Abdominal Pain is a common complaint in children and may be due to a wide variety of conditions, both severe and benign (ex, Appendicitis, Strep Throat, Constipation, and Chronic Recurrent Abdominal Pain). It really can test our clinical skills. Is the presentation more concerning for mechanical issues like intussusception and malrotation? Is it related to unusual causes like cholelithiasis or nephrolithiasis or is it more likely to be a UTI? Often, these questions are not easy to answer. It requires a good history and physical, looking specifically for clues to help lead us to the correct answer. Of course, to know what to ask and what to look for, we have to know the potential conditions are. Let’s take a look at another condition that may cause abdominal pain in at risk children and can be easy to miss – Cecal Volvulus:

Cecal Volvulus: Basic

• Cecal volvulus is rare in children.
  • Although it can be found in all age groups. [Kirks, 1981]
  • True incidence is not known.
  • Correct diagnosis and definitive surgical intervention may be delayed due to unfamiliarity with it. [Kirks, 1981]

• Cecal Volvulus is due to a mobile right colon.
  • Retroperitoneal attachments are lacking, which actually isn’t that uncommon.
  • Allows for rotation around ileocolic artery, impairing blood supply. [Shahramian, 2018]

• Cecal Volvulus is a misnomer: [Kirks, 1981]
  • It involves more than the cecum.
  • The terminal ileum and ascending colon are usually also involved.

• Complications of cecal volvulus include:
  • Cecal Gangrene / Bowel Perforation [Takada, 2007]
  • Death (mortality rate ~10%) [Kirks, 1981]

Cecal Volvulus: Evaluation

• Presentation:
  • Classic symptoms:
    • Abdominal Pain,
    • Distension,
    • Constipation/Obstipation, and
    • Vomiting
  • Typical presentation consists of nonspecific symptoms and findings of intestinal obstruction.
    • May have intermittent pain
    • May also be critically ill due to strangulated bowel or with altered mental status (bad bowel can make kids look “odd” or “off” – see Intussusception and Altered MS).

• Imaging: [Kirks, 1981]
  • Ultrasound
    • Not typically used, but Color Doppler can identify twisted mesenteric vessels. [Takada, 2007]
  • Plain Abdominal Xrays
    • May show generalized distension and small bowel obstruction.
    • Cecum may be dilated and located in the left mid-abdomen or left upper quadrant.
    • Look for “coffee bean” or “kidney-shaped” area of dilation. [Shahramian, 2018; Vo, 2005]
    • Findings of Airless rectum and dilated colon are sensitive, but not specific. [Shahramian, 2018; Marine, 2017]
  • Contrast Enema
    • Mainstay of diagnostic imaging [Folaranmi, 2012; Phillips, 2010]
    • “Bird-beak” obstruction of the ascending colon which points toward the dilated cecum can be seen.

• Management:
  • Some advocate for using endoscopic reduction in selected cases. [Shahramian, 2018]
    • Can only be attempted in stable patients without evidence of bowel compromise. [van de Lagemaat, 2018]
    • Necrosis, mucosal ulceration, or dark blood seen during procedure suggest strangulation and necessitates surgery. [Shahramian, 2018]
  • Surgery is most often required.
    • Colon resection and stoma formation may be required for necrotic bowel.
    • Cecopexy can be performed if bowel is viable. [Takada, 2007]

Cecal Volvulus: Risk Factors/Associations

• Chronic Constipation
• NeuroDevelopmental Delays (may obscure your ability to get a clear history and/or exam)
• Chronic Neurologic Conditions (ex, Cerebral Palsy, Cornelia de Lange Syndrome) [Takada, 2007]
• Malrotation
• Postoperative Ileus
• Recent Weight Loss
• Distal Colon Obstruction (ex, Hirschsprung’s)
• Intraperitoneal Adhesions
• Pregnancy

Moral of the Morsel

• Rare doesn’t mean Never. Be vigilant, especial with at risk patients (ex, kids with neurodevelopment delays and/or chronic constipation).
• Early detection saves bowel! Keep intestinal catastrophe and cecal volvulus on your list of concerns for the patient with abdominal distension.
• Constipation can be a problem and it can CAUSE a Problem! Don’t be cavalier and attribute the current condition to the child’s history of constipation.

References