Massive Cecal Dilation: Pseudoobstruction versus Cecal volvulus? Hugo V. Villar, MD, Tucson, Arizona Lawrence W. Norton, MD, Tucson, Arizona
Acute massive dilation of the cecum and right colon, without evidence of distal obstruction, is a well recognized complication in sick, bedridden patients. This condition, first described by Sir Heheage Ogilvie [I] in 1948, is termed pseudoobstruction or ileus of the colon. If untreated, distension can cause perforation, peritonitis, and death. Pseudoobstruction of the colon may be difficult to distinguish from other causes of colonic dilation, such as cecal or sigmoid volvulus or acute gastric dilation. Within one year, seven patients were encountered with massive distension of the right colon. Differential diagnoses and treatment options in these patients form the basis for the present report.
ease, and peripheral occlusive vascular disease washospitalized after a stroke. Hemiplegia gradually disappeared over the next week, but the patient remained semicomatose. Ten days after admission, progressive abdominal distension was noted. Plain abdominal x-ray films revealed a dilated cecum with a transverse diameter of 15 cm. A preoperative diagnosis of cecal volvulus was made, and because of progression of the cecal dilation (19 cm), the patient was explored. The anterior taenia were split from the cecum up to the hepatic flexure. Mucosa protruded throughout the taenia but appeared intact. A 3 cm area of necrosis was apparent in the anterior wall of the cecum. Cecostomy was performed after resection of the necrotic area. The patient died four days later from pulmonary failure. No evidence of peritonitis was present at necropsy.
Case Reports
Case III. A sixty-eight year old man with chronic renal failure was admitted to the hospital in congestive heart failure. He had two episodes of ventricular tachycardia and cardiac arrest with successful resuscitation. Four days after admission, progressive abdominal distension developed. A plain abdominal x-ray film revealed a distended cecum with a transverse diameter of 17 cm. Exploration revealed a massively distended cecum with splitting of the anterior taenia. Cecostomy was performed. Recovery was uneventful until the eighteenth postoperative day when he had another episode of ventricular tachycardia with cardiac arrest and could not be resuscitated.
Case I. A fifty-five year old white male with chronic obstructive pulmonary disease of ten years’ duration was hospitalized after falling at home. Spine x-ray films showed a compression fracture of Ll. Two days later massive abdominal distension developed, which progressed steadily over the next four days. Minimal abdominal discomfort was present. Abdominal x-ray films showed marked dilation of the cecum with a transverse diameter of 17 cm. Evidence of small bowel obstruction was present. A preoperative diagnosis of cecal volvulus was made, and the patient was explored. The cecum was massively dilated with splitting of the two anterior taenia coli and extrusion of mucosa. Several areas of patchy necrosis were present. The ascending and proximal transverse colon was dilated in decreasing degrees. Right hemicolectomy with end ileostomy and mucous fistula was performed. His postoperative course was complicated by brief, unexplained bleeding from the sigmoid colon and the development of gout. Four months later ileotransverse colostomy was performed uneventfully. Case II. A sixty-eight year old white male with chronic obstructive pulmonary disease, atherosclerotic heart disFrom the Department of Surgery, University of Arizona Health Sciences Center, Tucson, Arizona. Reprint requests should be addressed to Hugo V. Villar, MD, Department of Surgery, University of Arizona Health Sciences Center, Tucson, Arizona. Presented at the Thirtieth Annual Meeting of the Southwestern Surgical Congress, Palm Springs, California, April 17-20, 1978.
170
Case IV. An eighty-one year old woman was admitted with a two week history of fever and progressive muscle weakness. A diagnosis of Guillain-Barre syndrome was made. Four days after admission abdominal distension developed. A plain abdominal x-ray film revealed a distended cecum and right colon with a transverse diameter of 16.5 cm. Sigmoidoscopy was normal. In spite of nasogastric suction and enemas, the cecal diameter increased over the next 12 hours to 19 cm. At laparotomy, a massively distended cecum and right colon with splitting of the anterior taenia and extrusion of mucosa were found. An area of necrosis, approximately 2 cm in diameter, was present in the cecum. Cecostomy was performed after removal of this necrotic area. No free perforation was present. The patient had complete and immediate resolution of her cecal distension and was discharged, after several weeks, with some residual weakness.
The American Journal of Surgery
Massive Cecal Dilation
Case V. A seventy-two year old man with chronic obstructive pulmonary disease, asthma, and heart failure was admitted after being involved in an automobile accident. Multiple rib fractures were present without a hemo- or pneumothorax. One week after admission abdominal distension developed. Plain x-ray films of the abdotien revealed a distended cecum, right colon, and proximal half of the transverse colon. Cecal diameter was 15 cm. Proctoscopy was normal. Because of no improvement in spite of nasogastric decompression and enemas, an attempt at decompression with the fiberscope was made. Colonoscopy was quite easily performed and allowed aspiration of the cecum, ascending colon, and transverse colon. The distension disappeared and did not recur. Case VI. A fifty-one year old alcoholic woman, with liver cirrhosis and portal hypertension, was admitted with jaundice and mild ascites. One week after admission progressive abdominal distension developed with a large airfilled loop of large intestine in the middle upper abdomen. The transverse diameter of the cecum was 16 cm. A diagnosis of cecal volvulus was made, and because of the abdominal distension, laparotomy was performed. Cecal volvulus was found and reduced. She did well postoperatively until the fifteenth day when progressive renal failure developed. Death occurred on the twenty-fifth postoperative day. Necropsy revealed a cirrhotic liver, portal hypertension, and no other intraabdominal problems. Case VII. A sixty-two year old chronic alcoholic man was admitted with progressive abdominal distension, nausea, and vomiting. A plain abdominal x-ray film revealed a massively distended loop of large intestine in the left upper quadrant and evidence of small bowel obstruction. The transverse diameter of the loop was 16 cm. A preoperative diagnosis of cecal volvulus was made. He was explored 6 hours later and a cecal volvulus was confirmed and reduced. He did well postoperatively and was discharged on the tenth postoperative day.
Comments
Acute massive dilation of the cecum and right colon not associated with distal large bowel obstruction was first described by Ogilvie [I] in 1948. He referred to this condition as “large intestine colic due to sympathetic deprivation.” Robertson, Eddy, and Vosseler [2] in 1958 reported on the first patient with perforation of the cecum associated with Ogilvie’s syndrome. Two months later, Eckman, Wenzke, and Abramson [3] reported a similar case. This syndrome has been described after orthopedic and general surgery, cesarian section, vascular reconstruction, alcoholism, carcinoma, trauma, and aortocoronary bypass surgery [4-101. The condition usually occurs in elderly, sick, bedridden patients who have had an associated major system disorder or an operation not directly involving the gastroin-
Volume 197, Fobwary 1979
Figure 1. Pseudoobstruction of the colon. Massive segmental dilation of the cecum and ascending colon. Some gas is present in the descending colon and rectum.
testinal tract. It is more common in males than in females and is associated with a significant morbidity and mortality. Massive cecal and right colon distension will eventually lead to splitting of the taenia and necrosis of the bowel wall. With equal pressure throughout the colon, the greatest distension will occur in the portion of the colon with the largest diameter, the cecum. This explains the predilection of perforations to occur in the cecum [Ill. The cause of massive dilation of the cecum and right colon is unknown. Ogilvie [I] attributed the ileus to secondary interference with the sympathetic nerve supply to the colon. Dunlop [12] in 1949 thought it was possibly due to colonic muscle imbalance secondary to interruption of sympathetic pathways to the large intestine. As a result of this imbalance, coordinated activity between the proximal and distal parts of the colon could be lost. McFarland [5] considered dilation to be secondary to “spastic ileus” or “enter0 spasms.” The predominant clinical symptom is rapidly progressive abdominal distension. The abdomen is usually soft, without peritoneal signs. Nausea and vomiting are strikingly absent. Nasogastric tube aspirate is usually small in volume and clear, not characteristic of small bowel obstruction. The single best aid for diagnosis is the plain abdominal x-ray film. In pseudoobstruction the colon dilation is usually segmental, with marked distension of the cecum and ascending colon. Some gas is usually present in the descending cdlon and rectum. Small bowel distension is usually absent. Some of these features are shown in Figure 1.
171
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Figure 2. Case IV. Pseudoobstruction of the colon, Intraoperative view of a massively distended cecum.
Once the diagnosis of pseudoobstruction of the established, initial treatment begins with nasogastric decompression. Sequential abdominal films should be obtained every 12 hours to evaluate the degree of cecal distension. Lowman and David [13] called attention to the increased risk of perforation of the cecum when the transverse diameter is more than 9 cm. On the other hand, Adams [4] suggested 12 cm as the cutoff point. We believe that an initial 24 to 48 hours of conservative therapy is indicated, because some of these cases will resolve spontaneously. If there is not dramatic clinical improvement, that is, diminution in the transverse diameter of the cecum, decompression should be attempted. Exploratory laparotomy and construction colon is
of a tube cecostomy is, we believe, a safe procedure. It is simple, expedient, and curative, and is well tolerated even by critically ill patients. In a series of fourteen patients reported by Adams (41 who were treated with cecostomy, twelve fully recovered and eleven ultimately left the hospital. As the cecum and proximal colon dilate, anterior taeniae tear, allowing extrusion of mucosa. Such splitting can be confined to the cecum or extended to the hepatic flexure. The presence of taenia splitting was previously thought to mandate right colectomy as a means of preventing peritoneal contamination [B]. The current series of patients demonstrates that even with taenia splitting, decompression of bowel by cecostomy is sufficient to prevent perforation and peritoneal sepsis. An absolute indication for resection is patchy necrosis of colon over wide areas (case I). When nonviable bowel is localized to a single area a few centimeters in diameter (cases II and IV), excision of dead tissue and use of the defect as a site for cecostomy seem reasonable. In no case was cecostomy followed by perforation of adjacent cecum or leakage from the stoma site. Figure 2 shows the massively distended cecum and right colon in one of our patients who underwent tube cecostomy. Figure 3 shows the distended cecum and the splitting of the taeniae with extrusion of mucosa as seen at the time of exploration. Careful handling of the distended bowel during exploration is critical to prevent accidental perforation. The mortality of cecal perforation in patients with pseudoobstruction of the colon has been reported to be 46 per cent [9]. The high mortality attending perforation of the colon is, in part, due to the severity of associated diseases. It is also in some measure related to delay in operative intervention. Two of our five patients with pseudoobstruction died as a consequence of associated complications.
Figure 3. Pseudoobsiruction of the colon. Distended cecum and splitting the of anferlor taeniae. Extrusion of mucosa can be clearly seen. 172
The American Journal of Surgery
Massive Cecal Dilation
Figure 5. Cecal volvulus. Distended loop of large bowel in the upper abdomen. There is evidence small of bowel obsiruction proximal lo the volvulus.
Figure 4. Acute gasiric dilation a in diabetic pafieni with a 10 per cent Note burn. the massive distended loop of bowel in the left upper quadrant.
Kukora and Dent [14] reported in 1977 on six patients with massive cecal dilation in whom they were able to decompress the cecum and right colon with the use of fiberoptic colonoscopy. This is, we believe, a viable alternative which should be considered. Our experience with our last case confirms this result. The massive dilation of the colon made insertion of the colonoscope easier than anticipated. The differential diagnosis of a massively distended abdomen with a large air-filled intestinal loop on the plain abdominal x-ray film included cecal and sigmoid vo1vu1us, acute gastric dilation, and pseudoobstruction. All such patients should have their stomachs emptied through a nasogastric tube to rule out acute gastric dilation. Both acute gastric dilation and cecal volvulus may present as a large gas-filled viscus in the left upper quadrant. Figure 4 shows an acute gastric dilation that developed in a diabetic patient which might be confused with distension of the colon. In cases of cecal vo1vulus, the plain abdominal x-ray film will demonstrate, as shown in Figure 5, a large, distended loop of bowel with a central linear density in the left upper quadrant. Some evidence of Volume 137, February 1979
a small bowel obstruction proximal to the point of torsion could be present. In contrast, in patients with sigmoid volvu1us, the plain abdominal x-ray film will show, as in Figure 6, a large air-filled loop of intestine usually in the right upper quadrant, with its convex surface facing the right lower quadrant due to the counterclockwise rotation of the redundant sigmoid loop. Features of small bowel obstruction are usually absent. Distension of the ascending colon proximal to the sigmoid volvulus may be present. If the diagnosis is not clear on the plain abdominal film, a proctoscopic examination should be done. Frequently, proctoscopic examination and insertion of a large rectal tube will reduce a sigmoid volvulus. Similar results can be accomplished with the flexible colonoscope [15]. In contrast, insertion of a rectal tube and even performance of a barium enema will very rarely reduce a cecal volvulus or decompress a pseudoobstruction of the colon. The use of barium enema in the diagnosis of massively distended intestinal loops is desirable if the correct diagnosis cannot be made with plain abdominal x-ray and proctoscopy. Obviously, it should not be undertaken if there is any sign of peritonitis. In addition to differentiating among sigmoid and cecal volvulus and pseudoobstruction, barium enema will rule out any distal lesion that may be present in patients with cecal volvulus. 173
Villar and Norton
7. 8.
9.
10.
11. 12. 13.
14. 15.
Figure 6. Stgmoid volvulus. Distended bowel, of loop mostly in the right upper quadrant; some air is present in the transverse and descending colon proximal to the point of torsion.
Summary
Seven patients with acute and progressive abdominal distension secondary to massive cecal and right colon ileus are analyzed. Five had pseudoobstruction of the colon and two had cecal volvulus. Two of the patients with pseudoobstruction and one with cecal volvulus died from preexisting diseases. Pseudoobstruction of the colon is not a rare complication of elderly, sick, bedridden patients. Differential diagnoses include cecal and sigmoid volvulus and acute gastric dilation. Initial conservative therapy is warranted if no peritoneal signs are present. If the cecal diameter is more than 12 cm, colonoscopic decompression with a fiberscope should be attempted. If unsuccessful, tube cecostomy will provide curative, life-saving therapy even if taenia splitting is present. Perforation or widely scattered areas of necrosis make resection mandatory. References 1. Ogilvie H: Large intestine colic due to sympathetic deprivation. BrMedJ2: 671, 1948. 2. Robertson JA, Eddy WA, Vosseler AJ: Spontaneous perforation of the cecum without mechanical obstruction. Am J Surg 96:
174
448, 1958. Eckman WG, Wenzke F. Abramson W: Perforation of the cecum J 96: 718, 1958. complicating adynamic ileus. Am Surg Adams JT: Adynamic ileus of the colon. Arch Surg 109: 503, 1974. MacFarlane JA, Kay SK: Ogilvie’s syndrome of false colonic obstruction. Br Med J 2: 1287, 1949. MacManus Cl, Krippaehne Ww: Diastatic perforation of the cecum without distal obstruction. Arch Surg 112: 1227, 1977. Morton, JH, Schwartz SI, Gramiak R: lleus of the colon. Arch Surg 81: 425, 1980. Norton, L, Young D, Scribner R: Management of pseudo-obstruction of the colon. Surg Gynecol Obsfet 138: 595, 1974. Wojtalik RS, Lindenauer SM, Kahn SS: Perforation of the colon associated with adynamic ileus. Am J Surg 125: 601, 1973. Yeo R: Spontaneous perforation of the caecum; case reports and a review of the literature. PostgradA&d J 43: 65, 1967. Ravid, JM: Diastasls and diastatic perforation of the gastrointestinal tract. Am J fathol27: 33, 1949. Dunlop JA: Dgilvie’s syndrome of false colonic obstruction. Br Med J 1: 890, 1949. Lowman RM, David L: An evaluation of cecal size in impending perforation of the cecum. Surg. GynecolObstet 103: 7 11, 1958. Kukora JS, Dent TL: Colonoscopic decompression of massive nonobstructive cecal dilation. Arch Surg 112: 512, 1977. Ghazi A, Shinya H, Wolff WI: Treatment of volvulus of the colon by colonoscopy. Ann Surg 183: 263, 1976.
Discussion
Albert J. Kukral (Oklahoma City, OK): Are you able to get your gastroenterologists to perform colonoscopy for a cecal volvulus or a cecal dilation? ErichW. Pollak,(Kansas City, MO): Dr.Villar, hatie you had any recurrences of pseudoobstruction in the patients with the method described? Raymond 0. Frederick (St. Louis, MO): I question the wisdom of watching these patients or correcting electrolyte levels over a 24 or 48 hour period. A volvulus or pseudovolvulus is an acute emergency, and I think the general feeling is that they should be operated on immediately. Hugo V. Villar (closing): We think the patients should be observed at least 12,to 24 hours because they are quite sick to begin with. Each one of these patients was admitted to the hospital for something else. If you are following them quite closely, some of the massive cecal dilations will disappear, and surgery will be avoided. Obviously, it is an individual decision; there were cases in which, as you suggest, we operated right away. We perform our 0~ colonoscopies, so we do not have to convince anybody. There were six patients described in the October issue of AFC~~WS of Surgery [14],in whom colonoscopy was performed successfully. -We were very encouraged by that. This is why we did it in the last case. None of our patients died from peritoneal contamination. They all died from the main disease that motivated their admission. Pseudoobstruction is more common than cecal volvulus.
The American Journal of Surgery
Acute massive dilation of the cecum and right colon, without evidence of distal obstruction, is a well recognized complication in sick, bedridden patients. This condition, first described by Sir Heheage Ogilvie [I] in 1948, is termed pseudoobstruction or ileus of the colon. If untreated, distension can cause perforation, peritonitis, and death. Pseudoobstruction of the colon may be difficult to distinguish from other causes of colonic dilation, such as cecal or sigmoid volvulus or acute gastric dilation. Within one year, seven patients were encountered with massive distension of the right colon. Differential diagnoses and treatment options in these patients form the basis for the present report.
ease, and peripheral occlusive vascular disease washospitalized after a stroke. Hemiplegia gradually disappeared over the next week, but the patient remained semicomatose. Ten days after admission, progressive abdominal distension was noted. Plain abdominal x-ray films revealed a dilated cecum with a transverse diameter of 15 cm. A preoperative diagnosis of cecal volvulus was made, and because of progression of the cecal dilation (19 cm), the patient was explored. The anterior taenia were split from the cecum up to the hepatic flexure. Mucosa protruded throughout the taenia but appeared intact. A 3 cm area of necrosis was apparent in the anterior wall of the cecum. Cecostomy was performed after resection of the necrotic area. The patient died four days later from pulmonary failure. No evidence of peritonitis was present at necropsy.
Case Reports
Case III. A sixty-eight year old man with chronic renal failure was admitted to the hospital in congestive heart failure. He had two episodes of ventricular tachycardia and cardiac arrest with successful resuscitation. Four days after admission, progressive abdominal distension developed. A plain abdominal x-ray film revealed a distended cecum with a transverse diameter of 17 cm. Exploration revealed a massively distended cecum with splitting of the anterior taenia. Cecostomy was performed. Recovery was uneventful until the eighteenth postoperative day when he had another episode of ventricular tachycardia with cardiac arrest and could not be resuscitated.
Case I. A fifty-five year old white male with chronic obstructive pulmonary disease of ten years’ duration was hospitalized after falling at home. Spine x-ray films showed a compression fracture of Ll. Two days later massive abdominal distension developed, which progressed steadily over the next four days. Minimal abdominal discomfort was present. Abdominal x-ray films showed marked dilation of the cecum with a transverse diameter of 17 cm. Evidence of small bowel obstruction was present. A preoperative diagnosis of cecal volvulus was made, and the patient was explored. The cecum was massively dilated with splitting of the two anterior taenia coli and extrusion of mucosa. Several areas of patchy necrosis were present. The ascending and proximal transverse colon was dilated in decreasing degrees. Right hemicolectomy with end ileostomy and mucous fistula was performed. His postoperative course was complicated by brief, unexplained bleeding from the sigmoid colon and the development of gout. Four months later ileotransverse colostomy was performed uneventfully. Case II. A sixty-eight year old white male with chronic obstructive pulmonary disease, atherosclerotic heart disFrom the Department of Surgery, University of Arizona Health Sciences Center, Tucson, Arizona. Reprint requests should be addressed to Hugo V. Villar, MD, Department of Surgery, University of Arizona Health Sciences Center, Tucson, Arizona. Presented at the Thirtieth Annual Meeting of the Southwestern Surgical Congress, Palm Springs, California, April 17-20, 1978.
170
Case IV. An eighty-one year old woman was admitted with a two week history of fever and progressive muscle weakness. A diagnosis of Guillain-Barre syndrome was made. Four days after admission abdominal distension developed. A plain abdominal x-ray film revealed a distended cecum and right colon with a transverse diameter of 16.5 cm. Sigmoidoscopy was normal. In spite of nasogastric suction and enemas, the cecal diameter increased over the next 12 hours to 19 cm. At laparotomy, a massively distended cecum and right colon with splitting of the anterior taenia and extrusion of mucosa were found. An area of necrosis, approximately 2 cm in diameter, was present in the cecum. Cecostomy was performed after removal of this necrotic area. No free perforation was present. The patient had complete and immediate resolution of her cecal distension and was discharged, after several weeks, with some residual weakness.
The American Journal of Surgery
Massive Cecal Dilation
Case V. A seventy-two year old man with chronic obstructive pulmonary disease, asthma, and heart failure was admitted after being involved in an automobile accident. Multiple rib fractures were present without a hemo- or pneumothorax. One week after admission abdominal distension developed. Plain x-ray films of the abdotien revealed a distended cecum, right colon, and proximal half of the transverse colon. Cecal diameter was 15 cm. Proctoscopy was normal. Because of no improvement in spite of nasogastric decompression and enemas, an attempt at decompression with the fiberscope was made. Colonoscopy was quite easily performed and allowed aspiration of the cecum, ascending colon, and transverse colon. The distension disappeared and did not recur. Case VI. A fifty-one year old alcoholic woman, with liver cirrhosis and portal hypertension, was admitted with jaundice and mild ascites. One week after admission progressive abdominal distension developed with a large airfilled loop of large intestine in the middle upper abdomen. The transverse diameter of the cecum was 16 cm. A diagnosis of cecal volvulus was made, and because of the abdominal distension, laparotomy was performed. Cecal volvulus was found and reduced. She did well postoperatively until the fifteenth day when progressive renal failure developed. Death occurred on the twenty-fifth postoperative day. Necropsy revealed a cirrhotic liver, portal hypertension, and no other intraabdominal problems. Case VII. A sixty-two year old chronic alcoholic man was admitted with progressive abdominal distension, nausea, and vomiting. A plain abdominal x-ray film revealed a massively distended loop of large intestine in the left upper quadrant and evidence of small bowel obstruction. The transverse diameter of the loop was 16 cm. A preoperative diagnosis of cecal volvulus was made. He was explored 6 hours later and a cecal volvulus was confirmed and reduced. He did well postoperatively and was discharged on the tenth postoperative day.
Comments
Acute massive dilation of the cecum and right colon not associated with distal large bowel obstruction was first described by Ogilvie [I] in 1948. He referred to this condition as “large intestine colic due to sympathetic deprivation.” Robertson, Eddy, and Vosseler [2] in 1958 reported on the first patient with perforation of the cecum associated with Ogilvie’s syndrome. Two months later, Eckman, Wenzke, and Abramson [3] reported a similar case. This syndrome has been described after orthopedic and general surgery, cesarian section, vascular reconstruction, alcoholism, carcinoma, trauma, and aortocoronary bypass surgery [4-101. The condition usually occurs in elderly, sick, bedridden patients who have had an associated major system disorder or an operation not directly involving the gastroin-
Volume 197, Fobwary 1979
Figure 1. Pseudoobstruction of the colon. Massive segmental dilation of the cecum and ascending colon. Some gas is present in the descending colon and rectum.
testinal tract. It is more common in males than in females and is associated with a significant morbidity and mortality. Massive cecal and right colon distension will eventually lead to splitting of the taenia and necrosis of the bowel wall. With equal pressure throughout the colon, the greatest distension will occur in the portion of the colon with the largest diameter, the cecum. This explains the predilection of perforations to occur in the cecum [Ill. The cause of massive dilation of the cecum and right colon is unknown. Ogilvie [I] attributed the ileus to secondary interference with the sympathetic nerve supply to the colon. Dunlop [12] in 1949 thought it was possibly due to colonic muscle imbalance secondary to interruption of sympathetic pathways to the large intestine. As a result of this imbalance, coordinated activity between the proximal and distal parts of the colon could be lost. McFarland [5] considered dilation to be secondary to “spastic ileus” or “enter0 spasms.” The predominant clinical symptom is rapidly progressive abdominal distension. The abdomen is usually soft, without peritoneal signs. Nausea and vomiting are strikingly absent. Nasogastric tube aspirate is usually small in volume and clear, not characteristic of small bowel obstruction. The single best aid for diagnosis is the plain abdominal x-ray film. In pseudoobstruction the colon dilation is usually segmental, with marked distension of the cecum and ascending colon. Some gas is usually present in the descending cdlon and rectum. Small bowel distension is usually absent. Some of these features are shown in Figure 1.
171
Villar and Norton
Figure 2. Case IV. Pseudoobstruction of the colon, Intraoperative view of a massively distended cecum.
Once the diagnosis of pseudoobstruction of the established, initial treatment begins with nasogastric decompression. Sequential abdominal films should be obtained every 12 hours to evaluate the degree of cecal distension. Lowman and David [13] called attention to the increased risk of perforation of the cecum when the transverse diameter is more than 9 cm. On the other hand, Adams [4] suggested 12 cm as the cutoff point. We believe that an initial 24 to 48 hours of conservative therapy is indicated, because some of these cases will resolve spontaneously. If there is not dramatic clinical improvement, that is, diminution in the transverse diameter of the cecum, decompression should be attempted. Exploratory laparotomy and construction colon is
of a tube cecostomy is, we believe, a safe procedure. It is simple, expedient, and curative, and is well tolerated even by critically ill patients. In a series of fourteen patients reported by Adams (41 who were treated with cecostomy, twelve fully recovered and eleven ultimately left the hospital. As the cecum and proximal colon dilate, anterior taeniae tear, allowing extrusion of mucosa. Such splitting can be confined to the cecum or extended to the hepatic flexure. The presence of taenia splitting was previously thought to mandate right colectomy as a means of preventing peritoneal contamination [B]. The current series of patients demonstrates that even with taenia splitting, decompression of bowel by cecostomy is sufficient to prevent perforation and peritoneal sepsis. An absolute indication for resection is patchy necrosis of colon over wide areas (case I). When nonviable bowel is localized to a single area a few centimeters in diameter (cases II and IV), excision of dead tissue and use of the defect as a site for cecostomy seem reasonable. In no case was cecostomy followed by perforation of adjacent cecum or leakage from the stoma site. Figure 2 shows the massively distended cecum and right colon in one of our patients who underwent tube cecostomy. Figure 3 shows the distended cecum and the splitting of the taeniae with extrusion of mucosa as seen at the time of exploration. Careful handling of the distended bowel during exploration is critical to prevent accidental perforation. The mortality of cecal perforation in patients with pseudoobstruction of the colon has been reported to be 46 per cent [9]. The high mortality attending perforation of the colon is, in part, due to the severity of associated diseases. It is also in some measure related to delay in operative intervention. Two of our five patients with pseudoobstruction died as a consequence of associated complications.
Figure 3. Pseudoobsiruction of the colon. Distended cecum and splitting the of anferlor taeniae. Extrusion of mucosa can be clearly seen. 172
The American Journal of Surgery
Massive Cecal Dilation
Figure 5. Cecal volvulus. Distended loop of large bowel in the upper abdomen. There is evidence small of bowel obsiruction proximal lo the volvulus.
Figure 4. Acute gasiric dilation a in diabetic pafieni with a 10 per cent Note burn. the massive distended loop of bowel in the left upper quadrant.
Kukora and Dent [14] reported in 1977 on six patients with massive cecal dilation in whom they were able to decompress the cecum and right colon with the use of fiberoptic colonoscopy. This is, we believe, a viable alternative which should be considered. Our experience with our last case confirms this result. The massive dilation of the colon made insertion of the colonoscope easier than anticipated. The differential diagnosis of a massively distended abdomen with a large air-filled intestinal loop on the plain abdominal x-ray film included cecal and sigmoid vo1vu1us, acute gastric dilation, and pseudoobstruction. All such patients should have their stomachs emptied through a nasogastric tube to rule out acute gastric dilation. Both acute gastric dilation and cecal volvulus may present as a large gas-filled viscus in the left upper quadrant. Figure 4 shows an acute gastric dilation that developed in a diabetic patient which might be confused with distension of the colon. In cases of cecal vo1vulus, the plain abdominal x-ray film will demonstrate, as shown in Figure 5, a large, distended loop of bowel with a central linear density in the left upper quadrant. Some evidence of Volume 137, February 1979
a small bowel obstruction proximal to the point of torsion could be present. In contrast, in patients with sigmoid volvu1us, the plain abdominal x-ray film will show, as in Figure 6, a large air-filled loop of intestine usually in the right upper quadrant, with its convex surface facing the right lower quadrant due to the counterclockwise rotation of the redundant sigmoid loop. Features of small bowel obstruction are usually absent. Distension of the ascending colon proximal to the sigmoid volvulus may be present. If the diagnosis is not clear on the plain abdominal film, a proctoscopic examination should be done. Frequently, proctoscopic examination and insertion of a large rectal tube will reduce a sigmoid volvulus. Similar results can be accomplished with the flexible colonoscope [15]. In contrast, insertion of a rectal tube and even performance of a barium enema will very rarely reduce a cecal volvulus or decompress a pseudoobstruction of the colon. The use of barium enema in the diagnosis of massively distended intestinal loops is desirable if the correct diagnosis cannot be made with plain abdominal x-ray and proctoscopy. Obviously, it should not be undertaken if there is any sign of peritonitis. In addition to differentiating among sigmoid and cecal volvulus and pseudoobstruction, barium enema will rule out any distal lesion that may be present in patients with cecal volvulus. 173
Villar and Norton
7. 8.
9.
10.
11. 12. 13.
14. 15.
Figure 6. Stgmoid volvulus. Distended bowel, of loop mostly in the right upper quadrant; some air is present in the transverse and descending colon proximal to the point of torsion.
Summary
Seven patients with acute and progressive abdominal distension secondary to massive cecal and right colon ileus are analyzed. Five had pseudoobstruction of the colon and two had cecal volvulus. Two of the patients with pseudoobstruction and one with cecal volvulus died from preexisting diseases. Pseudoobstruction of the colon is not a rare complication of elderly, sick, bedridden patients. Differential diagnoses include cecal and sigmoid volvulus and acute gastric dilation. Initial conservative therapy is warranted if no peritoneal signs are present. If the cecal diameter is more than 12 cm, colonoscopic decompression with a fiberscope should be attempted. If unsuccessful, tube cecostomy will provide curative, life-saving therapy even if taenia splitting is present. Perforation or widely scattered areas of necrosis make resection mandatory. References 1. Ogilvie H: Large intestine colic due to sympathetic deprivation. BrMedJ2: 671, 1948. 2. Robertson JA, Eddy WA, Vosseler AJ: Spontaneous perforation of the cecum without mechanical obstruction. Am J Surg 96:
174
448, 1958. Eckman WG, Wenzke F. Abramson W: Perforation of the cecum J 96: 718, 1958. complicating adynamic ileus. Am Surg Adams JT: Adynamic ileus of the colon. Arch Surg 109: 503, 1974. MacFarlane JA, Kay SK: Ogilvie’s syndrome of false colonic obstruction. Br Med J 2: 1287, 1949. MacManus Cl, Krippaehne Ww: Diastatic perforation of the cecum without distal obstruction. Arch Surg 112: 1227, 1977. Morton, JH, Schwartz SI, Gramiak R: lleus of the colon. Arch Surg 81: 425, 1980. Norton, L, Young D, Scribner R: Management of pseudo-obstruction of the colon. Surg Gynecol Obsfet 138: 595, 1974. Wojtalik RS, Lindenauer SM, Kahn SS: Perforation of the colon associated with adynamic ileus. Am J Surg 125: 601, 1973. Yeo R: Spontaneous perforation of the caecum; case reports and a review of the literature. PostgradA&d J 43: 65, 1967. Ravid, JM: Diastasls and diastatic perforation of the gastrointestinal tract. Am J fathol27: 33, 1949. Dunlop JA: Dgilvie’s syndrome of false colonic obstruction. Br Med J 1: 890, 1949. Lowman RM, David L: An evaluation of cecal size in impending perforation of the cecum. Surg. GynecolObstet 103: 7 11, 1958. Kukora JS, Dent TL: Colonoscopic decompression of massive nonobstructive cecal dilation. Arch Surg 112: 512, 1977. Ghazi A, Shinya H, Wolff WI: Treatment of volvulus of the colon by colonoscopy. Ann Surg 183: 263, 1976.
Discussion
Albert J. Kukral (Oklahoma City, OK): Are you able to get your gastroenterologists to perform colonoscopy for a cecal volvulus or a cecal dilation? ErichW. Pollak,(Kansas City, MO): Dr.Villar, hatie you had any recurrences of pseudoobstruction in the patients with the method described? Raymond 0. Frederick (St. Louis, MO): I question the wisdom of watching these patients or correcting electrolyte levels over a 24 or 48 hour period. A volvulus or pseudovolvulus is an acute emergency, and I think the general feeling is that they should be operated on immediately. Hugo V. Villar (closing): We think the patients should be observed at least 12,to 24 hours because they are quite sick to begin with. Each one of these patients was admitted to the hospital for something else. If you are following them quite closely, some of the massive cecal dilations will disappear, and surgery will be avoided. Obviously, it is an individual decision; there were cases in which, as you suggest, we operated right away. We perform our 0~ colonoscopies, so we do not have to convince anybody. There were six patients described in the October issue of AFC~~WS of Surgery [14],in whom colonoscopy was performed successfully. -We were very encouraged by that. This is why we did it in the last case. None of our patients died from peritoneal contamination. They all died from the main disease that motivated their admission. Pseudoobstruction is more common than cecal volvulus.
The American Journal of Surgery
