I asked this question more than a year ago in this forum and never got an answer.
I do not believe that cecal volvulus can anatomically exist. This empirical nomenclature misdirects the diagnosis of practitioners, however, a recent article was published about " Cecal Volvulus mimicking Ogilvie's Syndrome..." in Annals of Med and Surg., London, May 2016". The picture looks like Cecocolic Torsion with Psedocystic configuration previously described elsewhere.
The two entities in the article above mentioned, are different nosologic problems. While Cecal torsion is a mechanic problem, the Ogilve syndrome y a functional problem and yes it can be demonstrated clinical, radiological and endoscopically and those findings can be correlated atvthe time of surgery when you find a rather large cecum detached from the retroperitoneum with thickening of that structure and the chances to reproduce the torsion manually. Best regards.
Dear Dr Tirol
As you study the paper or references , all about cecal volvulus is usually case reports.
like cecal volvulus in endometriosis or due laparoscopy procedure .
I recommend to read this paper:
J Clin Diagn Res. 2015 Apr; 9(4): PJ01.
Published online 2015 Apr 1. doi: 10.7860/JCDR/2015/13112.5806
PMCID: PMC4437115
Cecal Volvulus-A Diagnostic Challenge
T. Anil Balraj,corresponding author1 M. Jagan Mohan,2 and Sridhar Reddy P3
Author information ► Article notes ► Copyright and License information ►
A 12-year-old male child with mental retardation and cerebral palsy since birth on treatment was admitted with pain and distension of abdomen since three days and vomiting since two days. He was not passing stools and flatus since three days. On examination, abdomen was distended and tense. There was tenderness on palpation and tympanic note all over abdomen on percussion. On per rectal examination, rectum was empty and no flatus was observed on passing the flatus tube.
Initial X-ray abdomen in erect position showed dilated bowel loops filling the upper abdomen occupying both the hypochondria [Table/Fig-1a]. We managed conservatively by doing continuous nasogastric aspiration and passing flatus tube for 24 h. X-ray abdomen was repeated after 24 h which showed no much difference compared to the previous film [Table/Fig-1b]. Abdominal ultrasonography showed gaseous distended bowel loops without any free fluid in abdomen. Routine laboratory investigations including serum electrolytes were within normal limits.
[Table/Fig-1a]:
[Table/Fig-1a]:
X-Ray abdomen erect on admission
[Table/Fig-1b]:
[Table/Fig-1b]:
X-Ray abdomen erect after 24 h
Based on the above findings, we suspected intestinal obstruction as the primary cause and planned for exploratory laparotomy. On exploration, it was found that, there was a gross dilatation of cecum, ascending colon and hepatic flexure and twisted around the mesocolon by two turns clock wise as the cecum and ascending colon was not fixed [Table/Fig-2a]. There was congestion of bowel which improved on oxygenation [Table/Fig-2b]. Hence, cecostomy was done after decompressing the colon by passing flatus tube per anus. Post operatively, patient improved and passed stools freely on third post operative day. Cecostomy drain was removed on ninth post operative day and he got discharged on 10th day. On follow up, he was doing well after three months.
[Table/Fig-2a]:
[Table/Fig-2a]:
Showing dilated cecum, ascending colon, and transverse colon
[Table/Fig-2b]:
[Table/Fig-2b]:
Showing congested bowel viable after detorsion of volvulus
We would like to give attention to this uncommon cause of intestinal obstruction, which might be overlooked during the first hours after its onset and lead to serious sequelae, including cecal necrosis. Preoperative diagnosis of cecal volvulus is rarely achieved in most cases because of its rarity and non specific presentation [1]. Plain X-ray abdomen is the initial diagnostic test of choice in case of obstruction due to cecal volvulus [2]. It shows coffee bean sign where an axial view of dilated cecum with air and fluid pointing to left upper quadrant. Radiographs, however, will clearly diagnose the condition in less than 20% of the cases [3]. As in our case, we made an early diagnosis of cecal volvulus by serial radiological findings and clinical monitoring. Thus on exploration, detorsion made cecum viable and cecopexy with tube was performed. Prompt recognition and urgent treatment may avoid gangrenous changes of the bowel, which is believed to be an important cause of high morbidity and mortality.
Dear Dr. Mahmoodzadeh and Esparza, Thank you for your discussion. = Nomenclature not withstanding, a great case. You however have not described an anatomical cecal volvulus but described a typical, classical Cecocolic Torsion resulting from an unfixed and mobile cecocolon. If indeed it completed two 360 degrees of torsion into a volvulus (regardless whether it is clockwise or counterclockwise) there should have been strangulation and also involvement of the ileum and its mesentery. There should have been strangulation of the ileo-cecocolon also but by its absence I suspect that you had a cecocolic torsion. It explains why there was still a viable cecum and ascending colon up to the hepatic flexure because the blood supply via the right colic and ileocolic were not torsed and obstructed completely. It allowed you to perform a cecopexy which automatically created fixation..
My youngest patient was 16 months old with cecocolic torsion reduced by gastrografin enema and my oldest was 76 years old also mistaken for Ogilvie's cured with cecopexy. The undiagnosed cases result from waiting for a "volvulus" .With index of suspicion, diagnosis is not difficult. The poor suffering patients with recurrent RLQ pains are often mistaken for IBS, Appendicial colic, (multiple) had pelvic surgeries, etc., etc..
I can not imagine the reality of a true anatomical cecal volvulus. Pictures? If it were an innocuous diagnostic nomenclature we can forego this discussion as mere empirical terminology, however, even up to six months ago, I had an 18 year old female who already had cholecystectomy and appendectomy and was still was suffering from recurrent RLQ pain, who.was cured after a cecocolopexy after being diagnosed as having recurrent cecocolic torsion.
Please google : Cecocolic Torsion, Classif.,Clinical Diagnosis, Treatment : J.Soc Laparoendosc Surg, 2005; Congenital Hyperrotated colon, Abdmn. Surg.Winter/Spring 2015. Please see bibliography for more references.
Regards.
I treated a single case in 1975, no question that it was an oleo-caecal valveless with several twists and a highly mobile caecum. I have not seen another in 40 years!
Dear Dr. Motson,
Did you mean colo-cecal volvulus? If the level of the volvulus/twist (360 degrees or more of torsion) was at the ascending colon, was the ileum also included in the twist? Was there a Parietocolic Band or a Jackson's membrane? Did you have a coffee bean sign x-ray?
A mobile cecum can not twist 360 degrees because it is shorter than wide and it has no mesentery. It has no mesocolic vasculature but has the anterior and posterior cecal arteries which is the reason why it does not strangulate readily when it folds.After multiple torsions and spontaneous resolutions, it becomes a chronic affair usually misdiagnosed or undiagnosed. . It can swing and fold and obstruct called a Cecal Bascule by the French. I finally operated on a patient in 1979 for recurrent right lower abdominal colics after several missed diagnosis by me and several physicians and surgeons. Eventually I encountered three more cases, and published those three in Abdominal Surgery in 1998. I even called them Phantom Tumors in respect to the English surgeon who coined the term in 1858. Being aware of the diagnosis, I encountered more variants and felt the " obligation of duty" to inform the medical world so I published and delivered talks about them specially at the Laparoendoscopic Society in 2005 in New York. If there is any one out there who will take my offer, I will mail a fresh, crisp hundred dollar bill to the first person who can show me a picture proof of a Cecal Volvulus or a cecum in a 360 degrees of torsion . As I suggested in the preceding communication, anyone who is didactically interested in perusing the topic may and can Google them easily. A profusion of pictures in those articles. will visually explain why Cecal Volvulus is an empirical knee-jerk diagnostic misnomer which can be morbidly misdirecting because it does not exist anatomically.
Dear Dr. Zakaria,
Cecal Volvulus not only is rare but is non-existent. What is usually seen is Cecocolic Torsion which is misnamed as volvulus. The exemplifying pictures that one sees are schematic line drawings in Ellis of Maingot"s Textbook of Abdominal Operations, many more drawings elsewhere, and Ponsky in Cameron's Surgical Therapy, 7th Edition. This latter also depicts in photograph a Cecal volvulus but if you carefully analyze it you will notice that the ileum is normal, the torsion is at the ascending colon, and the cecum has normal configuration. I duplicated this picture angle and it published it as Fig. 2 in Tirol, FT: Congenital Hyperrotated Colon; Abdm. Surg., Winter/Spring:2016, 11-15. For a more detailed information, please google: Tirol, F.T.: Cecocolic Torsion: Classification, Pathogenesis, and Treatment; Journ Soc. Laparoendosc. Surg, 20056:328:334. The bibliography has more sources. I welcome your email if you so desire to communicate with me.Thank you for your comment.
I meant ileo-caecal and not just the caecum and took the two terms to be synonymous. As you really do mean just caecal I am sad to say I cannot claim your $100 bill!
Dear Dr. Motson,
Fair enough! I will continue to keep my 100 dollar bill in escrow just in case I am wrong. After all, I know that I do not walk on water.
The reason why the nomenclature of "Volvulus of the Cecum" should be purged from medical terminology is because it does not exist, it can not exist anatomically, it is not an innocuous misnomer because it is diagnostically misdirecting. It masks the symptoms of the other variants secondary to the congenital or acquired lack of fixation of the cecocolon , whether with normal rotation or Congenitally Hyperrotated. The variants include acute or chronic and recurrent: Cecal Bascule, Recurrent Cecocolic Torsion, PseudoTumor, Pseudocyst, Pseudoobstruction, Phantom Tumor (described by Dr. Gill, London, 1858). These torsions are facilitated by Jackson's and also by Parieto-colic membrane when present ( Ladd's membrane iin Malrotation).
I also habitually missed diagnosing these variants because I was academically chained to this myth from textbooks and journals and, per reflex, looking for a Cecal Volvulus. All the while it was Recurrent Cecocolic Torsions. I blamed many diagnoses including Appendiceal colic, Irritable bowel syndrome, Ogilvie's syndrome, Chilaiditi's, Pelvic problems when associated with dyspareunia, Phantom tumors, etc.. After I stopped calling it Volvulus my mind opened via another diagnostic perspective to recognize the other pathological entities that I mention above. This was simply because I lost the mentally inhibiting influence by adhering stubbornly to the term volvulus of the cecum.
I have seen only one case. This was a 26 year old male who had gut malrotation. His caecum was on the left side at exploratory laparotomy. We thought pre -op that it was a sigmoid volvulus. He didn't have situs inversus. No way we could have made the diagnosis preoperatively.
Dear Dr. Irabor,
= If the cecum was part of Malrotation then it had no right paracolic gutter attachment. A volvulus of the cecum is not possible unless it also involved the ileum and colon and therefore it was a cecocolic Volvulus.
= if it was a Congenitally Hyperrotated Colon it would also be untethered to the right gutter and would also swing to the left hemiabdomen and involve both the ileum an ascending colon.
= A pure Cecal Volvulus CANNOT exist because it is an anatomical Impossibility!
= Please google Cecocolic Torsion by TIrol and find more references in bibliography.
= If you have a picture of your Cecal Volvulus case please forward me one for proof, then I will send you the 100 bucks
Sincerely,
Dr. Tirol
Dear Irabor,
= The cecum is normally located at the right iliac fossa because the Colon rotates 270 degrees. When it is malrotated ( underrotated) the usual obstructioni is the 2nd segment of the duodenum by a Ladd’s band. Congenital Hyperrotation has NOT been written up that I know of until I did in 2015 complete with pictures. Volvulus in this instance involves the ileum and ascending Colon so it is cecocolic. This is sometimes facilitated by a parietocolic band I have described elsewhere. Cecal bascule occurs facilitated likewise by a band when present. The easiest diagnostic maneuver is a positional gastrografin enema regardles the level of the colic obstruction. Please google the article recommended as it will help. Best regards. Dr. Tirol
most often than not it is a cecocolic volvulus. Till now i have seen isolated cecal volvulus in just a single case...and that also the caecum was rotated by 180 degrees back on itself...more appropriately called as a caecal bascule
Dear Dr. Rashad,
= Do you have a picture of a Cecal Volvulus which is a Cecum that is rotated 360 degrees upon itself? Was it strangulated? If you do, please send me a picture and I’ll mail you the 100 dollars forthwith!
= Rotation by only 180 degrees is a TORTION and until it COMPLETELY rotates 360 degrees you DO NOT have a Volvulus.
= Perhaps you saw (or have a picture of ) what the French workers in the field call a Cecal Bascule, to wit: a cecum that has swung and FOLDED upon itself anteriorly facilitated by a Jackson’s membrane. I published picturesvof it in my articles which you can google.
= To this day I still can not believe that a Cecal Volvulus exists. Please prove me wrong!
Very respectfully,
Dr. Tirol
The cecum is too small to undergo volvulus alone without including the terminal ileum. Francisco has not clarified whether he thinks Cecal volvulus includes or is the same as ileo-cecal volvulus, possibly because the answer might cost him $100!
Dear Dr. Motson,
= A pleasure to hear from you.
=We (I) who went through extra morphological training by subaudition regard the line that demarcates the cecum from the ascending colon as that line where the inferior border of the ileum is extended to cross the colon. This is the level where the anterior and posterior cecal arteries start to supply the cecum and where the apppendicial artery also starts. The root of the appendix also begins here. The ileum is supplied only by the ileal artery and the ascending colon by the mesocolic artery.
= A Cecal Volvulus by definition should only include the Cecum in a 360 degrees of completed torsion. It can not occur because 1. It is too short 2. It can not torse 360 degrees 3. It can only fold (the French call it a Bascule) 4. A Jackson’s membrane that acts as a fulcrum may be present ( Thorek 1937 - not an adhesion) 5. It should strangulate the blood supply if it were a completed torsion.
= Ergo: The factual implication is that Cecal Volvulus can not exist by itself. It ceases to be that diagnosis if one includes the ileum and the ascending colon and does not complete 360 degrees of torsion. It can only be an ileocecocolic or ileocolic torsion or volvulus but NOT a cecal volvulus.
= What impelled me to dig into this topic was because I kept missing the diagnosis of Recurrent Cecal Bascule and/or Cecocolic Torsion and its variants because that academic eidolon or mythological diagnostic misnomer Cecal Volvulus became an arms-length reflex diagnosis. The English physicians in the 1850’s were more justified in calllng it “Phantom Tumor”.
= I am emancipated from that terminology and have written several articles on Cecocolic Torsion and Congenital Hyperrotation of the Colon which you can google and dig into the bibliography for more.
=I still have the hundred and I will raise it to 150 bucks.
Regards,
F.T.TIROL
Dear F.T Tirol sir,
I too have always failed to imagine a true cecal volvulus. But if I find one in the 'magic-box' someday, I ll definitely try to get a prize of 100 bucks!
:)
Dear Doctor Nabi,
= I raised the prize to $150.00.
= The clinical conceptual peril of believing in Cecal Volvulus is awaiting for it diagnostically and missing more mundane diagnoses of right lower abdominal quadrant problems.
= In Latin it is an ”ignis fatuus”.
FTTirol, MD.
With your tighter definition of Cecal volvulus, which excludes ileo-caecal volvulus you can safely raise the prize money to US$1000,000! You will not lose!!
Dear Dr. Motson,
= You are correct!
= It should now be obvious why this ‘very’ strict definition is necessary! Perhaps you now realize that this question is a leading attempt at presenting the topic previously NOT found in publications that I know of, to wit: the proved anatomical FACT of Congenital Hyperrotation ( or Overrotation ) of the Colon. Why is this topic ignored by the millions of medical authorities to this day? Anyone can Google this topic written by me in 2005, Abdominal Surgery with contrast xrays, pictures, and case reports?
= And yet, there is a plethora of Malrotation (Underrotation) of the Colon topics!
= Ileocecocolic Volvulus is the only possible entity that CAN occur! ......AND ....only if there is a Hyperrotation of the Colon and/or absent coloparietal peritoneal attachment.
= This is the only answer to that will-o-the-wisp Cecal Volvulus divulged and unmasked by inductive anatomical embryolical analysis with proof of facts by pictured cases. Those honest and wise British workers in the field since 1830’s and 1850’s called it Phantom Tumor and I laud them by not calling it Cecal Volvulus, a misleading misnomer.
FTTirol
Dear Everyone!
= After all these (> 20) years that I have written and posed this challenge, there is NO ONE out there who can prove the existence of the IMAGINED entity Cecal Volvulus....because it CANNOT occur.
= At this era, I am chagrined and scandalized at how the medical community can be so pathologically obstinate and so factually obdurate as to insist on the terminology of a nonexistent entity! It is not a harmless foible when physicians in contemplating actual clinical differential diagnoses await a misleading myth and end up with a disastrous complication! It has happened to me in 1998 ( article on Phantom Tumor) and I do not want nor wish it would happen to any physician out there! ( Subsequent articles on Cecocolic Torsion).
= The $200.00 prize is still here!
= Prove me wrong!
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