CURRENT STATUS James M. Church, M.D., Editor The Management of Cecal Volvulus T. E. Madiba, M.Med.(Chir), F.C.S.(SA), S. R. Thomson, Ch.M., F.R.C.S. From the Department of Surgery, University of Natal, Durban, South Africa Cecal volvulus is second only to sigmoid volvulus in its frequency of occurrence. Diagnostic doubt is not uncom- mon in cecal volvulus; nonoperative decompression is rarely achievable; and if gangrene supervenes, mortality rises appreciably. Resection is mandatory for gangrene and a grossly distended, thin-walled cecum. Cecopexy and ce- costomy seem less-effective and more morbid options than resection and anastomosis for viable bowel. However, their role needs reappraisal in the light of advances in minimally invasive techniques. [Key words: Cecal volvulus; Resec- tional procedures; Nonresectional procedures] Madiba TE, Thomson SR. The management of cecal volvu- lus. Dis Colon Rectum 2002;45:264–267. V olvulus is a condition wherein a loop of bowel and its mesentery twist on a fixed point at the base. It occurs when a large, mobile segment of colon has a narrow, fixed mesenteric attachment, which readily allows axial rotation to occur. 1,2 Once twisted, gas and fluid accumulates in the obstructed loop, leading to distention, ischemia, gangrene, and perfo- ration. 1,2 Volvulus may arise in the sigmoid colon, cecum, splenic flexure, and transverse colon, in de- scending order of frequency. 1–3 Cecal volvulus accounts for 10 to 40 percent of colonic volvulus. 1,4–8 It can be divided into two sub- groups: axial ileocolic volvulus, which accounts for 90 percent of cases, and cecal bascule, which accounts for 10 percent of cases. 1,2,9 In the conventional ileo- colic volvulus the torsion is usually a counterclock- wise rotation in an oblique fashion, also displacing the ileum. 1,9 In cecal bascule the cecum rotates in a horizontal plane anteriorly upward, with the obstruc- tion at the point of folding 1,9,10 A prerequisite for cecal volvulus to occur is an abnormal mobility of the cecum that results from improper developmental fu- sion of the mesentery of the cecum and the ascending colon with the posterior parietal peritoneum in the right gutter. 3–5,9,11 This fact has been confirmed by dissection of adult male cadavers by Wolfer et al. 11 who have shown that 11 percent of the population has a cecum sufficiently mobile to allow the develop- ment of torsion. In another study 12 the cecum was sufficiently mobile in 25.6 percent to allow cecal bas- cule to occur. Despite this anatomic predisposition, the cause and predisposing factors are multifactorial and include adhesions and recent surgical manipula- tion. 3,4 Volvulus of the cecum is common in eastern and western Europe as well as the United States. 5,7,13 The average age at presentation in the West is 53 years, whereas that in India is 33 years. 5 There is no refer- ence in the literature to incidence of cecal volvulus in Africa. No clear-cut gender predisposition exists. 9 The clinical signs and symptoms are not specific, and they vary in intensity depending on the amount of bowel involved and on the degree and duration of the twist. 2,9 Generalized abdominal pain (90 percent), abdominal distention (80 percent), constipation or obstipation (60 percent), and vomiting (28 percent) constitute the usual clinical presentation. 7,9 The diagnosis is rarely made on clinical grounds alone, and abdominal radiographs are the main ad- juncts in diagnosis. 4,5,9,14 A single fluid level may be seen in the dilated cecum, which may be seen located anywhere in the abdomen, depending on its original position, the degree of gaseous distention, and the site, degree, and duration of the twist. Distended small-bowel loops are often present and seen to the right of the dilated cecum, and there is relative ab- sence of gas in the distal colon. 4,5,9,14 Other radiologic findings include a coffee bean sign 4 and a CT whirl sign. 15 The radiologic diagnosis of cecal volvulus can be made with confidence in 90 percent of cases. 14 Differential diagnosis includes gastric dilation, sig- moid volvulus, small intestinal volvulus, and colonic obstruction with a competent ileocecal valve. 2,9,10 Although successful nonoperative decompression by colonoscopy has been reported, 3,16–18 it has not been popular, because of the high failure rate. 1,3,5,18 Address reprint requests to Professor Madiba: Department of Sur- gery, University of Natal, Private Bag 7, Congella 4013, South Africa. 264