Caecal volvulus in third trimester of pregnancy

We present a case of an uncommon cause of abdominal pain in a pregnant woman in the third trimester. This report outlines the presentation and investigations that resulted in the diagnosis and subsequent surgical management for this patient.

Case report

A 31-year-old Gravida 3 Parida 2 (G3P2) 37+1 pregnant woman was admitted under Obstetrics with abdominal pain. Following serial cardiotocography readings and obstetric evaluation she was deemed to not be in labour, and a general surgical review was sought.

She had no significant medical or surgical history. Prior deliveries were vaginal and during this pregnancy an elective caesarean section (C-section) was planned.

Symptoms of abdominal pain and anorexia were present for 4 days and worsened in the last 24 hours with two episodes of vomiting, prompting presentation to hospital. The last reported bowel movement was 3 days prior, not out of keeping with the patient’s usual bowel habit.

Examination revealed a generally tender and distended abdomen, beyond that of a gravid uterus. There was no peritonism, including on serial examination. Blood results were unremarkable with a normal white blood cell count (10) and a C-reactive protein <3, including on repeat bloods 8 hours later. Urinalysis was negative.

Initial imaging was an ultrasound, which reported a small volume of simple free fluid and echogenic mesentery in the right iliac fossa. The appendix was not identified. The patient proceeded for a magnetic resonance imaging (MRI), which showed swirling of the mesentery and vessels within the right upper quadrant.

View Figure 1.

Over the period of these investigations, pain had escalated such that the patient now required patient-controlled analgesia delivery with fentanyl.

Following General Surgery and Obstetrics discussion, a joint decision was made to proceed to theatre for a C-section and exploratory laparotomy, particularly given the pregnancy was at term. Delivery of the foetus was uncomplicated. Exploratory laparotomy revealed a meso-axial caecal volvulus with mildly dilated small bowel without bowel compromise. Intra-operatively, the decision was made to perform a caecopexy as we presumed the underlying pathology was due to displacement caused by the gravid uterus, due to the absence of a narrowed and elongated mesentery.

The patient and newborn recovered well and were discharged a few days later.

Discussion

Volvulus is an unusual cause of abdominal pain and obstruction in pregnancy, with current literature suggesting that caecal volvulus is rarer than sigmoid volvulus.¹ Two cases have been reported with pregnant women presenting with sepsis due to intestinal ischaemia secondary to caecal volvulus. In both cases symptoms were present for approximately 24 hours prior to presentation and the foetus was delivered stillborn.^2,3

A further case outlined a patient at 18 weeks gestation for whom diagnosis was confirmed on abdominal X-ray. This patient required a right hemicolectomy due to an ischaemic caecum.¹ This case discussed the presence of this pathology in the right upper quadrant, possibly secondary to displacement caused by the gravid uterus.

Patients may present with non-specific symptoms: abdominal pain, obstipation and vomiting. Clinical examination may reveal a tender abdomen with or without focal tenderness and peritonism. Imaging findings may be both non-specific and non-confirmatory. MRI was readily available at our hospital; however, computed tomography would be an alternative. In the third trimester the risk is largely to the foetus, both to development and the cumulative childhood cancer risk.

The standard of treatment for caecal volvulus is a right hemicolectomy; however, we presumed the pathology in this case to be different and therefore a caecopexy was performed. Should the patient represent with volvulus, a right hemicolectomy would be the operative management.

Although uncommon, clinical suspicion must remain in the situation of persistent abdominal pain without obvious clinical signs and reassuring inflammatory markers. A high index of suspicion is required given the risk to both mother and foetus. We suggest a low threshold for imaging and/or exploratory surgery, particularly in the situation where the foetus is at term.