Cecal Volvulus in Children: Is There Place for Colonoscopic Decompression?
A 14-year-old boy with severe kyphosis and spastic tetraparesis based on pontocerebellar hypoplasia presented with progressive abdominal distension and nonbilious vomiting. Physical examination demonstrated a painful, severely distended abdomen with sparse peristalsis. Abdominal computed tomography showed marked distension of a colonic loop (Fig. 1), suggestive of cecal volvulus without intestinal malrotation. To circumvent the need for mechanical ventilation in this respiratory compromised patient by severe kyphosis, emergency colonoscopy was performed under intravenous midazolam, instead of surgical intervention. A torsion of the ascending colon was detordated endoscopically. An extremely dilated cecum filled with air and feces was decompressed followed by drainage tube placement. Consequently, abdominal symptoms resolved completely. Unfortunately, there was cecal volvulus recurrence after 6 weeks. Despite increased perioperative risk, an ileocecal resection with end-to-end anastomosis was performed uneventfully.
Cecal volvulus accounts for 1% to 3% of large bowel obstructions (1). It is more common in children with psychomotor retardation (2,3) and/or chronic constipation. Diagnosing cecal volvulus is commonly challenging, reflected by delay in diagnosis of approximately 2 days from the onset of symptoms. Patterns of clinical presentations vary from intermittent abdominal pain to acute fulminant patterns associated with intestinal strangulation and sepsis (4). Therapy in adults and children usually consists of laparotomy with ileocecal resection (1). In adults, colonoscopic detorsion and decompression has been reported as alternative intervention (5,6) with up to 30% success rate (7), although recurrence is common. A single attempt at colonoscopic decompression can therefore be considered in stable adults (5) at least as a bridge to surgery (8,9). We described the first pediatric case of cecal volvulus successfully detordated endoscopically. Cecal volvulus in children calls for immediate surgical intervention. In children who are, however, unlikely to withstand laparotomy/general anesthesia, endoscopic detorsion may be considered. This intervention should be performed only in stable children without bowel compromise or perforation, and exclusively in experienced hands with surgical standby.