Programas
  

Mobile cecum as a syndrome – Is it a myth or a fact?

Autores:

Júlio César M Santos Jr.[1]   TSBCP, Ana Carolina Cavalca[2], Carlos Enrique Quiroz Caso[3]

E mail: instmed@provale.com.br 

 

 Abstract

 Purpose: Mobile cecum is due to an embryological anatomic variation of ascending and/or cecum colon as a result of failure of right colon fusion with lateral peritoneum. This study was designed to evaluate the outcome of cecopexia as a treatment of intermittent abdominal complains of pain, colic, distension, constipation and/or diarrhea in patients managed as having irritable bowel syndrome or others non solved disease.

Patients and methods: From 1996 to 2004, 34 patients (twenty four women and seven men – median age, 39,6 – ranged 3 to 72) seen in private office had clinical diagnosis of mobile cecum. All but seven of them were previously cared as having irritable bowel syndrome (IBS). All patients with medical diagnosis of mobile cecum were programmed for cecopexia. Fifteen refused the surgical treatment and are on clinical follow-up in private office.

Results: All operated patients with fixed cecum followed from 3 to 72 months (median, 19) are well. The non-operated patients followed from 2 to 48 months (median, 21) are with the same complains.

Conclusion: We recommend that all patients with obscure cause for intermittent right lower abdominal pain, distension, colic, constipation or diarrhea with or without diagnosis of IBS must be investigated as sick person probably with mobile cecum needing of cecopexia.

Key words: mobile cecum syndrome, irritable bowel syndrome, intermittent abdominal complains, abdominal pain, colic, diarrhea, constipation, cecal volvulus.

 


Introduction

Mobile cecum is due to an embryological anatomic variation of ascending and/or cecum colon as a result of failure of right colon fusion with lateral peritoneum. This unattachment of ascending and/or cecum colon affords the opportunity for free partial rotation or folding upon itself causing intermittent mechanical intestinal sub obstruction symptoms or, by a complete torsion it causes a volvulus with total intestinal obstruction and segmental ischemia. Contributory factor to the sub occlusive folded cecum are the presence of Jackosn’s membrane or Ladd’s band. 1

That abnormality is found occurring in 10 to 33% of the populations1-6, but  most of references are about complete twist of cecocolon (“volvulus”) with acute complete obstruction frequently involving cecal necrosis.7-14

  This acute condition is an uncommon surgical emergency accounting for less than 2% of cases of adult intestinal obstruction having a high mortality rate.15

A review of 390 cases from 10 series all concerning with cecal volvulus and emergency treatment has demonstrated an overall mortality of 22%.11,15-24

Some articles deal with folded cecum and the intermittent sub occlusive condition, its clinical presentation, signals and symptoms, diagnosis and treatment.1,25-30

The aim of this report is discuss the mobile cecum syndrome as a cause for (lower quadrant) abdominal pain, abdominal distension, and colic from obscure causes in healthy persons with a clinical past characterized by a long history of bowel dysfunction (diarrhea or constipation) who were frequently cared for irritable bowel syndrome.

 

Patients and methods

 

From 1996 to 2004, 34 patients (twenty six women and eigth men – median age, 39,6 – ranged 3 to 72) seen in private office had clinical diagnosis of mobile cecum. All but seven of them were previously cared as having irritable bowel syndrome (IBS) (Table 1).

 

 Tables 1. Patients with diagnosis of cecum mobile syndrome

                           

 Complains

 

Previous diagnosis

 

 

n=34

 

 

age

 

Distension/Pain

 

Constipation/Colic

 

Diarrhea

 

IBS/IPD

 

others

 

M:F

 

8/26

 

39,6

 

33(97%)/26(76%)

 

17(50%)/15(44%)

 

11(32%)

 

27(79,4%)

 

7(20,6%)

 

 

 

 

 

 

 

 

 

M=male; F=female; ipd=inflammatory pelvic disease; ibs=irritable bowel syndrome;

 

Complaint

 

In accordance with patients' judgment, after clinical inquiry we classified the first, the second, and the third most important mentioned symptoms for all patients. (Table 2)

 

     Table 2. Symptoms in accordance with importance graded by patients

Symptoms

First

Second

Third

Number of complains

Pain

24(70,5%)

1(3,%)

1(3%)

26(76,4%)

Distension

9(26,5%)

20(58,8%)

4(11,7%)

33(97%)

Colic

-

9(26,4%)

6(17,6%)

15(44%)

Diarrhea

-

1(3%)

10(29,4%)

11(32%)

constipation

1(3%)

3(8,8%)

13(38,2%)

17(50%)

Total

34

34

34

102

 

Diagnosis

All patients diagnoses were based on clinical observation, and in 16(47%) patients it was confirmed by radiographic contrasted bowel exam with the following technique:

a.       Patients were oriented to take a 40 ml barium meal without previous preparation or altering habitual feeding on the day of the exam, neither before nor after the ingestion of radiological contrast.

b.             Abdominal plain film radiography was taken 5 hours and 10 hours after barium meal including the lesser pelvis in horizontal and standing position.

        Figure 1 to 2 illustrate exams.

 

Figure 1. Patient is on orthostatic position

Figure 2. Patient is on  Trendelemberg's position - 150) 

 

   

  Fig.1                     Fig.2      

 

      

 Fig.3                     Fig. 4                    Fig.5

 

Figure 3 to 4 are X-ray barium enema showing cecal bascule

 

Surgery

 

Eleven patients (8 women and 3 men – median age, 39, - ranged 3 to 72) refusing surgery are on clinical follow-up in private office. Nineteen patients (15 women and 4 men - median age, 39 – ranged 6 to 70) underwent planned operation for cecopexy – 9 with previously confirmed diagnosis by contrasted exam and 10 without radiographic exam, but with confirmed diagnosis on the table.

The cecum-ascending colon was fixed using modifications of the technique described by Dixon and Meyer31 that  consist of an incision made on the peritoneum of the right paracecal and paracolic gutter that is  extended up to include the unattached segment of ascending colon. The mobile cecum or ascending colon is laid in contact with retroperitoneal surface in this uncovered area where it is fixed.27,32

 

Results

All operated patients with fixed cecum followed from 3 to 72 months (median, 19,2) are well. The non-operated patients followed from 2 to 48 months (median, 21) are with the same complains. (Table 3)

 

Table 3. Operated and non-operated patients – outcome and follow-up

                                          

Operated

 

                      

Non-operated

 

 

 

X-ray

 

Outcome

Follow-up

 

 

X-ray

Outcome

Follow-up

 

           n=19

 

 

age

 

Y/N

 

G/R

 

m

 

n=15

 

age

 

Y/N

 

G/U

 

m

 

M:F

 

 

4/15

 

 

39

 

9/10

 

18(94%)/1

 

19

 

4/11

 

39

 

7/8

 

0/15

 

21

M=male; F=female; Y=yes; N=non; G=good; R=regular; m=month; U=unchanged

 

Discussion

Most of the articles published about mobile cecum are concerning with acute abdomen due to obstructive phenomenon caused by a complete torsion of large bowel cecum-ascending segment.7-14

Some authors took interest in mobile cecum as a cause for another abdominal disease. So, they have given reason for demonstration, for example, that dyspareunia may be associated with cecal bascule,1,26,27 besides pointed out26-30 that recurrent cecum torsion must be considered in all causes of intermittent abdominal pain of obscure cause mainly located in right lower quadrant.

In our series patients complained of constipation or diarrhea with intermittent colic, abdominal pain, and distension, most of all previously seen as having IBS were planned for elective surgery consisting of cecopexy because of mobile cecum. The result of surgical management was considered good for all patients since they have felt free of previous symptoms. So, intermittent symptoms carrying to a diagnosis of IBS could also be considered due to mobile cecum, since 79% of patients from this series, most of them women, were managed as a sick person having irritable bowel syndrome.

 Twenty six patients (76,4%) complained pain, 97% abdominal distension, 50% constipation, 44% colic, and 32% diarrhea those are reasonable symptoms for a  mistaken diagnosis of irritable bowel syndrome. Therefore, we recommend that all patients with obscure cause for intermittent right lower abdominal pain, distension, colic, constipation or diarrhea with or without diagnosis of IBS must be investigated as sick person probably with mobile cecum.

 

 

References

1.      Tirol FT. Recurrent cecocolic torsion: “Phantom Tumor”. Abdm Surg 1999, Fall:20-24

2.      Ingelfinger FJ. Intermittent volvulus of the mobile cecum. Arch Surg 1942;45: 156-63.

3.      Wolfer JA, Beaton LE, Anson BJ. Volvulus of the cecum . Anatomical factors in its etiology. Report of a case. Surg Gynec

      Obstet1942;74:882-892.

4.      Donhauser JL, AtweIl S. Volvulus of the cecum. Arch Surg1949;58:129-48.

5.      Meyers JR, Heifetz Cl, Baue AE. Cecal volvulus. Arch Surg1972;104:594-9.

6.      Spitz L. Neonatal intestinal obstruction and intussusceptions in childhood. In Maingot’s Abdominal Operations, p.1054-1062, Chap. 40,

      Appleton-Century-Crofts, Stamford, ed. 1985.

7.      Grodsinsky C, Ponka JL. Volvulus of the colon. Dis Colon Rectum 1977;20:314-24.

8.      Tejler G, Jiborn H. Volvulus of the cecum. Report of 26 cases and review of the literature. Dis Colon Rectum 1988;31:445-9.

9.      Elechi EN, Elechi GN. Intussusceptions: is floating caecum a causative factor? Analysis of 10 cases. East Afr Med J 1990; 67(11):779-84.

10.  Rabinovici R Simansky DA, Kaplan O, Mavor E, Manny J. Cecal volvulus. Dis Colon Rectum 1990;33:765-9.

11.  Gupta S, Gupta SK. Acute caecal volvulus: report of 22 cases and review of literature.Ital J Gastroenterol 1993; 25: 380-384.

12.  Ce HS, Merlo CV, Covatti EL, Zanin RL, Madalosso CA. Volvo de ceco / Volvulum of cecum Rev. med. Hosp. Säo Vicente de Paulo 1994;

      6:52-4.

13.  Ismail A Recurrent colonic volvulus in children. J Pediatr Surg 1997;32:1739-42.

14.  Haller C, Guenot C, Azagury D, Rosso R. Intestinal barotrauma after diving-mechanical ileus in incarceration of the last loop of the small 

      intestine between a mobile cecum and sigmoid. Swiss Surg 2003;9:181-3.

15.  Ballantyne GH, Brandner MD, Beart RW, et al.  Volvulus of the colon. Incidence and mortality. Ann Surg 1985;202:83-92.

16.  Wolf RY, Wilson H. Emmergency operation for volvulus of the cecum. Review of 22 cases. Am Surg 1966;32:96-102.

17.  Andersson A, Bergdhal L, Van der Linden W. Volvulus of the cecum. Ann Surg 1975;181:876–80.

18.  Todd GH, Forde KA. Volvulus of the caecum. Choice of operation. Am J Surg 1979;138:632–4.

19.  Anderson JR, Welch GH. Acute volvulus of the right colon. An analysis of 69 patients. World J Surg 1986;10:336-42.

20.  Påhlman L, Enblad P, Rudberg C, Krog M. Volvulus of the colon. A review of 93 cases and current aspects of treatment. Acta Chir Scand

      1989;155:53–6.

21.  Geer DA. Colonic volvulus: The Army Medical Center experience 1983–1987. Am Surg 1991;57:295–300.

22.  Hiltunen K, Syrja H, Matikainen M. Colonic volvulus. Diagnosis and results of treatment in 82 patients. Eur J Surg 1992;158:607–11.

23.  Benacci JC, Wolff BG. Cecostomy: therapeutic indications and results. Dis Colon Rectum 1995;38:530–4.

24.  Tuech JJ, Becouarn G, Cattan F, Arnaud JP. Volvulus du colon droit. Plaidoyer pour l’hemicolectomie droite. Apropos d’une serie de 23 cas.  

      J Chirurgie 1996;133:267–9.

25.  Tirol FT. Dyspareunia : A symptom of recurrent cecocolic torsion. Abdom Surg 2001;Fall:)

26.  Tirol FT Recurrent cecocolic torsion: radiological diagnosis and treatment JSLS 2003;7(1):23-31.

27.  Rogers LR, and Harford FJ. Mobile cecum syndrome. Dis Colon Rectum 1984;27:399-402. 

28.  Printen KJ. Mobile cecal syndrome in the adult. Am Surg 1976;42:204-5.

29.  Schutter FW, Muller E, Willber B. The mobile cecum – a contribution to the independence of this disease and to its surgical treatment. Z

      Kinderchir 1982;37:6-10.

30.  Ris HB, Stirnemann H, Doran JE. The mobilce cecum syndrome: appendectomy and cecopexy or only appendectomy? Chirurg 1989;60:277-

      81.

31.  Dixon CF, Meyer AC. Volvulus of the cecum. Surg Clin North Am 1948;28:953-63.

32.  Smith WR, Goodwin JN. Cecal volvulus. Am J Surg 1973;126:215-22.