • A condition called ileus that can happen after surgery or procedures where the bowel "quiets down" from the effects of anesthesia and sedation
  • Shifting organs as a result of pregnancy

The majority of cases are diagnosed in older adult patients who are acutely ill or hospitalized—though not necessarily with bowel complaints initially. People who are elderly, chronically ill, or acutely ill with another condition that requires hospitalization are more at risk for complications if they develop cecal volvulus, including strangulation or perforation of the bowel.

Diagnosis

Cecal volvulus is usually seen in adults of both sexes and all racial backgrounds who are between the ages of 30 and 60. The symptoms of cecal volvulus can be similar to other gastrointestinal conditions, such as appendicitis, irritable bowel syndrome, inflammatory bowel disease, gastroenteritis (stomach flu), or gastroesophageal reflux disease.

If a person's symptoms are recurrent, intermittent, and spontaneously resolve, rather than acute, it may take longer for them to be diagnosed. When the condition becomes acute, several types of imaging tests can be used to determine the cause.

In the emergency room, a doctor will usually order a plain abdominal X-ray first to look for a bowel obstruction. Sometimes, a contrast enema may be administered so that different parts of the intestine are more visible on X-rays or other imaging, like a CT scan. This can help doctors see where the obstruction is and figure out what might be causing it.

If a person has had the symptoms before, they may also look for signs of damage or infection caused by a previous episode of cecal volvulus that got better on its own. If there is concern about an infection or if a person is very ill, a doctor may order other tests to assess them.

Other tests that might be ordered if a doctor suspects a person has cecal volvulus include:

  • blood tests to look at the number of white blood cells in their blood, which can indicate infection
  • a comprehensive metabolic panel to assess their overall state of health, which can be important to know if they are going to need surgery
  • a sigmoidoscopy or colonoscopy to look inside the lower portion of the bowel

Treatment

Surgery is necessary for most cases of cecal volvulus. However, the procedure a surgeon chooses will depend on the reason for the volvulus and the person's state of health. In some cases, doctors may want to try other methods to reduce the volvulus that don't require surgery.

Treating cecal volvulus can be difficult—even with surgery, it is a problem that tends to come back (recur) and can get worse over time. A person who experiences cecal volvulus due to having a mobile cecum is likely to have repeated episodes of volvulus unless the section of unattached intestine is repaired.

If part of the intestine has stopped working or the tissue is strangled, it may need to be removed completely to prevent infection and help restore bowel function.

There are several surgical procedures that can be performed to treat cecal volvulus. A surgeon will choose the procedure they believe will have the best outcomes and lowest risk for each individual. When a person goes to the hospital and is diagnosed with acute cecal volvulus, elective surgery can usually be performed that day or very soon after the visit.

Surgical procedures that can be used to treat cecal volvulus include:

  • Cecoplexy: If a person's intestine is not correctly attached (mobile or floppy cecum), it may be able to be attached, or reattached, to the abdominal wall. The bowel must still be healthy and working for this procedure to be done.
  • Colon resection and stoma: If a portion of the bowel no longer works or has become necrotic, the surgeon may need to remove it completely. One way they can do this is by resecting the colon and forming a stoma, an artificial opening made in the abdomen. Stool can pass through the stoma and be collected in a bag worn outside the body, called an ostomy.

Sometimes, stomas are only temporary and another surgery can be performed later to reconnect the bowel. If this is successful, the stoma can be closed. If the bowel cannot be reconnected, a person will need to keep the stoma and wear an ostomy bag to ensure fecal matter can leave their body.

The surgeon will usually try to perform these procedures using minimally-invasive techniques such as laparoscopy. However, in more complex cases, they may need to use or switch to a more invasive (open) technique. The potential for complications and the amount of recovery time a person needs will depend on which type of surgery is performed.

In some cases, a doctor may want to try more conservative treatment before surgery. This option is only possible in patients who are deemed medically stable and who do not have signs of bowel perforation or infection.

Non-surgical options for attempting to treat cecal volvulus include the decompression of the bowel via colonoscopy or sigmoidoscopy. The method is successful in untwisting the bowel in about 15 percent of cases; however, it is only a temporary measure and the intestine will usually twist or fold again.

Cecal volvulus is not a common condition and surgeons may only see a few cases in their careers. Therefore, there are no definitive guidelines or treatment recommendations for all cases. Medical professionals will make treatment decisions on a case-by-case basis and take a person's health and medical history into account, their own experience, as well as the surgical expertise and the capabilities of the hospital where they operate.

A Word From Verywell

Cecal volvulus is an uncommon cause of bowel obstruction that most often occurs in adults. Cases of cecal volvulus can be recurrent (come and go) and resolve spontaneously on their own, but they may also be or become acute and lead to a partial or complete bowel obstruction.

While there is no definitive course of treatment, most patients will need to have surgery, particularly if part of their intestine has become damaged due to repeated episodes of cecal volvulus. Be sure to discuss your options with your doctor who should be able to evaluate the best options for you based on your individual needs.

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