Download Caecal Volvulus following a repeat caesarean

Caecal Volvulus following a repeat caesarean: A case
report and review of literature
Y Igzeer, HY Wan Hussein, O Amu
BACKGROUND
Caecal volvulus is a rare condition especially when related to
pregnancy. It carries a high morbidity and mortality rate due to delay in recognition. It is
thought to have an embryological pathogenesis giving anatomical susceptibility. When
coupled with conditions of late term pregnancy such as, adynamic ileus, chronic
constipation and distal colon obstruction, it is thought to lead to caecal displacement,
hyperperistalsis and colonic distension. Clinical series2-4 have also reported an
association with previous abdominal surgery postulating that postoperative adhesions
promote volvulus formation through creation of fixation points and fulcrum of rotation for
the mobile right colon.
CASE REPORT
A 36 year old woman was found to have a caecal volvulus at
laparotomy 4 days after a repeat caesarean section at term. She previously had an
elective caesarean and a history of endometriosis. At the time of repeat caesarean,
abdominal entry was difficult due to fibrosis from her previous scar. She was discharged
home on Day 2. Within 24 hours she was readmitted with abdominal distension and
pain. Abdominal X-ray (Figure 1) showed a large distended right loop of bowel and
distal colon showed evidence of faecal loading. Phosphate enema failed to resolve her
symptoms. The X-ray was then reviewed by a radiologist suggesting a caecal volvulus.
At laparotomy she underwent ileocaecal resection, appendicectomy, right colon fixation
and caecostomy. A Foleys catheter was inserted through the caecostomy for
decompression. She was discharged ten days later.
Figure 1: Abdominal Xray showing distended loop of bowel in the right
upper quadrant highly suggestive of a caecal volvulus
Table 1: Reported cases of caecal volvulus in English Literature
Reported Cases
Number of cases
References
Before 1980
10
Victor A ,Peter F H ,Demetrios Y,Patrick V.Caecal volulus following
Cesarean section. Obstet Gynecol 1980; 55:131-34.
1981-1999
1
Fanning J, Cross CB. Post-cesarean section cecal volvulus. Am J
Obstet Gynecol 1988; 158(5):1200-1202.
2000-2009
3
I.
Al Salamah SM, El Keyali AY. Ileo-caecal volvulus postcesarean section: a case report. Saudi J Gastroenterol
2000; 6(3):163-164.
II.
Pal A, Corbett E, Mahadevan N. Caecal volvulus
secondary to malrotation presenting after caesarean
section. J Obstet Gynaecol 2005; 25(8):805-806.
III.
Marren A, Wong K. Caecal volvulus associated with
intestinal malrotation immediately following caesarean
section. N Z Med J 2006; 119(1240):U2130.
DISCUSSION
The overall incidence of caecal volvulus is reported between 2.8 to
7.1 per million people per year1. It accounts for 1% of adult intestinal obstructions and
25% of all volvulus. As previously mentioned, clinical series2-4 have reported up to 53%
of patients having had previous abdominal surgery making previous caesarean section
a major risk factor as it is such a common procedure. Table 15 demonstrates the
increasing trend, which we attribute to the increase in numbers of caesarean sections
performed over the years. Therefore, unusual complications like this are likely to
continue to surface.
A high index of suspicion is crucial to accurately diagnose and
ensure prompt treatment, in order to minimise morbidity and mortality. It is currently
typical to discharge women home only 2 days after caesarean section which may
contribute towards delay in diagnosis of such a rare complication, and hence, its
outcome. We have to educate women and community healthcare workers to be vigilant
and have a clear pathway for readmission in potential cases.
2010
1
Salih A, Rafi J, Salim E. Caecal Bascule: A Rare Complication
Following Caesarean Section. J Med Cases •
2010;1(1):21-22
References:
1. Consorti ET, Liu TH. Diagnosis and treatment of caecal volvulus. Postgrad Med J2005;81:772-776
2. Tejler G, Jiborn H. Volvulus of the cecum. Report of 26 cases and review of the literature. Dis Colon Rectum 1988;31:445–9.
3. Theuer C, Cheadle WG. Volvulus of the colon. Am Surg 1991;57:145–50.
4. O’Mara CS, Wilson TH, Stonesifer GL, et al. Cecal volulus. Analysis of 50 patients with long-term follow-up. Ann Surg 79; 189:
724–31.
5. Salih A, Rafi J, Salim E. Caecal Bascule: A Rare Complication Following Caesarean Section. J Med Cases • 2010;1(1):21-22