Teaching Case

A 56-year-old female patient was admitted to Emergency Ward because of abdominal pain, alimentary vomiting and obstipation. Clinical examination revealed abdominal pain in lower right quadrant, negative Blumberg sign and peristalsis almost entirely absent. Vital signs were unremarkable.

Abdominal X-ray shows large bowel air-fluid distension in mesogastric region. In the pelvic region there are distended loops of small bowel without physiologic meteorism in the rest of the abdominal quadrants. On the right upper quadrant we can observe a high density image referring to a cholecystic calculus. CT scans show volvulus of large bowel and intestinal malrotation (type “non-rotation”).

Caecal volvulus is a rare entity defined as caecal torsion around its own mesentery. From an epidemiological point of view it accounts for 10-30% of colonic volvulus and 1-3% of cases of intestinal obstruction [1, 2]. We can distinguish some anatomical predisposing factors that determine congenital or acquired hypermobility as the abnormal fixation of the caecum to the posterior parietal peritoneum. Chronic constipation, bowel distension, pregnancy, weight loss, scarring, adhesions, or an abdominal mass that serves as a fulcrum for rotation represent all contributing factors for developing of vovlulus [3]. According to the pathophysiological mechanism, three types of torsion can be detected [2]: axial torsion type (type I), loop type (type II) and caecal bascule type (type III). Common symptoms as colicky abdominal pain, nausea, vomiting, abdominal distension and obstipation (that is to say signs of bowel obstruction) are not specific and may vary with the degree of rotation, duration, and bowel involvement. The imaging role is to demonstrate the level of bowel obstruction and eventually the cause. Most appropriate imaging study is abdomen CT because abdominal radiographic signs can be non-specific (as small-bowel distension, caecal distension, decompression of the distal colon, imaging evidence of caecal haustra). CT signs with high sensibility and specificity are the so called “whirl sign” (twisting of mesenteric fat and vessels at base of caecal twist), severe caecal distension and ectopic location of caecum. Air-fluid levels, distended terminal ileum, ileocaecal twist and distended terminal ileum. The most important differential diagnosis is with the sigmoid volvulus. If not recognized this condition can be complicated by bowel obstruction and then with a vascular compromise followed by gangrene, perforation complications and death. The gold standard treatment is surgery. In the absence of gangrene, the treatment is controversial but may include detorsion and/or caecopexy (fixation of the caecum to the abdominal wall) [1, 4].