A 70-year-old man with abdominal pain and vomiting came to our emergency department,
and was found to be in a serious condition. Arterial blood gas analysis showed a pH
of 7.24, with bicarbonate 12.9 mmol/L, lactate 6.51 mmol/L, and anion gap 26.7 mmol/L,
and therefore lactic acidosis was considered. Laboratory results found elevated aspartate
aminotransferase at 463 U/L, alanine aminotransferase at 371 U/L, creatine kinase
at 1566 U/L, and lactate dehydrogenase at 779 U/L. Computed tomography findings indicated
that his cecum was grossly dilated and inverted, and mesenteric whirl signs were also
noted ([Fig. 1]). A diagnosis of cecal volvulus with intestinal necrosis was made.
Fig. 1 Computed tomography scan showing a grossly dilated and inverted cecum, along with
mesenteric whirl signs (arrow).
Despite adequate fluid infusion and noradrenaline administration at high dosage, the
patient’s blood pressure gradually dropped to 60/40 mmHg and he lost consciousness.
An emergency laparotomy was planned, but his general condition was not considered
adequate to undergo this, so endoscopic detorsion of the cecal volvulus was therefore
attempted. A colonoscopy was performed without the patient being sedated to prevent
a further decrease in his blood pressure from such medication, and because he was
already unconscious. When the colonoscope (PCF-H290ZI, with attachment D-201-13404;
Olympus Corp., Tokyo, Japan) was inserted into the ascending colon, white and dark
purple coloring of the twisted site was seen, along with obstruction that prevented
advancement of the colonoscope ([Fig. 2] and [Fig. 3]). After insertion of a guidewire, a thin ileus tube (Hydrophilic Long Intestinal
Tube Type CP-II, 16 Fr; Create Medic Co., Ltd., Kawasaki, Japan) was inserted into
the cecum. The colonoscope was then successfully advanced into the cecum using the
tube as a guide ([Video 1]). The torsion was reduced by suctioning gas and twisting the cecum, and the patient’s
clinical status gradually improved. Thereafter, a laparotomy was performed as previously
planned and the patient was discharged without complications.
Fig. 2 Colonoscopic image of the ascending colon, showing the twisted area (arrow), along
with white and purple discoloration of the mucosa, similarly showing a twisted pattern.
Fig. 3 Fluoroscopic image of the ascending colon with amidotrizoate acid used as a contrast
agent showing twisting and obstruction of the ascending colon (arrow), with contrast
medium unable to pass through the twisted site.
Colonoscopy is performed in a patient with a cecal volvulus showing white and dark
purple coloring, and obstruction in the twisted portion of the ascending colon, which
is successfully treated by advancing a colonoscope into the cecum using an ileus tube
as a guide.Video 1
Unlike for a sigmoid volvulus, endoscopic detorsion is not generally recommended as
initial management for a cecal volvulus, because of its low success rates and the
high risk of intestinal perforation [1]. In the present patient, insertion of an ileus tube loosened the torsion and provided
a guide for advancement of the colonoscope. When emergency surgery is difficult, initial
management by ileus tube-assisted endoscopic detorsion should be considered as a potentially
lifesaving procedure.
Endoscopy_UCTN_Code_TTT_1AQ_2AF
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