Epidemiology & Risk Factors

Less common (~15-20% of colonic volvulus).
Typically affects younger pts (30-60 years old).
Congenital etiology:
- Mobile cecum due to incomplete embryologic retroperitoneal fixation of the ascending colon.
Triggers: severe constipation, pregnancy, prior abdominal surgery, high-fiber diet.

Clinical Features

Acute, rapid onset of severe abdominal pain, distention, and early-onset nausea/vomiting (mimics a small bowel obstruction [SBO]).
Distended, tympanitic abdomen with diffuse tenderness.
Peritoneal signs (guarding, rigidity) develop early due to rapid progression to ischemia.

Initial Test: Plain abdominal XR.
- Shows a dilated, air-filled cecum forming a “coffee bean” sign (or “teardrop” shape).
- The apex points toward the LUQ or epigastrium, arising from the RLQ.
Confirmatory / Gold Standard: CT scan of abdomen/pelvis w/ IV contrast.
- Shows “whirl sign” of twisted cecum, mesentery, and ileocecal vessels.
- Often demonstrates associated small bowel distention with air-fluid levels (closed-loop obstruction).
Key Labs: Leukocytosis (CBC), elevated lactic acid (highly concerning for gangrene/perforation).

Sigmoid Volvulus: Diff by older age, chronic constipation, and XR showing coffee bean apex pointing to the RUQ (base in LLQ).
Small Bowel Obstruction (SBO): Diff by absence of cecal twisting/whirl sign on CT, though clinical presentation is virtually identical.
Acute Appendicitis: Diff by localized RLQ pain (McBurney’s point), lack of massive abdominal distention, and CT showing inflamed appendix rather than rotated cecum.
Cecal Cancer: Diff by subacute/chronic presentation, weight loss, iron deficiency anemia, and CT showing a mass rather than a volvulus.

Endoscopic Decompression:
- Contraindicated / Avoided: Colonoscopy is rarely effective and carries a high risk of perforation; should not be attempted.
All Patients (Stable or Unstable):
- Emergent/Urgent Surgical Intervention is required.
- Bowel is Viable: Right hemicolectomy (or ileocecal resection) w/ primary anastomosis. Alternatively, cecopexy (suturing cecum to abdominal wall) if pt is highly unstable, though recurrence risk is higher.
- Bowel is Non-viable (Gangrenous/Ischemic/Perforated): Right hemicolectomy w/ end ileostomy (resection w/ primary anastomosis is avoided in unstable pts or severe peritoneal contamination).

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