Definition
Cecal bascule is a rare subtype of cecal volvulus in which the cecum folds anteriorly and superiorly, creating a functional obstruction without axial twisting of the bowel. The displaced cecum typically rests against the anterior abdominal wall, leading to luminal blockage and possible vascular compromise.
Epidemiology
- Accounts for approximately 10 % of all cecal volvulus cases.
- Occurs predominantly in adults, with a slight female predominance reported in some series.
- Associated risk factors include a mobile cecum, prior abdominal surgery, chronic constipation, and conditions that increase intra‑abdominal pressure.
Pathophysiology
The cecum is normally fixed to the retroperitoneum. Congenital or acquired laxity of the peritoneal attachments permits excessive mobility. In cecal bascule, upward folding of the mobile cecum over the ascending colon creates a “flap” that obstructs the lumen. Unlike classic cecal volvulus, there is no torsion of the mesentery, which may reduce the incidence of immediate vascular ischemia, though prolonged obstruction can still lead to compromised blood flow and necrosis.
Clinical Presentation
- Acute onset of abdominal pain, usually periumbilical or right lower quadrant.
- Abdominal distension and obstipation.
- Nausea and vomiting may be present.
- Physical examination may reveal tympanic abdomen with localized tenderness; signs of peritonitis suggest progression to ischemia or perforation.
Diagnostic Evaluation
- Plain abdominal radiography: May show a dilated cecum positioned in the mid‑abdominal or suprapubic region with a “gas‑filled “bowl‑shaped” appearance and absence of the normal right‑lower‑quadrant cecal silhouette.
- Contrast‑enhanced computed tomography (CT): Demonstrates a markedly dilated cecum folded anteriorly, a “bird’s beak” sign at the point of inflection, and may assess for ischemia (wall thickening, lack of enhancement, mesenteric stranding).
- Contrast studies (e.g., water‑soluble enema) can delineate the point of obstruction but are less commonly used in the acute setting.
Management
- Initial resuscitation: Intravenous fluid replacement, nasogastric decompression, and broad‑spectrum antibiotics if perforation is suspected.
- Non‑operative reduction: Endoscopic decompression is generally ineffective for cecal bascule due to the anatomic configuration.
- Surgical intervention: Definitive treatment is surgical. Options include:
- Right hemicolectomy with primary anastomosis or ileostomy, preferred for viable bowel.
- Cecopexy (fixation of the cecum to the abdominal wall) may be considered when the bowel is viable and the patient is a high‑risk surgical candidate, though recurrence rates are higher.
- Detorsion alone is not appropriate because the underlying mobility remains.
- Laparoscopic approaches have been described but open surgery remains common, especially in unstable patients.
Prognosis
- Early diagnosis and prompt surgical management result in low mortality (approximately 5–10 %).
- Delayed treatment leading to cecal necrosis, perforation, or sepsis markedly increases morbidity and mortality.
- Recurrence after cecopexy is reported in up to 20 % of cases; resection reduces recurrence risk.
Historical Note
The term “bascule” is derived from the French word for “seesaw,” reflecting the folding mechanism of the cecum in this condition. The entity was first distinguished from classic cecal volvulus in the mid‑20th century as imaging and surgical experience clarified its unique anatomy.