Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2000  |  Volume : 6  |  Issue : 3  |  Page : 163-164
Ileo-caecal volvulus post-cesarean section: A case report


Department of Surgery, College of Medicine & King Khalid University Hospital, Riyadh, Saudi Arabia

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Date of Submission06-Feb-1999
Date of Acceptance02-May-2000
 

How to cite this article:
Al Salamah SM, El Keyali AY. Ileo-caecal volvulus post-cesarean section: A case report. Saudi J Gastroenterol 2000;6:163-4

How to cite this URL:
Al Salamah SM, El Keyali AY. Ileo-caecal volvulus post-cesarean section: A case report. Saudi J Gastroenterol [serial online] 2000 [cited 2019 Aug 17];6:163-4. Available from: http://www.saudijgastro.com/text.asp?2000/6/3/163/33480


Caecal volvulus is a rare cause of intestinal obstruction occurring for approximately 1% of cases [1] . It is a surgical emergency caused by the axial twist of the caecum, distal ileum and proximal colon in the absence of normal caecal fixation [2] .

The main differentiating factors in post cesarean large bowel distension are sigmoid volvulus and pseudo-obstruction of colon. Caecal volvulus after cesarean section is rare [3] . Two cases of ileo-caecal volvulus post cesarean section have been reported in the English literature in the last two decades [3],[4].


   Case Report Top


A 30-year-old female patient developed marked abdominal pain, distension accompanied by repeated vomiting and constipation on the fourth day after delivery by lower cesarean section. Her laboratory investigations including serum amylase were normal. The physical examination showed a distended tympanic abdomen with decreased bowel sound and no tenderness. There was no previous abdominal surgery before this cesarean section. The abdominal radiography demonstrated several air-fluid levels of small bowel. There was a markedly dilated fluid filled loop of bowel in the left upper quadrant of abdomen. Despite insertion of a nasogastric tube and parenteral fluid infusion, the abdominal distention was still marked for two days. Contrast bowel meal study showed stopping of the contrast in lower part of the ileum with no visualization of colon.

Computerized tomography (CT) of the abdomen showed a markedly dilated inverted U-shape bowl loop occupying the upper abdomen suggestive of a sigmoid volvulus. Colonoscope reached up to the transverse colon and no pathology was found. The patient condition deteriorated, she developed fever with picture of diffuse abdominal peritonitis. Subsequently, laparotomy revealed fecal peritonitis with rupture of the gangrenous caecal wall. Caecum and terminal ileum were found high in left hypochondrium where it was twisted clockwise. After untwist, the caecum and the proximal part of ascending colon were found to have a long mesentry.

A right hemicolectomy with end-to-end anastomosis was performed. The patient had an unremarkable post-operative course and was discharged on the twelfth day after surgery.


   Discussion Top


Puerperal abdominal surgical emergency is uncommon and tends to occur only after cesarean section [5] .

The most frequent cause of intestinal obstruction in pregnancy and the puerperium is adhesion from previous abdominal operation usually appendectomy. The changes in the position of the abdominal organs after delivery can lead to rotation around these bands of adhesions [5] . Diagnosis of intestinal obstruction tends to be late in the pregnancy and the puerperium

which may result in morbidity [6],[7] . Moreover, abdominal pain and distension, vomiting and constipation are common symptoms in pregnancy which makes the diagnosis more difficult. Plain abdominal radiograph has been reported to be diagnostic of caecal volvulus in only 44-46% of cases. It showed a dilated caecum with a single fluid level and distended loops of small bowel [8] . Contrast enema has been diagnostic in 83-90% of cases [8] . With the increasing use of CT scan as an initial imaging modality in patients with acute abdominal symptoms and for evaluating bowel abnormalities, the "whirl sign" has been diagnostic of bowel volvulus. The actual whirl sign is comprised of the twisted mesentery as well as collapsed bowel loops, which may be seen in case of intestinal volvulus [9] . The surgical treatment of caecal volvulus in the absence of gangrene is controversial. Detorsion with subsequent cecopexy was proposed as a relatively safe procedure [10] . However, because various series have reported a high rate of recurrence after caecal fixation, resection has been advocated for all cases of caecal volvulus [11] . Despite the elimination of possible recurrence, resection should not be performed in patient with viable colon as it has been associated with a two fold mortality rate and increased morbidity as compared with detorsion alone or cecopexy [12] .

In our case, the decision for right hemicolectomy was made straight forward as caecum was gangrenous and ruptured. However, in case of viable bowel, we feel that untwisting and caecopexy will be the proper management.


   Conclusion Top


In conclusion, diagnosis of ileo-caecal volvulus post-cesarean may often be delayed due to its rarity and a consequent tendency to concentrate on other causes of intestinal obstruction as paralytic ileus and adhesion post abdominal operation.

Abdominal x-ray photography revealing a dilated caecum with a single fluid level and a distended loops of small bowel, is often helpful for prompt diagnosis of ileo-caecal volvulus.

 
   References Top

1.Zambarda E, Impieri M. Caecal volvulus: Report of a case and review of the literature. Acta Chir Beig 1984;84:79-82.  Back to cited text no. 1    
2.Rokitansky C. Intestinal strangulation. Arch Gen Med 1837;14:202-6.  Back to cited text no. 2    
3.James Fanning, Do and C Bernard Cross, MD. Post cesarean section caecal volvulus. Am J Obstet Gynecol 1988;158:1200-2.  Back to cited text no. 3    
4.Pratt AT, Donaldson RC, Evertson LR, Yon JL. Caecal volvulus in pregnancy. Obstet Gynecol 1981;57:37-9.  Back to cited text no. 4    
5.Reece EA, Petrie RH. Colonic pseudo-obstruction following obstetrical surgery. Diagnostic Gynecol Obstet 1982;4:275-9.  Back to cited text no. 5    
6.Beck WW. Intestinal obstruction in pregnancy. Obstet Gynecol 1974;43:374-7.  Back to cited text no. 6  [PUBMED]  
7.Munro A, Jones PF. Abdominal surgical emergencies in the purperium. Br Med J 1975;4:691-5.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Rabinovici R, Simansty DA, Koplan O, Mavon Manny J. Caecal volvulus. Dis Colon Rectum 1990;33:765-9.  Back to cited text no. 8    
9.Paul AB, Dean PM. Computed tomography in volvulus of the midgit. Br J Radiol 1990;63:893-4.  Back to cited text no. 9    
10.O'masa CS, Wilson TH Jr, Stonessiger GI, Gameron JL. Caecal volvulus. Ann Surg 1979;189:724-31.  Back to cited text no. 10    
11.Rivas AA, Dennison HC. Volvulus of the caecum. Am Surg 1978;44:332-8.  Back to cited text no. 11  [PUBMED]  
12.Tejler G, Jibom H. Volvulus of the caecum: Report of26 cases and review of the literature. Dis Colon Rectum 1988;31:445-9.  Back to cited text no. 12    

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Correspondence Address:
Saleh M Al Salamah
Consultant General Surgeon, University Unit, Riyadh Medical Complex, P.O. Box 31168, Riyadh 11497
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864713

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