Bascule caecal volvulus: a rare cause of intestinal obstruction
A 58-year-old female with a past medical history of a large intrathoracic hiatus hernia presented to her general practitioner and was subsequently referred to our surgical department with symptoms of sudden onset severe epigastric pain associated with vomiting and abdominal distension. Her abdomen was generally tender, maximally in the epigastric region, although she was not peritonitic. The admission erect chest radiograph showed a large hiatus hernia and an elevated right hemidiaphragm with a large loop of distended bowel (Fig. ). Subsequent computed tomography (CT) scan demonstrated an almost completely intrathoracic stomach with a degree of volvulus, and the liver medially displaced by a loop of large bowel felt to be caecum (Fig. ). Since the patient remained otherwise well, bidirectional endoscopy was performed, and given that a volvulus point could not be identified and the ileocaecal junction was not identified, contrast studies were requested (Figs –) which demonstrated an incomplete obstruction caused by a volved caecum rotated anteriorly and cephalad.\nAfter the contrast study partial resolution of symptoms occurred but given the development of free fluid in her contrast CT scan, the decision was taken to manage her surgically. A midline laparotomy was performed, with the finding of a freely mobile, grossly distended caecum flipped anteriorly over the ascending colon as demonstrated on her CT scan (Fig. ). This was therefore removed with a right hemicolectomy and primary ileo-colic anastomosis. Additionally, there was no evidence of a gastric volvulus (suggesting partial twisting) and since her stomach was completely intra-abdominal, there was no need to address her hiatus hernia at that point in time. The patient was admitted to the high dependency unit post-operatively, made a good recovery and was discharged home within a week of surgery.