Cecal Volvulus in Children

Cecal Volvulus in ChildrenAbdominal 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

Miura da Costa K1,2, Saxena AK1. A systematic review of the management and outcomes of cecal and appendiceal volvulus in children. Acta Paediatr. 2018 Jun 27. PMID: 29949184. [PubMed] [Read by QxMD]

Shahramian I1, Bazil A2, Ebadati D3, Rostami K3, Delaramnasab M2. Colonoscopic decompression of childhood sigmoid and cecal volvulus. Turk J Gastroenterol. 2018 Mar;29(2):221-225. PMID: 29749331. [PubMed] [Read by QxMD]

van de Lagemaat M1, Blink M1, Bakx R2, de Meij TG3. Cecal Volvulus in Children: Is There Place for Colonoscopic Decompression? J Pediatr Gastroenterol Nutr. 2018 Feb;66(2):e59-e60. PMID: 28953530. [PubMed] [Read by QxMD]
Kapadia MR1. Volvulus of the Small Bowel and Colon. Clin Colon Rectal Surg. 2017 Feb;30(1):40-45. PMID: 28144211. [PubMed] [Read by QxMD]

Marine MB1,2, Cooper ML3,4, Delaney LR3,4, Jennings SG4, Rescorla FJ5, Karmazyn B3,4. Diagnosis of pediatric colonic volvulus with abdominal radiography: how good are we? Pediatr Radiol. 2017 Apr;47(4):404-410. PMID: 28246899. [PubMed] [Read by QxMD]

Lee EK1, Kim JE, Lee YY, Kim S, Choi KH. A case of cecal volvulus presenting with chronic constipation in lissencephaly. Pediatr Gastroenterol Hepatol Nutr. 2013 Jun;16(2):131-4. PMID: 24010118. [PubMed] [Read by QxMD]

Folaranmi SE1, Cho A, Tareen F, Morabito A, Rakoczy G, Cserni T. Proximal large bowel volvulus in children: 6 new cases and review of the literature. J Pediatr Surg. 2012 Aug;47(8):1572-5. PMID: 22901919. [PubMed] [Read by QxMD]

Takada K1, Hamada Y, Sato M, Fujii Y, Teraguchi M, Kaneko K, Kamiyama Y. Cecal volvulus in children with mental disability. Pediatr Surg Int. 2007 Oct;23(10):1011-4. PMID: 17653554. [PubMed] [Read by QxMD]

Phillips G1, Parisi MT. Cecal volvulus: classic imaging appearance of an uncommon pediatric entity. Pediatr Radiol. 2010 Dec;40 Suppl 1:S98. PMID: 20336289. [PubMed] [Read by QxMD]
Kirks DR, Swischuk LE, Merten DF, Filston HC. Cecal volvulus in children. AJR Am J Roentgenol. 1981 Feb;136(2):419-22. PMID: 6781272. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

You may also like...

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.