Journal of Surgical Case Reports, 2021;4, 1–3 doi: 10.1093/jscr/rjab148 Case Report CASE REPORT Caecal volvulus and jejunostomy: challenging diagnostic A. Morera-Grau1 ,*, E. Membrilla-Fernández1 ,2 , A.M. González-Castillo1 ,2 , A. Pelegrina-Manzano1 , M.A. Guerrero-Ortiz1 , C. Téllez-Marquès1 , M.J. Pons-Fraguero1 , J. Guzmán-Ahumada1 ,2 , M. Pera-Román1 ,2 and J.J. Sancho-Insenser1 ,2 1 General Surgery Department, Hospital del Mar, Barcelona, Spain and 2 Surgery Department, Autonomous University of Barcelona, Barcelona, Spain *Correspondence address. General Surgery Department, Hospital del Mar, Passeig Marítim de la Barceloneta, 25, 29, Barcelona 08003, Spain. Tel: +0034676360172; E-mail: alxmoreragrau@gmail.com Abstract Caecal volvulus represent the 20–40% of colonic volvulus, being the second most frequent localization. It causes intestinal occlusion symptomatology (nausea, vomiting, abdominal distension). We present a case of 45-year-old women with feeding jejunostomy tube due to connatal anoxia. She arrives at A&E after 12 h of vomits and abdominal pain. The CT scan shows a small intestine dilation that suggested a small intestine volvulus. A laparotomy is performed showing a caecal volvulus, so ileo-cequectomy with primary anastomosis is performed. After several complications, she was discharged after 60 days of hospital stay. Caecal volvulus can be challenging to diagnose by clinic, because it can be hardly differenced from other intestinal occlusion causes. CT scan can be useful to reach the diagnostic and see signs of tissue suffering. In contrast with sigma volvulus, endoscopic treatment has not shown any benefit to solve it. BACKGROUND Personal antecedents include cognitive disability due to con- natal anoxia that causes severe dysphagia, for which she was The caecal volvulus is a torsion of this part of large intestine. placed a feeding jejunostomy, a spastic tetraparesia in the left It represents 20–40% of colon volvulus and is the second most half of the body due to several strokes; structural epilepsy and common location after sigmoid colon. It causes about 1–1.5% of an emergency laparotomy due to intestinal occlusion when she intestinal occlusions in adults [1]. was 9. Clinically, it causes an inespecific occlusive syndrome. The patient is hemodynamically stable (blood pressure of Definitive treatment is essentially surgical, ranging from 132/76 mmHg, heart rate 91 beats/min), a respiratory rate of cechectomy to right hemicolectomy. 16 breaths/min, an O2 saturation of 99% baseline, afebrile. The abdominal examination shows a globular abdomen, diffusely painful on palpation, without signs of peritoneal irritation and CASE REPORT with diminished peristalsis. A 45-year-old woman is admitted in our hospital because of a Fluid therapy, analgesia and antiemetics are administrated. A 12-h clinic of alimentary vomits and hypoactivity. nasogastric tube and urinary catheter are placed. Received: March 10, 2021. Accepted: March 26, 2021 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2021. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 A. Morera-Grau et al. Figure 1: Image of the volvulus in the abdominal X-rays. The emergency blood test showed a normochromic and normocytic anemia with an hemoglobin of 10.1 mg/dl and a Figure 2: Sagital plane of cecum volvulus on CT scan. leukocytosis of 11.150/ul with 70% neutrophils. The abdominal radiography showed a prominent dilation of a small bowel loop. The CT scan reported an 18-cm dilated loop. The main diagnostic suspicion was a small bowel volvulus without signs of ischemia or perforation (Figs 1–3). With this diagnosis, an emergency laparotomy is performed. It showed a cecum volvulus that compromised 6 cm of dis- tal ileum. The cecum was ischemic, with transmural necrosis. Ileocechectomy was performed including a 15-cm segment of distal ileum. Intestinal transit was reconstructed with mechan- ical latero-lateral ileo-colic anastomosis with manual reinforce- ment. The closure of the abdominal wall was performed with a supraaponeurotic prophylactic mesh. At 24 h after surgery, she presented abdominal distension, pain and anemia with an hemoglobin of 4.9 g/dl. A CT scan reports little blood traces inside the colon without identifying active bleeding, as well as loop dilation suggestive of paralytic ileus. After the transfusion of three packed red blood cells, the patient recovers a hemoglobin of 8 mg/dl. Intraoperative cultures of the peritoneal exudate are negative. Treatment with endove- Figure 3: Axial plane of cecum volvulus on CT scan. nous cefotaxime (2 g every 6 h) and metronidazole (500 mg every 12 h) is administered for 5 days. On the ninth post-operative day, she presents a pseu- domembranous colitis that responded to oral treatment with (25–40%), transverse colon (1–4%) and splenic flexure (1%). Its Vancomycin for 10 days 500 mg/6 h. She is discharged after 2 annual incidence is 2.8–7.1 cases per million inhabitants [4]. months of hospital stay. There are three types of caecal volvulus: axial rotation (type 1), the ‘loop’ [axial torsion and inversion (type 2)] and the caecal bascule [the dilated cecum bends on the ascending colon (type DISCUSSION 3)]. Type 1 and 2 represent 80% of cecum volvulus. Caecal volvulus is a rare entity, characterized by a torsion of Volvulus of the cecum can be caused embryologically by an the cecum, generating a retrograde intestinal dilation and an inadequate fixation of the ascending colon or by an absence of occlusive syndrome. fusion of the ascending colon with the lateral peritoneum. Other Intestinal volvulation is the third cause of obstruction in important predisposing factors are abdominal surgery history; the large intestine behind neoplastic diseases and diverticulitis. chronic constipation; distal colon obstructions, pregnancy and Sigmoid volvulus is the most frequent (75%), followed by cecum adynamic ileus [1]. Caecal volvulus and jejunostomy 3 In 50% of cases, a mobile cecum syndrome is described before techniques include cecopexy, or detorsion without poste- true volvulation occurs [5], which later resolves after flatulence rior fixation, with poorer results in terms of mortality and occurs. recurrence [6]. In cases where true volvulation occurs, the symptoms are Factors that increase the risk of necrosis in volvulation indistinguishable from those of a small bowel obstruction. include a history of cardiovascular disease, chronic kidney When it comes to intestinal volvulation, the diagnostic and disease, hemiplegia and prolonged duration of symptoms [7]. therapeutic speed have a great importance. A volvulus of any type entails a compromise of vascularization due to the rotation CONCLUSION of the mesentery, which can lead to necrosis and, therefore, perforation, increasing morbidity and mortality in the patient. Cecum volvulus is a rare pathology, so it can be difficult to diag- For the diagnosis of this entity, a certain degree of clinical nose. Clinically, it does not differ from other intestinal obstruc- suspicion must be counted since the exploration is common to tion. CT scan is key to determine the etiology of the occlusive that of any occlusive process. condition, as well as to show ischemia and perforation. Defini- The blood analysis of patients with cecum volvulus is also not tive treatment is always surgical, using one technique or another very specific, reflecting only patterns compatible with intestinal depending on the findings. obstruction or sepsis: hydroelectrolyte alterations, leukocytosis, increase in acute phase reactants or alterations in coagulation. REFERENCES In the abdominal X-ray, one of the three typical signs can be observed: dilation of the cecum, a single air-fluid level in the 1. Consorti ET, Liu TH. 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