Cecal bascule

Clinical History

A 74-year-old lady was admitted for emergency joint replacement after traumatic hip fracture. The procedure was performed without any complications.
After 4-6 days of progressive constipation, nausea, vomiting and increasing abdominal distention an abdominal X-ray demonstrates dilated, air-filled caecum in the left upper quadrant. A CT examination was performed.

Imaging Findings

Contrast-enhanced CT showed a severe dilation of the caecum, reaching 11 cm width and 30 cm length, with air and faeces within it, but no mesenteric or vascular torsion.
CT did not show any signs of ischaemia, and the small bowel was of a normal calibre.
These findings were subsequently confirmed by surgical procedure, in which a complete right hemi-colectomy with ileocolic anastomosis was performed.

Discussion

Caecal bascule is an extremely rare type of intestinal obstruction, that occurs when a mobile caecum folds upward over the ascending colon across bands that may be congenital, post-operative, or inflammatory, obstructing it through a valvular mechanism. [1, 2]
It accounts only for approximately 0.2% of all intestinal obstructions. [3]
Caecal bascule is classified as type 3 caecal volvulus, different from types 1 and 2, where an axial rotation around the mesenteric axis, including the ascending colon and terminal ileum is involved (type 1 being clockwise and type 2 counter-clockwise). Caecal bascule doesn’t involve any kind of rotation.
Therefore, types 1 and 2 have a higher risk of complications, since the mesenteric torsion can lead to vascular compromise, gangrene, and perforation.

The chance of developing any kind of caecal volvulus is increased during periods of simultaneous medical conditions. 12-28% of the reported cases of acute caecal volvulus involved patients hospitalized for another illness. [4]
Only about 10% of all caecal volvulus cases are caecal bascules. [5]
Some authors do not include caecal bascule as a type of volvulus, since there is no torsion, and the risk of vascular suffering is reduced. [6]

Multi-detector CT of the abdomen is the diagnostic imaging modality of choice, since it can not only show the folded caecum, but also demonstrates any findings suggestive of ischaemia, such as wall thickening, poor mural enhancement or infiltration of the adjacent fat. Reformation of coronal images may be helpful to identify the obstruction site. [7]
Regardless of the cause of caecal distention, a caecal diameter greater than 10-12 cm should be interpreted as a sign of severity, indicating risk of imminent perforation. [1]
Optimal patient management includes metabolic support and early diagnosis, but the definitive therapy for most cases of caecal bascule is surgery. [5]

Differential Diagnosis List

Final Diagnosis

Acute caecal volvulus, type caecal bascule.

URL:	https://www.eurorad.org/case/12277
DOI:	10.1594/EURORAD/CASE.12277
ISSN:	1563-4086