Description

A 7-year-old boy presented to the paediatric department of district general hospital with persistent and diffuse abdominal pain, bilious vomiting, constipation and abdominal distention of about 24 h duration. He had a background of prematurity, developmental delay, and chronic constipation with chronic recurrent unexplained abdominal pain. He had undergone an uneventful percutaneous endoscopic gastrostomy 5 years ago for feeding difficulty and failure to thrive. During the abdominal examination, a palpable, firm and tympanitic mass was identified in the mid-portion of the upper abdomen, and diffuse tenderness with peritoneal irritation was noted. The plain radiographs of the abdomen showed a prominent segment of dilated intestine suggestive of volvulus (figure 1A, B). His general condition suddenly became poor and was referred to us. He was resuscitated and transferred to us after stabilisation. Chest radiograph in upright position showed saddle bag sign with gross pneumoperitoneum. The patient underwent an urgent exploratory laparotomy, with findings at the operation showing axial rotation of the caecum with gangrene, perforation and large subserosal pneumatocele. The operative treatment consisted of resection of the terminal ileum and caecum followed by primary ileo-ascending anastomosis. The patient had uneventful recovery postoperatively. He was asymptomatic at 1 year follow-up. Caecal volvulus is very rare in paediatric age and is considered as one of the manifestations of intestinal malrotation and malfixation anomalies.1 ,2 Diagnostic uncertainty and delay is usual and no consensus on treatment modalities including conservative, de-volvulus only, de-volvulus with caecopexy, appendicular stump caecostomy and resection with anastomosis have been suggested. Resection and primary anastomosis has the best long-term results.1–3

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Figure 1

(A) Plain abdominal radiograph showing abnormal gas in the central and left upper abdomen. (B) An erect chest radiograph at arrival showing massive pneumoperitoneum with saddle bag sign (wide arrows), note massive caecal pneumatosis seen as thin line in left upper abdomen (thin dark arrows; AP, anteroposterior; PEG, percutaneous endoscopic gastrostomy).