Clinical Challenges

What is your diagnosis? - March 2019

A 56-year-old woman with no prior medical history presented to the emergency department with abdominal pain 12 hours after a screening colonoscopy.

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Figure A

The procedure was uneventful with no suspicious masses or lesions detected and no biopsies performed. The patient was discharged to home after recovery from anesthesia, where she slept for several hours. She was awoken with right-sided abdominal pain, nausea, vomiting, and abdominal distension. Her nausea, distension, and abdominal pain worsened as the evening progressed, prompting the patient to seek evaluation at the emergency department.

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Figure B

On examination, she was afebrile with normal vital signs. Her abdomen was mildly distended with right-sided tenderness but no peritoneal signs. Her white blood cell count was 8.5 × 109/L and all of her other laboratory values were normal. An upright abdominal radiograph showed no evidence of free air under the diaphragm, although a markedly dilated colon on the right side was noted (Figure A). An abdominal computed tomography scan was obtained (Figure B).


 

Partial malrotation and cecal volvulus after colonoscopy

The patient presented with partial malrotation and cecal volvulus after colonoscopy, which was confirmed by abdominal computed tomography scan. The patient gave consent and taken urgently to the operating room where she underwent an exploratory laparotomy and right hemicolectomy. Upon entering the abdomen, a mesenteroaxial cecal volvulus was noted immediately. The involved colon segment was dusky without frank necrosis. The distal ascending and proximal transverse colon were tethered to the left abdominal wall, and the ascending colon lacked its usual retroperitoneal attachments, consistent with partial malrotation. The adhesions were lysed, and a right hemicolectomy with primary side-to-side ileocolonic anastomosis was performed. The patient recovered well and was discharged to home on postoperative day 4.

Screening colonoscopy for colorectal cancer is a commonly performed procedure with an established survival benefit. Up to one-third of patients experience abdominal pain, nausea, or bloating afterward, which may last hours to several days. Fortunately, severe complications including hemorrhage, perforation, and death are rare, with a total incidence of 0.28%.1 Although abdominal pain is common after colonoscopy, severe pain that persists or worsens warrants investigation. Perforation is the most frequently encountered complication in this context, although splenic injury/rupture and intestinal obstruction do occur. Cecal volvulus is a very rare complication with few reports in the literature.2,3 Colonic malrotation, which occurs in up to 0.5% of the population, increases the risk of volvulus owing to a lack of retroperitoneal attachments. This diagnosis should be considered for patients with known risk factors for volvulus.

References

1. Whitlock EP, Lin JS, Liles E, et al. Screening for colorectal cancer: a targeted, updated systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149:638-58.

2. Viney R, Fordan SV, Fisher WE, et al. Cecal volvulus after colonoscopy. Am J Gastroenterol. 2002;97:3211-2.

3. Anderson JR, Spence RA, Wilson BG, et al. Gangrenous caecal volvulus after colonoscopy. Br Med J (Clin Res Ed). 1983;286:439-40.

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