Cecal Volvulus in a 2 - M o n t h - O l d Baby

By Sanjay Khope and P.L.N.G. Rao

Manipal, India

�9 A case of primary cecal volvulus in a 2-month-old boy is reported. He is probably the youngest patient to be reported with this condition. �9 1988 by Grune & Strat ton. Inc.

INDEX WORDS: Cecal volvulus; intestinal obstruction.

W H I L E V O L V U L U S of the c e c u m accoun t s for

t% of all in tes t ina l obs t ruc t ions in adul ts , ~ its

o c c u r e n c e is e x t r e m e l y r a re in ch i ld ren , and even m o r e so in infants . 2

CASE REPORT

V.S., a 2-month-old boy, was admitted on August 31, 1986 with abdominal distension, fever, vomiting, and constipation of 24 hours' duration. Upon examination, the patient was toxic with a pulse rate of 160 per minute, febrile, and apathetic.

The abdomen was silent, tender, tense, and distended with a vague mass in the right lumbar region. Following rectal examination, the child passed normal stools. Since the patient was toxic and the abdomen tender with a vague mass, a clinical diagnosis of acute intestinal obstruction with strangulation of the bowel was made. But for mild anemia, all other investigations were within normal limits. An abdominal x-ray in the vertical position showed a large distended loop occupying the upper abdomen with multiple air fluid levels. As gangrene was suspected, the patient was explored by transverse supraumbilical incision after a brief preoperative resuscitation.

Laparatomy showed a cecal volvulus with clockwise rotation of 180 ~ , with gangrene of the cecum, appendix, and part of the ascending colon. The volvulus was derotated, and resection of gangrenous segment with ileotransverse colostomy was performed. The patient had an uneventful recovery and was discharged on the ninth postoperative day. Upon follow-up 3 months later, the child was doing well.

DISCUSSION

C e c a l volvulus is so r a re in in fan ts and ch i ld ren tha t

its t rue inc idence is u n k n o w n ) '4 In r ev iewing the few

From the Department of Pediatric Surgery, Kasturba Medical College & Hospital' Manipal, India.

Address reprint requests to Dr P.L.N.G. Rao, Official Professor & Head, Department of Paediatric Surgery, Kasturba Hospital' Manipa1576 119, lndia.

�9 1988 by Grune & Stratton, Inc. 0022-3468/88/2311-0021 $03.00/0

i so la ted case reports , 4'5 we fa i led to d i scover any nota-

ble series on this sub jec t in ch i ldren . T h e younges t

pa t i en t r epor t ed in the l i t e r a tu r e was a 10 -mon th -o ld baby. 5

F ree ly mobi l e cecum, which occurs as a resu l t o f

m a l r o t a t i o n a n d / o r i m p r o p e r fus ion o f ceca l mesen-

tery, is an essent ia l p re requ i s i t e for the d e v e l o p m e n t o f

ceca l vo lvu lus? I t can p resen t e i the r as a cu t e fu lmina t -

ing type, wh ich rap id ly progresses to g a n g r e n e as seen

in our case, or as a cu t e obs t ruc t ive type, wh ich resul ts

in r e c u r r e n t col icky a b d o m i n a l pa in wi th r igh t i l iac fossa mass. 6

As in our pa t ien t , mos t of ten the d iagnos is is m a d e

r e t r o s p e c t i v e l y ) P la in fi lms usua l ly show g e n e r a l i z e d

a b d o m i n a l d is tens ion wi th focal d is tension o f the

c e c u m assoc ia ted wi th sma l l bowel obs t ruc t ion . T h e

c e c u m appea r s as a l a rge air-f i l led s t r u c t u r e in the lef t

m i d a b d o m e n or lef t upper q u a d r a n t . A k idney - shaped

a p p e a r a n c e o f the ma lpos i t i oned c e c u m wi th air in t he

i l eum ( sugges t ing the h i l um of the k idney) is be l ieved

to be c h a r a c t e r i s t i c of r igh t colon volvulus. 5 B a r i u m

e n e m a m a y be useful for ch ron ic cases, bu t in acu t e

cases t he pa t i en t ' s gene ra l cond i t ion does not p e r m i t

this inves t iga t ion .

A l t h o u g h opinions di f fer on the cho ice o f ope ra t ive

p rocedure for t he a c u t e obs t ruc t ive type, resec t ion wi th

p r i m a r y anas tomosis , as p e r f o r m e d in our pa t ien t , is

the t r e a t m e n t o f cho ice w h e n e v e r g a n g r e n e is present .

REFERENCES

1. O'Mara CS, Wilson TH Jr, Stonesifer GL, et al: Cecal volvulus: Analysis of 50 patients with a long term followup. Ann Surg 189:724-731, 1979

2. Forshall I: Acquired conditions of colon and rectum, in Mason Brown JJ (ed): Surgery of Childhood, chap 35. London, Edward Arnold, 1962, pp 979-981

3. Bill AH: Malrotation and failure of fixation of intestinal tract, in Holder TM, Asheraft KW (eds): Pediatric Surgery, chap 27. Philadelphia, Saunders, 1980, pp 346-355

4. Hinshaw DB, Carter R, et al: Volvulus of cecum or right colon: A study of 14 cases. Am J Surg 98:175, 1959

5. McGraw JP, Kreman A J, Ringlet LG: The roentgen diagnosis of volvulus of cecum. Surgery 24:793-804, 1948

6. Kirks DR, Swischuk LE, Merten DF, et al: Cecal volvulus in children. A JR 136:419-422, 1981

1038 Journal of Pediatric Surgery, Vot 23, No 11 (November), 1988: p 1038