Teaching Case

The patient presented to the emergency room complaining of increasing abdominal distension, crampy severe abdominal pain and constipation for the past 5 days. He had a firm, massively distended, tympanitic abdomen with decreased bowel sounds. He had no temperature .

The patient presented to the emergency room complaining of increasing abdominal distension, crampy severe abdominal pain and constipation for the past 5 days.

Physical examination showed a firm, massively distended, tympanitic abdomen with decreased bowel sounds and diffuse tenderness. He had no fever. An abdominal radiograph demonstrated several air-filled dilated loops of bowel. A computed tomographic (CT) scan of the abdomen and pelvis demonstrated a markedly dilated (12cm) air-filled loop of the caecum, associated with dilated small bowel. This was considered to be a massively distended caecum leading to a point of torsion around its mesentery, compatible with volvulus. An iodine contrast enema was performed to confirm the diagnosis and ascertain the exact point of the obstruction. This showed the "whirl sign" - a typical finding where the column of contrast is cut off with convergence of the mucosal folds.

The patient underwent surgery that confirmed the caecal volvulus. A right hemicolectomy with an end-to-end ileocolic anastomosis was performed.

Volvulus of the caecum and/or right colon is responsible for 0.8-4.1% of cases of intestinal obstruction. Caecal volvulus is caused by an abnormal fixation of the caecum to the posterior parietal peritoneum. Compared with sigmoid volvulus, caecal volvulus is less common and occurs in a younger age group of patients (30-60 years old). Although mobility of the right colon is often seen on barium enema, it rarely causes a volvulus. Predisposing causes of caecal volvulus include: a freely mobile caecum, pregnancy, previous abdominal surgery or colonoscopy, and distension of the colon from mechanical obstruction of the ileus.

Two types of caecal volvulus have been described: the axial and the loop types. In the axial type, the caecum makes a clockwise rotation about its long axis, remaining in the right lower quadrant. In the loop type, the caecum is in an ectopic location, typically in the left upper quadrant. The caecal volvulus in this case was of the loop type, as shown in Figures 1-3.

The diagnosis of caecal volvulus can be made on plain radiographs in more than 50% of patients when the characteristic dilated air-filled loop of ectopic caecum is seen in the left upper quadrant. CT scans assist in diagnosis by showing caecal distention, an ectopic caecum, and the typical "whirl sign".

Knowledge of the characteristic pattern of history, frequently associated diseases, and physical and radiological findings most often allows a diagnosis of caecal volvulus to be established without delay. Late diagnosis may result in a fatal outcome, which explains why surgical treatment is always necessary.