Anal Fistula

Caecal volvulus is torsion of a mobile caecum, terminal ileum and often ascending colon around their mesenteric axis, causing closed loop large bowel obstruction.

A related variant, caecal bascule, occurs when the mobile caecum folds anteriorly without classic axial torsion.

Caecal volvulus carries substantial risk of strangulation, gangrene and perforation and differs fundamentally from sigmoid volvulus because endoscopic decompression is unreliable.

• Presentation resembles small or large bowel obstruction with acute abdominal pain, vomiting, distension and constipation.
• Pain can be right sided, central or diffuse depending on the position of the displaced caecum.
• Continuous pain, guarding, fever, tachycardia or haemodynamic deterioration suggests ischaemia or perforation.

Obtain full blood count, electrolytes, renal function and lactate.

CT abdomen and pelvis with IV contrast: identifies a markedly displaced dilated caecum with mesenteric twisting and assesses bowel viability.

Caecal volvulus is primarily a surgical disease.

Unlike sigmoid volvulus, routine colonoscopic decompression should not be attempted. ASCRS reports successful endoscopic reduction in only about 14 percent of historical cases and recommends surgery as initial treatment because failed attempts delay definitive care and may cause perforation.

Resuscitate with IV crystalloid, correct electrolytes and use nasogastric decompression when vomiting or associated small bowel distension is significant.

If ischaemia or perforation is suspected, start enteric Gram negative and anaerobic coverage:

Ceftriaxone 2 g IV every 24 hours plus metronidazole 500 mg IV every 12 hours.

Proceed to operative treatment.

Segmental resection is the preferred definitive treatment.

For viable bowel in a physiologically stable patient, right hemicolectomy or ileocaecal resection with primary ileocolic anastomosis provides definitive treatment with a low recurrence risk.

Gangrenous or perforated bowel requires resection. The decision between primary anastomosis and diversion depends on haemodynamic stability, perfusion, contamination, bowel oedema and overall physiological reserve.

Nonresectional procedures such as detorsion with caecopexy may occasionally be considered when bowel is viable and resection risk is exceptionally high, but recurrence is higher and resection remains preferred.

Caecostomy carries substantial morbidity and is generally reserved for highly selected patients in whom definitive resection cannot be safely performed.