EP227 - The Curious Case of a Cecal Volvulus Secondary to an Omental Cord Constricting the Small Bowel

Purpose/Background: A volvulus is when a portion of bowel wraps around a mesenteric axis, potentially sequestering blood supply and causing bowel obstruction. There are many risk factors for developing a cecal volvulus, but one that has yet to be explored is prolonged opioid use.

Methods/Interventions: Our patient is a 38-year-old male with a past medical history significant for an open appendectomy at 18 years, intravenous substance use disorder, and untreated infection with hepatitis C virus. He initially presented to the emergency department with active extravasation from his left groin after self-injection. Upon cross-sectional imaging, it was incidentally found that he had a saccular splenic artery aneurysm, pulmonary embolism, and significant bowel dilation (Figure 1). We initially managed our patient conservatively with a nasogastric tube, decompressive colonoscopy, and a rectal tube up to the transverse colon. However, this resulted in a partial resolution of symptoms, and we therefore performed an exploratory laparotomy. We began by eviscerating the small bowel, but this quickly proved difficult as there were extensive global adhesions that we first had to lyse. In doing so, we found that the small bowel had volvulized around the root of the mesentery – and it was not alone. A dense, necrotic cord of tissue had also wrapped itself around the mesenteric root, in addition to a loop of bowel. Upon further inspection, we discovered that this tissue was tightly-wound omentum, and we excised the band. At this point, the small bowel was eviscerated, and we could fully appreciate the extensively dilated cecum that extended from our patient’s right side cephalad into his left upper quadrant. We then resected ascending colon by ligating proximally at the ileocecal valve and distally at the transverse colon, just prior to the right colic artery arcade. With the specimen removed (Figure 2), we performed a side-to-side isoperistaltic ileocolic anastomosis and closed.

Results/Outcomes: The patient recovered well postoperatively and was medically ready for discharge within three days.

Conclusion/Discussion: Constipation, respiratory depression, sedation, and narcotic bowel syndrome are already well-established side effects of opioid use, but this case may suggest that volvulus and bowel obstruction are additional adverse outcomes. We hypothesize that our patient’s long-term use of opioids resulted in chronic constipation which, along with his previous appendectomy, then led to recurrent episodes of bowel volvulus. The abnormal orientation of bowels within the peritoneal cavity then resulted in the omentum also becoming distorted, forming a dense cord that subsequently created a cecal volvulus and bowel obstruction. It is important to recognize a cecal volvulus early to reduce the risk of bowel strangulation, perforation, and ischemia. With our patient’s case in mind, knowing about a patient’s substance use disorder may prime clinicians to consider the diagnosis of a cecal volvulus earlier and thereby augment their patient’s road to recovery.

Figure 1. Initial anterior-posterior supine X-ray image.
There is visible distention of the gastrointestinal tract, with marked dilation of what was first interpreted to be the stomach. This was later found to be the cecal volvulus.

Figure 2. Removed specimens.
On the left is the dilated cecum and ileum. At the top right is the excised omentum, now a thick, tightly-wound band. At the bottom right is a segment of removed small bowel.