Caecal volvulus following a complicated caesarean section

Abstract

A caecal volvulus is a rare, but severe complication to a caesarean section, with serious risks of perforation, necrosis and peritonitis. We describe a case of a Middle Eastern woman admitted for an elective caesarean section due to a history of three cesareans in her home country. The operation was complicated by massive adhesions and a postpartum bleed of 1750 mL. She developed severe abdominal pain refractory to strong pain medication postoperatively. She was diagnosed with a caecal volvulus without perforation on CT, which was confirmed by laparotomy. The patient was treated with a hemicolectomy and made a full recovery.

Background

In Denmark, the prevalence of delivery by caesarean section (CS) for singleton pregnancies has been stable at around 20% since 2007.¹ Indications for elective CS are numerous, including previous CS, prior uterine surgery such as myomectomy or surgery for a cornual pregnancy, fetal malpresentations, placenta previa and previous rupture of the anal sphincter.² CSs are associated with risk of bleeding, acute and chronic abdominal pain, infection and intestinal paralysis (Ogilvie’s syndrome), though an elective CS minimises these risks compared with an emergency CS.³ Volvulus following CS is an extremely rare, but a very severe complication. Volvuli are a type of bowel obstruction, where a piece of the colon twists around its own mesentery. This compromises blood flow to the bowel, causing ischaemia, pain and ultimately perforation of the bowel with peritonitis and necrosis, and most cases require surgical intervention.⁴ Sigmoid volvulus (SV) is most common, and the occurrence of a caecal volvulus (CV) is highly unusual.^{4 5}

We describe a case of a young woman who developed a CV following an elective CS.

Case presentation

A Middle Eastern woman in her mid-30s was scheduled for an elective CS in her 38th week of gestation due to a history with three CS. Her previous CS had all been performed in her home country. The first and the third were emergency CS, while the second was an elective CS. She had no history of other abdominal surgeries. The elective CS was performed with the patient in spinal anaesthesia and was very complicated due to massive adhesions with complete fusion of the muscles of the abdominal wall with the fascia and the uterus. After the delivery of a healthy baby, the uterus was mobilised to suture the uterotomy, which was complicated by the adhesions. Perioperative blood loss was estimated to 1750 mL. During surgery, the patient received 2 g of intravenous tranexamic acid, an intravenous injection of 5 IE oxytocin, a concentrated oxytocin intravenous solution of 20 IE in 500 mL saline and 1.5 g of cefuroxime. Following the surgery, the patient continued to have intractable abdominal pain that did not respond to common postoperative pain treatment.

Investigations

Because of persisting pain and initially low blood pressure (BP) of 88/56, the patient was evaluated twice with abdominal palpation and transabdominal ultrasound during the first 24 hours following surgery, without findings of intra-abdominal bleeding. Abdominal palpitation at the first two evaluations was with a soft, but expectedly sore abdomen without guarding or rigidity. At the third evaluation approximately 24 hours following the CS, the patient presented with stable BP and other vital parameters, but with continuous and severe abdominal pain, now with guarding and rigidity at abdominal examination and a CT scan was therefore performed 1-day postoperative.

Differential diagnosis

Initially, intra-abdominal bleeding was considered due to the difficulty of the surgery, but because of severe pain, lack of intra-abdominal free fluid on transabdominal ultrasound and development of abdominal rigidity and guarding, Ogilvie’s syndrome or bowel perforation were suspected. However, a complete volvulus of the coecum and right colon without perforation was observed on the abdominal CT scan (figure 1A,B).

Figure 1.

(A, B) Coronal and horizontal view of the patients abdominal CT scan. The blue arrows show the coecum dilated and displaced medial and to the left.

Treatment

The low BP responded well to treatment with intravenous fluids and blood transfusion and the pain was initially managed with orally administered paracetamol 1 g and ibuprofen 400 mg four times a day as well as intravenous morphine 5 mg maximum six times a day. When the CT scan revealed a CV, the general surgeons were contacted immediately. They performed an exploratory laparotomy, revealing a total volvulus of the right colon with dilation, but no necrosis or perforation. They performed a right hemicolectomy with end-to-end anastomosis.

Outcome and follow-up

The patient made a relatively quick recovery and was discharged on postoperative day 6, with no long-term complaints at the 8-week follow-up with a consulting obstetrician.

Discussion

CSs are associated with risk of bowel obstruction, most commonly in the form of Ogilvie’s syndrome, which is a pseudo-obstruction due to intestinal paralysis following surgery.⁶ Ogilvie’s is normally treated with neostigmine or colonoscopic exsufflation. In rare cases, as we describe here, a patient presents with all the symptoms of pseudo-obstruction but are suffering from a real obstruction such as a volvulus. Regardless of the type of volvulus, fast diagnosis and treatment are of great importance to avoid necrosis and bowel perforation. Very few reports exist of CV in the days following a CS.^7–9 Larger studies on this specific population do not exist due to the rarity of this complication, so risk factors and long-term outcomes have not been investigated. SV is more frequent in men >70 years of age, where CV seems to be more frequent among women. A retrospective analysis from 2022 of 36 cases of CV reported that 78% of patients with a CV where female, elderly >70 years of age and with at least one medical comorbidity. One-third of the patients had a history of previous abdominal surgery. Most common symptoms were abdominal pain and 84% of patients underwent surgery for the CV. Median length of admission at the hospital was 9 days.⁴ However, none of the patients in the study developed a CV following CS and these results are therefore not directly applicable to this case.

CV as well as other types of bowel obstructions could be associated with pregnancy due to a dilation of the caecal mesentery from the growth of the pregnant uterus. It is however rare and of the 1 in 10 000 pregnant women presenting with bowel obstruction, volvulus only accounts for 25%.¹⁰ Other factors predisposing pregnant women to CV are an underlying congenital malrotation,¹⁰ chronic constipation and frequent laxative use, which causes caecal displacement, colonic distension and increased peristalsis of the bowel.¹¹ Finally, abdominal or pelvic surgery could create a more mobile coecum, as well as cause intra-abdominal adhesions¹⁰ to where coecum can adhere, rotate and ultimately cause a CV. Treatment of CV is resection of the displaced bowel, usually a right hemicolectomy with an ileotransverse anastomosis, where length of resection is determined by mobility and degree of ischaemia and necrosis.¹² Untwisting of the bowel and colopexy without resection increases rate of recurrence, morbidity and mortality and is not used a standard treatment. Finally, it is not recommended to perform colonoscopic exsufflation to resolve CV due to low success rates around 30%.¹³

Learning points.

• A caecal volvulus (CV) is a rare, but severe condition that if left untreated can result in necrosis, bowel perforation and peritonitis.

• Only a small number of case reports exist regarding CV following a caesarean section (CS), and even though it is not the most common cause of postoperative abdominal pain following a CS, it is a diagnosis that cannot be overlooked.

• A patient with severe abdominal pain and no signs of intra-abdominal bleeding on ultrasound after a CS should always be evaluated with a CT scan of the abdomen to determine the cause of pain.

• If a CV or other type of volvulus is present, contact with the general surgeons is of high priority to ensure that the patient undergo surgery, before perforation or necrosis occur and to decrease overall morbidity and mortality.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).