Should cecal volvulus be managed differently in HIV-positive patients?

May 24, 2007

John J. Chi, Medical Student, College of Medicine; Emand Kandil, Chief Resident, Department of Surgery; Hatem Moussa, Clinical Associate Professor, Department of Surgery; Alexander Schwartzman, Chief of Surgery, Department of Surgery; Michael Zenilman, Chairman, Department of Surgery, State University of New York? Downstate Medical Center, Brooklyn, NY

John J. Chi, MA Medical Student

College of Medicine

Emad Kandil, MD Chief Resident

Department of Surgery

Hatem Moussa, MD Clinical Associate Professor

Department of Surgery

Alexander Schwartzman, MD Chief of Surgery

Department of Surgery

Michael Zenilman, MD Chairman

Department of Surgery

State University of New York—Downstate Medical Center

Brooklyn, NY

Cecal volvulus is a life-threatening surgical emergency caused by malrotation of the cecum, which results in partial or complete bowel obstruction and subsequent vascular impairment to the bowel. We report the case of a 52-year-old man who presented with abdominal pain and distension. The patient had a history of acquired immunodeficiency syndrome (AIDS), hepatitis C, and intravenous drug abuse. He had no surgical history. The patient was found to have peritoneal signs and underwent emergent exploratory laparotomy, which revealed cecal volvulus.

Case report

A 52-year-old man presented to the Kings County Hospital emergency department because of a 3-day history of abdominal distension, suprapubic abdominal pain, nausea, vomiting, and loss of appetite. He also reported a change in bowel habits, having had no bowel movement or flatus for 3 days. The patient described experiencing a similar episode 2 years earlier for which he underwent nasogastric tube decompression and was discharged home without consequence.

The patient’s medical history was significant for human immunodeficiency virus (HIV) seropositivity and AIDS, which was diagnosed in 2000. Additional comorbidities included chronic hepatitis C, tuberculosis, diabetes mellitus, hypertriglyceridemia, and hypertension. His medications included abacavir/lamivudine and fosamprenavir calcium. The patient had a history of intravenous drug abuse. He had not undergone any previous abdominal surgeries.

The patient had a temperature of 100.8° F, blood pressure of 110/70 mm Hg, and a heart rate of 92 beats per minute. Upon physical examination, his abdomen was distended and tenderness was appreciated in the hypogastrium upon palpation. Guarding with rebound tenderness was present. No bowel sounds could be auscultated. A stool sample was guaiac-positive.

Abdominal radiographs demonstrated multiple air-filled dilated loops of small bowel in the left upper quadrant of the abdomen with a paucity of gas in the colon. Air fluid levels were also present, and small bowel loops were noted to stack on each other. These findings were consistent with small bowel obstruction (Figure 1). A contrast-enhanced computed tomography (CT) scan of the abdomen showed a dilated stomach and a small bowel with air-fluid levels to the distal ileum (Figure 2). Both the ascending and distal colon had collapsed, with small amounts of air and stool present in the transverse colon (Figure 3). These findings were consistent with a small bowel obstruction at the level of the distal ileum.

Laboratory evaluations revealed a white blood cell count of 7.13 x 103/mL, pH of 7.447, and bicarbonate of 26.1 mmol/L. The patient’s most recent CD4 cell count dated 2 weeks before his admission was 106 µL, with a CD4 of 10% and an HIV-1 viral RNA fewer than 400 copies/mL.

The patient was taken to the operating room for an exploratory laparotomy. Intraoperatively, an axial cecal volvulus with a massively distended ileum and proximal cecum were found. Early signs of strangulation necrosis were noted at the volvulus and surrounding area. A right hemicolectomy and distal ileal resection were performed, followed by an ileocolic anastomosis. The patient experienced an uncomplicated postoperative recovery and regained bowel function on postoperative day 6. He was discharged home on postoperative day 8.

Gross pathological examination of the specimen revealed a massively dilated cecum and ileum with early signs of necrosis (Figure 4). Microscopic examination revealed multifocal cecal mucosal necrosis. The specimen margins were viable, and the appendix was unremarkable.

Discussion

Cecal volvulus is a surgical emergency that requires prompt treatment to prevent significant morbidity and mortality. The condition is caused by malrotation of the cecum, which results in a partial or complete bowel obstruction with subsequent vascular impairment to the bowel. Cecal volvulus is the second most common type of colonic volvulus after volvulus of the sigmoid colon.1 Since Rokitansky’s discussion of cecal volvulus in 1837,2 investigations have identified a wide range of incidences, etiologies, and other factors that need to be considered in managing this condition.

Age, geographical, and race-related variations in the incidence of cecal volvulus have been reported.3 A review of 568 cases of cecal volvulus suggested that the average age of presentation in the Western world is 53 years,4 whereas a review of 22 patients in India established an average age of 33 years.5 Other studies have reported differing age ranges of incidence, including a Mayo Clinic review of 71 patients with a mean age of 58 years.1,6,7 While some reviews have found the preponderance of occurrences in women,4 others note a greater incidence in men.6 Although age, geography, and race appear to affect the epidemiology of cecal volvulus, the relative infrequency of the condition has prevented definitive answers on the subject, except to suggest that its epidemiology is variable.

Cecal volvulus typically presents as a distal closed-loop small bowel obstruction. Patients exhibit symptoms consistent with bowel obstruction, including abdominal pain, distension, constipation, obstipation, nausea, and vomiting.1,8 A history of self-limited cecal volvulus is reported in some patients.1 Abdominal pain is the most common presenting symptom, and abdominal distension is the most common finding upon physical examination.4 The severity of the clinical presentation depends on the degree and duration of the resultant bowel obstruction and the patient’s comorbidities.9

Anatomy The two general types of cecal volvulus are axial ileocolic torsion and cecal bascule. Axial ileocolic torsion results from rotation of the distal ileum and proximal colon around a mesenteric axis. This rotation leads to twisting of the mesentery and blood vessels, occluding the arterial supply and resulting in venous and lymphatic drainage. In cases of cecal bascule, there is no true rotation; the cecum folds transversely and superiorly over the ascending colon. Although cecal bascule does not cause torsion of the vasculature or mesentery, it may still lead to necrotic bowel due to distension and resultant ischemia of the bowel. In one Mayo Clinic study, axial ileocolic torsion accounted for 90% of cases and cecal bascule accounted for 10%.1 Regardless of the type, incomplete fixation of the bowel during embryological development is a major contributing factor in the development of volvulus.

The cecum normally lies in the right lower quadrant of the abdomen. The cecum is derived from the embryologic midgut and receives its blood supply from the superior mesenteric artery via the ileocolic artery. During embryological development, the midgut temporarily enters the umbilical cord and rotates counterclockwise about the superior mesenteric artery before re-entering the abdominal cavity. After re-entry, the cecum and ascending colon become fixed to the retroperitoneum. If this fixation does not occur properly, there is increased mobility of the cecum and ascending colon, which allows for the formation of a cecal volvulus. Malrotation of the intestine during embryological development is another predisposing factor for volvulus.10

The caliber of the large intestine is greatest at the cecum; thus, in accordance with Laplace’s law, the cecum is susceptible to the greatest amount of wall tension. This increased tension puts the cecum at increased risk for gangrene and perforation in the event of a large bowel obstruction.

Etiology Review of the current literature suggests a multifactorial etiology for cecal volvulus. Implicated factors include pregnancy, distal bowel obstruction, adhesions, institutionalization, and recent surgical or endoscopic manipulation of the bowel.1,3,8,11 Additionally, a hypermobile cecum appears to be necessary but not sufficient for the development of cecal volvulus.4 This point was illustrated in a Northwestern University Medical School examination of 125 cadavers, which found that approximately 37% of the cecums had enough mobility to allow the development of a cecal volvulus.1,12 Based on this study, it can be assumed that the incidence of cecal volvulus in the general population does not approach the incidence of hypermobile cecum, and other factors may play a role in the development of cecal volvulus.

Diagnosis The diagnosis of cecal volvulus usually can be established based upon clinical presentation, abdominal radiographs, and CT scans.3,4,8 The clinical presentation of distal small bowel obstruction suggests pathologies such as small intestinal volvulus, sigmoid volvulus, and large bowel obstruction with a competent ileocolic valve. Radiographic findings suggestive of cecal volvulus include the coffee bean sign and the bird beak sign. The coffee bean sign is produced by a focal collection of air in the bowel, giving the cecum the appearance of a coffee bean.13 The “point” of the coffee bean sign in cecal volvulus is usually directed toward the left upper quadrant.1 The bird beak sign can be elicited with a barium enema contrast study and appears when there is cessation of contrast flow at the point of torsion. Although a barium enema has been shown to be diagnostic in 88% of cases, it should not be used in patients for whom the diagnosis is clear or in those at high risk for perforation.4

While the clinical presentation of cecal volvulus may be varied and images on abdominal radiographs are dependent upon the orientation of fluid- and air-filled loops of bowel, CT scanning correctly identifies and locates this condition, making this modality essential in evaluating cecal volvulus.13 The CT scan finding of a whirl sign is highly suggestive of volvulus. This sign is caused by soft tissue density bowel loops whirling around a point of torsion with low-attenuating mesentery and enhancing blood vessels radiating from the bowel.13 The result is a CT image that resembles a hurricane on a weather map.14

Treatment Treatment of cecal volvulus focuses on early diagnosis and decompression of the volvulus to prevent the complications of necrosis and perforation. Options for management are largely surgical and include detorsion, detorsion and colopexy, resection with colostomy, and resection with primary ileocolic anastomosis.3 Of these options, resection with colostomy has been associated with the highest rates of complications, mortality, and recurrence. Detorsion alone and colopexy are associated with the lowest rates of complications, mortality, and recurrence.4 The selection of treatment options depends heavily upon the patient’s clinical presentation and the state of the bowel upon laparotomy. The presence of gangrene mandates resection of the right colon with the option of colostomy or primary anastomosis. When the bowel is viable and intact, the choice of surgical procedures lies with the surgeon and remains a controversial one.

Anecdotal reports of nonsurgical treatment via colonoscopic decompression and barium enema have been reported in the literature. These findings, however, have not been consistently achievable and both procedures carry an increased risk of colonic perforation.6 One study found spontaneous resolution of the cecal volvulus in 2% of patients taken to the operating room for laparotomy.4

Surgical considerations for HIV and AIDS patients In 2004, over 400,000 persons were living with HIV or AIDS in the United States.15 The advent of highly active antiretroviral therapy (HAART) has prolonged the life expectancy of HIV-positive patients and altered the course of the disease.16 As a result, HIV-positive individuals appear to be at greater risk of contracting illnesses observed in individuals not infected with HIV.

Prior to the HAART era, surgical intervention for cecal volvulus was associated with little improvement in outcome. Moreover, since nonspecific abdominal pain is common among HIV/AIDS patients, the emphasis was placed upon early detection of illness followed by appropriate treatment, whether medical or surgical.17,18 The tendency toward conservative nonsurgical management appeared prudent in light of the fact that many HIV/AIDS-related illnesses, such as Kaposi’s sarcoma and cytomegalovirus infection, rarely required surgical intervention. Only when gastrointestinal bleeding, obstruction, or perforation complicated these illnesses was there impetus for surgery.18 Because surgery usually was reserved for clinically unwell patients suffering from the complications of these illnesses, the corresponding morbidity and mortality rates were expectedly high, ranging from 57% to 86%. With the advent of the HAART era, the morbidity and mortality rates declined to 11% and 19%, respectively.19 As surgical morbidity and mortality in HIV-positive patients approaches that of HIV-negative patients, the benefits of early surgical intervention for HIV/AIDS-related illnesses and non— HIV/AIDS-related illnesses will continue to become more apparent.

Surgical emergencies such as appendicitis occur with the same frequency in HIV-positive patients as in non—HIV-positive patients and, following surgical intervention, equivalent outcomes are observed in both groups.19 One study suggested that only 11% of HIV-positive patients presenting with acute abdominal pain had an HIV/AIDS-related cause20; therefore, the presentation of an acute abdomen in an HIV-positive patient cannot be assumed to be related to the HIV/AIDS diagnosis. One review suggested that prolonged workups and errors in diagnosis were frequent in the evaluation of the acute abdomen in HIV/AIDS patients.18 There is also little preoperative evidence to assist the physician in distinguishing between AIDS-related and non—AIDS-related disease.18 While early and decisive intervention in the HIV-positive population has been correlated with improved outcomes, consideration of HIV/AIDS-related causes, although necessary, may delay the diagnosis of a common non—HIV/AIDS- related condition.

Conclusion

An early diagnosis is the essential first step in managing cecal volvulus. While nonsurgical modalities for reducing cecal volvulus would prevent the morbidity and mortality associated with surgery, there is currently no evidence to support the regular use of such interventions. Surgery remains the accepted approach in managing cecal volvulus, but selection of the best surgical procedure to use remains controversial.

Further complicating the presentation of cecal volvulus is the increasing comorbidity of HIV/AIDS and its associated considerations. The presentation of the acute abdomen in the HIV/AIDS patient could be due to HIV/AIDS-related causes or non—HIV/AIDS-related causes; therefore, cecal volvulus should be considered in the differential diagnosis of the acute abdomen in any HIV/AIDS patient presenting with abdominal pain.

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