Foreign Bodies and Bowel Obstructions

*Jessica Elizabeth Taylor and Devin Clegg*

#### **Abstract**

Foreign body ingestion most commonly occurs in the pediatric population, with approximately 80–90% of objects passing spontaneously in individuals who are evaluated by medical professionals. Objects may be lodged in a variety of anatomic locations. Only about 10% of foreign bodies progress past the stomach. Of the 10–20% of objects that fail to pass, less than 1% requires surgical intervention. Small bowel obstructions are a rare presentation of foreign body ingestions. There are case reports, guidelines, and retrospective reviews in the literature regarding the management of ingested foreign bodies. In patients who do not have spontaneous passage of foreign bodies, endoscopic and surgical techniques have been utilized for successful retrieval. The timing and indication for endoscopic intervention is dependent upon several factors, including the type and location of the foreign body and is also contingent upon patient symptoms. Numerous case reports and studies describe the successful endoscopic removal of foreign bodies in the upper and lower gastrointestinal tract. Although the type and location of an ingested object is critical for determining the success of endoscopic intervention, the patient's clinical exam and stability is also an aspect to consider when deciding on management of bowel obstructions caused by foreign bodies.

**Keywords:** foreign body, ingestion, obstruction, intestine, bowel

#### **1. Introduction**

Foreign body ingestion encompasses a wide range of objects. Most often, the patients that have ingested a foreign body are in the pediatric population, which can lead to its own challenges in management. In adults, there is even less literature that discusses foreign body ingestion and outcomes.

Foreign bodies can become lodged in various areas of the upper and lower gastrointestinal tracts. There are specific characteristics of objects and certain anatomic and physiologic regions of the gastrointestinal tract that create unique problems regarding management of the ingested foreign body. As is demonstrated in the pediatric literature, an algorithmic approach should be utilized to manage adults who have ingested an object. This approach includes systematic evaluation and work-up, determining appropriate management based on the clinical evaluation, and ultimately addressing complications as they may arise during the management process.

#### **2. Evaluation and work-up**

#### **2.1 Clinical history**

A very important aspect in the evaluation of foreign body ingestion is obtaining an accurate history. Whether the patient is pediatric or adult, if there was a witness to the ingestion, then determining the exact foreign body and its characteristics will be easier to determine. Adult ingestions, like pediatric, may be intentional or unintentional. Most adult foreign body ingestions occur in patients with developmental delay, elderly individuals, and prisoners seeking a secondary gain [1]. In these patients obtaining a history may be more challenging. The primary information that needs to be gathered during the history of present illness is type of foreign body, when it was ingested, and the onset of any associated symptoms [1]. When the clinician can determine characteristics about the type of foreign body, then it makes the decision on whether to pursue further diagnostic work-up less challenging.

Foreign bodies may be classified into several categories. **Table 1** lists the categories most often ingested. In the pediatric population, household objects are the most commonly ingested, which include coins, toys, jewelry, magnets, and batteries [1]. Following foreign body ingestion, children may present with symptoms immediately. In adults, objects such as partial dentures, razor blades, and toothbrushes have been reported as being ingested [2]. The size of the ingested objects impacts if these foreign bodies will become lodged and unable to pass through the gastrointestinal tract; although, it is reported in the literature that 80–90% of ingested foreign bodies pass spontaneously [3].

The European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guidelines recommend that diagnostic evaluation be considered based on the patient's history and symptoms. The symptoms that would indicate the presence of an esophageal foreign body include dysphagia, odynophagia, or chest pain. Other symptoms that may also be present include sore throat and vomiting. If the foreign body located in the esophagus is large, it may also cause respiratory symptoms due to compression on the trachea [1]. When the ingested foreign body has migrated through the esophagus patients may not report any symptoms.

Aspects of the patient's history that may be underappreciated include past medical problems and surgical procedures. When taking an adequate history, it is important to elucidate whether the patient has a history of inflammatory bowel disease or known malignancies that could impact the passage of the foreign body. Disease processes such as Crohn's or colon cancer could cause stricturing or narrowing in the gastrointestinal tract which may predispose the ingested foreign body to cause an obstruction or other complication. The past surgical history is also important to document, as past abdominal procedures could have altered the anatomy and created additional areas of narrowing which may inhibit the object from passing without complication. After obtaining a thorough history from the patient or other witnesses, then it is appropriate to proceed to physical examination.


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*Foreign Bodies and Bowel Obstructions DOI: http://dx.doi.org/10.5772/intechopen.92170*

The importance of the physical examination should not be underestimated when evaluating a patient with a suspected foreign body ingestion. Although the esophagus is the most common location for a foreign body to become lodged, once it passes into the stomach there are anatomic areas where it has a higher risk of causing obvious signs on physical examination. If the object fails to pass through the esophagus, there may be obvious findings on physical exam such as choking, stridor, or dyspnea, which may be due to aspiration of saliva [1]. In contrast, if the object becomes lodged in the stomach, then the patient may present with abdominal tenderness and distension with associated symptoms of nausea and vomiting. The small intestine, specifically at the ileocecal valve, is another location where a foreign

The gastrointestinal tract has several anatomic areas of narrowing, which are listed in **Table 2**. One physiological angulation that has been reported to cause difficulty in allowing foreign bodies to pass is the duodenal sweep. If an object is lodged in one of these areas pain may be present on physical exam or as a presenting

The areas of interest with regards to intestinal obstructions or complications include the ileocecal valve, anus, and duodenal sweep. If the patient has undergone prior operative procedures, in addition to the anatomic areas of narrowing, adhesions or alterations in intestinal anatomy may impact the passage of an ingested foreign body. Examining the abdomen for previous scars and evidence of surgical procedures should be carefully performed, especially in patients who are unable to

In patients who present with possible complications related to foreign body ingestion, physical exam findings may be more concerning. Patients with a perforation due to ingested foreign body may have vitals and exam findings which include tachycardia, fever, and peritonitis [1]. If the decision is made to admit and observe a patient who has ingested a foreign body, then monitoring vitals and serial exams

Following a thorough history and physical examination, diagnostic work-up should be initiated based on the information gathered from the patient. The diagnostic work-up can include labs and imaging. The imaging techniques discussed in

body may cause physical exam findings consistent with obstruction.

communicate their past medical and surgical histories.

becomes an important part in management.

the literature ranges from plain X-rays to CT scans.

**Anatomic areas of narrowing in gastrointestinal tract**

**2.3 Diagnostic work-up**

Upper esophageal sphincter

Left main stem bronchus Lower esophageal sphincter

*Anatomic narrowing of GI tract.*

Aortic arch

Pylorus Ileocecal valve

Anus

**Table 2.**

**2.2 Physical examination**

symptom.

**Table 1.** *Foreign body classifications.*

#### **2.2 Physical examination**

*Intestinal Obstructions*

**2.1 Clinical history**

**2. Evaluation and work-up**

ies pass spontaneously [3].

**Ingested foreign body classifications**

A very important aspect in the evaluation of foreign body ingestion is obtaining an accurate history. Whether the patient is pediatric or adult, if there was a witness to the ingestion, then determining the exact foreign body and its characteristics will be easier to determine. Adult ingestions, like pediatric, may be intentional or unintentional. Most adult foreign body ingestions occur in patients with developmental delay, elderly individuals, and prisoners seeking a secondary gain [1]. In these patients obtaining a history may be more challenging. The primary information that needs to be gathered during the history of present illness is type of foreign body, when it was ingested, and the onset of any associated symptoms [1]. When the clinician can determine characteristics about the type of foreign body, then it makes the decision on whether to pursue further diagnostic work-up less challenging.

Foreign bodies may be classified into several categories. **Table 1** lists the categories most often ingested. In the pediatric population, household objects are the most commonly ingested, which include coins, toys, jewelry, magnets, and batteries [1]. Following foreign body ingestion, children may present with symptoms immediately. In adults, objects such as partial dentures, razor blades, and toothbrushes have been reported as being ingested [2]. The size of the ingested objects impacts if these foreign bodies will become lodged and unable to pass through the gastrointestinal tract; although, it is reported in the literature that 80–90% of ingested foreign bod-

The European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guidelines recommend that diagnostic evaluation be considered based on the patient's history and symptoms. The symptoms that would indicate the presence of an esophageal foreign body include dysphagia, odynophagia, or chest pain. Other symptoms that may also be present include sore throat and vomiting. If the foreign body located in the esophagus is large, it may also cause respiratory symptoms due to compression on the trachea [1]. When the ingested foreign body has migrated

Aspects of the patient's history that may be underappreciated include past medical problems and surgical procedures. When taking an adequate history, it is important to elucidate whether the patient has a history of inflammatory bowel disease or known malignancies that could impact the passage of the foreign body. Disease processes such as Crohn's or colon cancer could cause stricturing or narrowing in the gastrointestinal tract which may predispose the ingested foreign body to cause an obstruction or other complication. The past surgical history is also important to document, as past abdominal procedures could have altered the anatomy and created additional areas of narrowing which may inhibit the object from passing without complication. After obtaining a thorough history from the patient or other

through the esophagus patients may not report any symptoms.

witnesses, then it is appropriate to proceed to physical examination.

**40**

Blunt Sharp Long

**Table 1.**

*Foreign body classifications.*

The importance of the physical examination should not be underestimated when evaluating a patient with a suspected foreign body ingestion. Although the esophagus is the most common location for a foreign body to become lodged, once it passes into the stomach there are anatomic areas where it has a higher risk of causing obvious signs on physical examination. If the object fails to pass through the esophagus, there may be obvious findings on physical exam such as choking, stridor, or dyspnea, which may be due to aspiration of saliva [1]. In contrast, if the object becomes lodged in the stomach, then the patient may present with abdominal tenderness and distension with associated symptoms of nausea and vomiting. The small intestine, specifically at the ileocecal valve, is another location where a foreign body may cause physical exam findings consistent with obstruction.

The gastrointestinal tract has several anatomic areas of narrowing, which are listed in **Table 2**. One physiological angulation that has been reported to cause difficulty in allowing foreign bodies to pass is the duodenal sweep. If an object is lodged in one of these areas pain may be present on physical exam or as a presenting symptom.

The areas of interest with regards to intestinal obstructions or complications include the ileocecal valve, anus, and duodenal sweep. If the patient has undergone prior operative procedures, in addition to the anatomic areas of narrowing, adhesions or alterations in intestinal anatomy may impact the passage of an ingested foreign body. Examining the abdomen for previous scars and evidence of surgical procedures should be carefully performed, especially in patients who are unable to communicate their past medical and surgical histories.

In patients who present with possible complications related to foreign body ingestion, physical exam findings may be more concerning. Patients with a perforation due to ingested foreign body may have vitals and exam findings which include tachycardia, fever, and peritonitis [1]. If the decision is made to admit and observe a patient who has ingested a foreign body, then monitoring vitals and serial exams becomes an important part in management.

#### **2.3 Diagnostic work-up**

Following a thorough history and physical examination, diagnostic work-up should be initiated based on the information gathered from the patient. The diagnostic work-up can include labs and imaging. The imaging techniques discussed in the literature ranges from plain X-rays to CT scans.

#### **Table 2.** *Anatomic narrowing of GI tract.*

Once it is established that a patient has ingested a foreign body, the initial imaging recommended by ESGE is plain X-ray evaluation of the neck, chest, or abdomen depending on the information obtained from the history. The purpose of the imaging is to determine several key pieces of information. Plain films are useful in establishing, initially, the actual presence of a foreign body. Second, X-rays can also provide an estimation as to the size and location. If multiple objects are suspected of being ingested, such as magnets, then the imaging can also help determine the number of foreign bodies [1]. Additionally, complications such perforation or obstruction may also be detected on initial plain films.

Other reports in the literature have discussed using serial X-rays to evaluate passage of objects, specifically magnets in the pediatric population. The protocol suggested by the North American Societies of Pediatric Gastroenterology, Hepatology, and Nutrition includes obtaining serial X-rays every 4–6 hours to monitor for progression [4]. Although obtaining serial abdominal films is considered a diagnostic study, it is also concurrently a part of the non-operative management of foreign body ingestion.

Despite plain radiographs being recommended as the initial diagnostic imaging, there is a reported false-negative rate of 47% [1]. Common objects that are not easily visualized on X-rays include wood, chicken bones, glass, and plastic [1]. If an adequate history supports the ingestion of an object that is difficult to visualize on initial work-up, then further imaging should be performed. Most literature supports that if a complication of foreign body ingestion is suspected, such as perforation or obstruction, then CT scan is the imaging of choice to perform for further evaluation [1].

**Figure 1** shows a CT scan obtained in the emergency department on a patient with mental disability and history of PICA. The patient was unable to provide a

#### **Figure 1.**

*CT scan demonstrating small bowel obstruction caused by foreign body. Black arrow represents foreign body and white arrow demonstrates patient's functional gastrostomy tube.*

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*Foreign Bodies and Bowel Obstructions DOI: http://dx.doi.org/10.5772/intechopen.92170*

ingested foreign bodies [5].

**3.1 Important considerations**

**3.2 Initial management**

**3. Management**

history, but per her caregivers she was noted to have increasing abdominal distension and blood coming from her ostomy. Review of the CT scan demonstrated a

Some literature in the pediatric population supports the use of ultrasound in evaluating foreign bodies in the gastrointestinal tract. One published case series showed that different sizes and types of ingested objects can be visualized using point-of-care ultrasound. Other parts of the study demonstrated that ultrasound can also be used to locate foreign bodies within the gastrointestinal tract as well as look for signs of bowel obstruction. Overall, the literature is lacking with regards to ultrasound use in foreign body ingestion, and further studies should be conducted to determine if it is an appropriate substitute for X-ray imaging when evaluating

The literature describing intestinal obstructions due to foreign bodies is replete with case reports, citing many different strategies that are unique based on patient, location, time course and object type, as well as facility resources. More than 100,000 foreign body ingestions are reported each year, with estimated mortality rates around 3% [6]. As previously mentioned, foreign body ingestion is most common in the pediatric population with the peak incidence between ages 6 months and 6 years [7]. This can also be encountered frequently by the general surgeon in the adult population. While the management of foreign bodies is generally well described when located in the upper gastrointestinal (GI) tract, those that pass beyond the gastroesophageal junction and eventually into the lower GI tract are less well documented. While considering the management of these patients, you must consider that between 80 and 95% of objects that traverse the gastroesophageal junction pass through the gastrointestinal tract without further complication, in both pediatrics and adults [6, 8]. Ingestions of foreign bodies or impacted food can lead to the need for emergency endoscopic intervention in 10–20% of cases, with only about 10% of foreign bodies progressing past the stomach, and only 1% requiring surgical intervention [6, 9]. While up to 80% of total foreign body ingestions occur in pediatric patients, in the adult population true foreign body ingestion of nonfood objects more commonly occurs in those with psychiatric illnesses and developmental delay [10].

With all foreign body ingestions, or in rare cases, migrations, the clinician must decide whether the intervention is warranted, the degree of urgency needed, and by what approach. Initial management of foreign body ingestion is first concerned with discerning signs and symptoms of airway compression as these patients may need a definitive airway with endotracheal intubation or other adjuncts. Asymptomatic patients can often describe what or how the object or foreign body was ingested which will aid in determining course of treatment. Patients who have passed the foreign object beyond the gastroesophageal junction or into the distal gastrointestinal tract may present with signs and symptoms of obstruction or perforation. This includes abdominal pain, fever, vomiting or peritonitis [8]. Patients presenting with these symptoms often undergo imaging initially and in rare cases, can present with obstruction or perforation secondary to previously placed surgical materials [6, 11, 12]. Abdominal plain films can be used to follow most radiopaque

foreign body causing an obstruction at the ileocecal valve.

#### *Foreign Bodies and Bowel Obstructions DOI: http://dx.doi.org/10.5772/intechopen.92170*

history, but per her caregivers she was noted to have increasing abdominal distension and blood coming from her ostomy. Review of the CT scan demonstrated a foreign body causing an obstruction at the ileocecal valve.

Some literature in the pediatric population supports the use of ultrasound in evaluating foreign bodies in the gastrointestinal tract. One published case series showed that different sizes and types of ingested objects can be visualized using point-of-care ultrasound. Other parts of the study demonstrated that ultrasound can also be used to locate foreign bodies within the gastrointestinal tract as well as look for signs of bowel obstruction. Overall, the literature is lacking with regards to ultrasound use in foreign body ingestion, and further studies should be conducted to determine if it is an appropriate substitute for X-ray imaging when evaluating ingested foreign bodies [5].

#### **3. Management**

*Intestinal Obstructions*

body ingestion.

evaluation [1].

Once it is established that a patient has ingested a foreign body, the initial imaging recommended by ESGE is plain X-ray evaluation of the neck, chest, or abdomen depending on the information obtained from the history. The purpose of the imaging is to determine several key pieces of information. Plain films are useful in establishing, initially, the actual presence of a foreign body. Second, X-rays can also provide an estimation as to the size and location. If multiple objects are suspected of being ingested, such as magnets, then the imaging can also help determine the number of foreign bodies [1]. Additionally, complications such perforation or

Other reports in the literature have discussed using serial X-rays to evaluate passage of objects, specifically magnets in the pediatric population. The protocol suggested by the North American Societies of Pediatric Gastroenterology, Hepatology, and Nutrition includes obtaining serial X-rays every 4–6 hours to monitor for progression [4]. Although obtaining serial abdominal films is considered a diagnostic study, it is also concurrently a part of the non-operative management of foreign

Despite plain radiographs being recommended as the initial diagnostic imaging, there is a reported false-negative rate of 47% [1]. Common objects that are not easily visualized on X-rays include wood, chicken bones, glass, and plastic [1]. If an adequate history supports the ingestion of an object that is difficult to visualize on initial work-up, then further imaging should be performed. Most literature supports that if a complication of foreign body ingestion is suspected, such as perforation or obstruction, then CT scan is the imaging of choice to perform for further

**Figure 1** shows a CT scan obtained in the emergency department on a patient with mental disability and history of PICA. The patient was unable to provide a

*CT scan demonstrating small bowel obstruction caused by foreign body. Black arrow represents foreign body* 

*and white arrow demonstrates patient's functional gastrostomy tube.*

obstruction may also be detected on initial plain films.

**42**

**Figure 1.**

#### **3.1 Important considerations**

The literature describing intestinal obstructions due to foreign bodies is replete with case reports, citing many different strategies that are unique based on patient, location, time course and object type, as well as facility resources. More than 100,000 foreign body ingestions are reported each year, with estimated mortality rates around 3% [6]. As previously mentioned, foreign body ingestion is most common in the pediatric population with the peak incidence between ages 6 months and 6 years [7]. This can also be encountered frequently by the general surgeon in the adult population. While the management of foreign bodies is generally well described when located in the upper gastrointestinal (GI) tract, those that pass beyond the gastroesophageal junction and eventually into the lower GI tract are less well documented. While considering the management of these patients, you must consider that between 80 and 95% of objects that traverse the gastroesophageal junction pass through the gastrointestinal tract without further complication, in both pediatrics and adults [6, 8]. Ingestions of foreign bodies or impacted food can lead to the need for emergency endoscopic intervention in 10–20% of cases, with only about 10% of foreign bodies progressing past the stomach, and only 1% requiring surgical intervention [6, 9]. While up to 80% of total foreign body ingestions occur in pediatric patients, in the adult population true foreign body ingestion of nonfood objects more commonly occurs in those with psychiatric illnesses and developmental delay [10].

#### **3.2 Initial management**

With all foreign body ingestions, or in rare cases, migrations, the clinician must decide whether the intervention is warranted, the degree of urgency needed, and by what approach. Initial management of foreign body ingestion is first concerned with discerning signs and symptoms of airway compression as these patients may need a definitive airway with endotracheal intubation or other adjuncts. Asymptomatic patients can often describe what or how the object or foreign body was ingested which will aid in determining course of treatment. Patients who have passed the foreign object beyond the gastroesophageal junction or into the distal gastrointestinal tract may present with signs and symptoms of obstruction or perforation. This includes abdominal pain, fever, vomiting or peritonitis [8]. Patients presenting with these symptoms often undergo imaging initially and in rare cases, can present with obstruction or perforation secondary to previously placed surgical materials [6, 11, 12]. Abdominal plain films can be used to follow most radiopaque

objects, but CT scan is recommended to delineate more detail. Patients with known foreign body ingestion can be expectantly managed with serial abdominal exams or serial imaging as most foreign bodies that have passed through the esophagus will be excreted without further injury. This is true even for sharp-pointed objects, despite an increased risk of perforation [7].

Impaction, perforation, or obstruction occurs most often at areas of acute angulation or narrowing such as the level of the cricopharyngeus muscle and the ileocecal valve. Other areas of concern, specifically with longer shaped objects, include the pylorus and duodenal c-loop [6]. Patients with prior GI tract surgery or congenitally malformed guts are at increased risk for obstruction and perforation and should be considered for intervention with any change in abdominal exam or imaging [7]. In addition to the signs and symptoms of perforation or obstruction, persistence of an asymptomatic foreign body in the stomach can be a relative indication for endoscopic retrieval, and those lodged distal to the stomach in a fixed persistent location for longer than 1 week may warrant operative intervention [8]. It has been suggested that the time required to excrete a foreign body is between 4 and 6 days, and rarely up to 4 weeks, with retention time in the duodenum being particularly important. If the object is retained in the duodenum for longer than 7 days, it has been shown to have an increased risk of perforation [9]. Gastrointestinal perforation requires emergent operative intervention, with bowel perforation often managed with an open approach, but can be considered for a laparoscopic approach depending on surgeon comfort and availability.

#### **3.3 Endoscopic management**

Urgent endoscopic management is often necessary when foreign body ingestion results in impaction within the esophagus, especially when the object is sharp or a button battery. It is also required to prevent aspiration when the foreign object or food bolus impaction creates a high-grade obstruction causing difficulty in managing secretions. Rigid and flexible esophagoscopy are both effective and safe methods of intervention for the removal of esophageal foreign bodies [7]. As rigid esophagoscopy requires general anesthesia, use of a flexible scope may be more feasible in certain situations.

Foreign objects that traverse the pylorus and are located in the distal gastrointestinal tract can still be retrieved endoscopically in certain situations. Single and double-balloon enteroscopy (DBE) can access the small intestine and is emerging as a reliable method of retrieval based on operator comfort and availability [9]. Accessories for the treatment of foreign bodies such as hoods, baskets and forceps have been designed for enteroscopes. Case reports have described the successful retrieval of retained video capsules [3, 12]. Asymptomatic patients are more likely to be candidates for endoscopic management, but case reports have described successful retrieval of retained objects at risk for obstruction or perforation [3]. As DBE is minimally invasive, it theoretically should decrease the length of hospitalization when compared with laparotomy and laparoscopy, although a study has not been specifically performed for this purpose.

The patient whose CT scan was shown in **Figure 1** underwent colonoscopy in an attempt to obtain the foreign body. **Figure 2** demonstrates the endoscopic retrieval of a gastrostomy tube that was causing an obstruction at the terminal ileum. The patient had ingested the feeding tube, and it migrated through the gastrointestinal tract until becoming lodged in the small bowel.

Other forms of lower endoscopy can also be considered based on object location and patient characteristics and include the use of a colonoscope. Endoscopic guidelines have been published more extensively but pertain particularly to the

**45**

*Foreign Bodies and Bowel Obstructions DOI: http://dx.doi.org/10.5772/intechopen.92170*

risk for perforation are managed operatively.

*Colonoscopy showing retrieval of foreign body.*

being more commonly reported as a successful alternative.

otomy and intracorporeal repair after retrieval [11, 15].

**3.4 Surgical management**

**Figure 2.**

**3.5 Laparoscopic management**

agement due to these limiting factors.

and anastomosis is recommended.

management of the upper gastrointestinal tract, and in the pediatric population [3, 7, 8, 13]. Guidelines for the management of foreign bodies in the lower gastrointestinal tract likely require more data and studies to be performed prior to formal recommendations. At this time, management is trending strongly towards the use of endoscopy for stable patients, while unstable patients or those at high-

Surgical management is often reserved for patients that present emergently with bowel obstruction, abscess formation, or perforation secondary to the foreign body ingestion. These patients have traditionally undergone open procedures as a first choice, but with advances in technique and availability, laparoscopic approaches are

Laparoscopy is an important method to consider when approaching the management of patients with retained foreign objects in the distal gastrointestinal tract. The trend towards minimally invasive surgery has been supported by decreased length of hospitalization and a lower rate of complication in abdominal surgery when compared to laparotomy. The use of this method largely depends on surgeon comfort, training and availability, as many facilities defer to laparotomy for man-

Most of the information on laparoscopic management of intestinal obstructions related to foreign body ingestion is anecdotal, with few studies being performed to date. A five-patient case series from Chia et al. reported successful management with laparoscopy after failed endoscopy. Three of five patients had abscess formation, with two patients complicated by perforation. All five had successful retrieval of the foreign body and primary repair of the bowel with intracorporeal suturing, as well as successful deroofing and drainage of the abscesses if needed [14]. Other case reports have reported similar methods and results, with some describing enter-

It is important to note, that with any surgical intervention performed, it is recommended that any potentially involved bowel be visualized for perforation or injury. As with all bowel injuries, if greater than 50% of its circumference, resection *Foreign Bodies and Bowel Obstructions DOI: http://dx.doi.org/10.5772/intechopen.92170*

*Intestinal Obstructions*

despite an increased risk of perforation [7].

depending on surgeon comfort and availability.

been specifically performed for this purpose.

tract until becoming lodged in the small bowel.

**3.3 Endoscopic management**

feasible in certain situations.

objects, but CT scan is recommended to delineate more detail. Patients with known foreign body ingestion can be expectantly managed with serial abdominal exams or serial imaging as most foreign bodies that have passed through the esophagus will be excreted without further injury. This is true even for sharp-pointed objects,

Impaction, perforation, or obstruction occurs most often at areas of acute angulation or narrowing such as the level of the cricopharyngeus muscle and the ileocecal valve. Other areas of concern, specifically with longer shaped objects, include the pylorus and duodenal c-loop [6]. Patients with prior GI tract surgery or congenitally malformed guts are at increased risk for obstruction and perforation and should be considered for intervention with any change in abdominal exam or imaging [7]. In addition to the signs and symptoms of perforation or obstruction, persistence of an asymptomatic foreign body in the stomach can be a relative indication for endoscopic retrieval, and those lodged distal to the stomach in a fixed persistent location for longer than 1 week may warrant operative intervention [8]. It has been suggested that the time required to excrete a foreign body is between 4 and 6 days, and rarely up to 4 weeks, with retention time in the duodenum being particularly important. If the object is retained in the duodenum for longer than 7 days, it has been shown to have an increased risk of perforation [9]. Gastrointestinal perforation requires emergent operative intervention, with bowel perforation often managed with an open approach, but can be considered for a laparoscopic approach

Urgent endoscopic management is often necessary when foreign body ingestion results in impaction within the esophagus, especially when the object is sharp or a button battery. It is also required to prevent aspiration when the foreign object or food bolus impaction creates a high-grade obstruction causing difficulty in managing secretions. Rigid and flexible esophagoscopy are both effective and safe methods of intervention for the removal of esophageal foreign bodies [7]. As rigid esophagoscopy requires general anesthesia, use of a flexible scope may be more

Foreign objects that traverse the pylorus and are located in the distal gastrointestinal tract can still be retrieved endoscopically in certain situations. Single and double-balloon enteroscopy (DBE) can access the small intestine and is emerging as a reliable method of retrieval based on operator comfort and availability [9]. Accessories for the treatment of foreign bodies such as hoods, baskets and forceps have been designed for enteroscopes. Case reports have described the successful retrieval of retained video capsules [3, 12]. Asymptomatic patients are more likely to be candidates for endoscopic management, but case reports have described successful retrieval of retained objects at risk for obstruction or perforation [3]. As DBE is minimally invasive, it theoretically should decrease the length of hospitalization when compared with laparotomy and laparoscopy, although a study has not

The patient whose CT scan was shown in **Figure 1** underwent colonoscopy in an attempt to obtain the foreign body. **Figure 2** demonstrates the endoscopic retrieval of a gastrostomy tube that was causing an obstruction at the terminal ileum. The patient had ingested the feeding tube, and it migrated through the gastrointestinal

Other forms of lower endoscopy can also be considered based on object location and patient characteristics and include the use of a colonoscope. Endoscopic guidelines have been published more extensively but pertain particularly to the

**44**

**Figure 2.** *Colonoscopy showing retrieval of foreign body.*

management of the upper gastrointestinal tract, and in the pediatric population [3, 7, 8, 13]. Guidelines for the management of foreign bodies in the lower gastrointestinal tract likely require more data and studies to be performed prior to formal recommendations. At this time, management is trending strongly towards the use of endoscopy for stable patients, while unstable patients or those at highrisk for perforation are managed operatively.

#### **3.4 Surgical management**

Surgical management is often reserved for patients that present emergently with bowel obstruction, abscess formation, or perforation secondary to the foreign body ingestion. These patients have traditionally undergone open procedures as a first choice, but with advances in technique and availability, laparoscopic approaches are being more commonly reported as a successful alternative.

#### **3.5 Laparoscopic management**

Laparoscopy is an important method to consider when approaching the management of patients with retained foreign objects in the distal gastrointestinal tract. The trend towards minimally invasive surgery has been supported by decreased length of hospitalization and a lower rate of complication in abdominal surgery when compared to laparotomy. The use of this method largely depends on surgeon comfort, training and availability, as many facilities defer to laparotomy for management due to these limiting factors.

Most of the information on laparoscopic management of intestinal obstructions related to foreign body ingestion is anecdotal, with few studies being performed to date. A five-patient case series from Chia et al. reported successful management with laparoscopy after failed endoscopy. Three of five patients had abscess formation, with two patients complicated by perforation. All five had successful retrieval of the foreign body and primary repair of the bowel with intracorporeal suturing, as well as successful deroofing and drainage of the abscesses if needed [14]. Other case reports have reported similar methods and results, with some describing enterotomy and intracorporeal repair after retrieval [11, 15].

It is important to note, that with any surgical intervention performed, it is recommended that any potentially involved bowel be visualized for perforation or injury. As with all bowel injuries, if greater than 50% of its circumference, resection and anastomosis is recommended.

#### **3.6 Open surgical management**

Laparotomy is still recommended for management of the unstable patient with suspected or confirmed perforation or obstruction that is threatening life or bowel. This presentation secondary to foreign body obstruction is rare, but it is important to consider. As the management trend has shifted towards minimally invasive, with endoscopic management often attempted first and laparoscopy considered if available, open surgical management is often reserved for emergency or for those facilities that do not have the resources the previously mentioned approaches [8, 9, 16, 17]. As with the laparoscopic management, the area of obstruction, perforation or abscess formation should be localized and an enterotomy made for retrieval. If the bowel is viable and can be repaired primarily this is recommended. If bowel injury is greater than 50% of its circumference, resection and anastomosis is recommended. If the patient is unstable and requires further resuscitation, or the abdomen is grossly contaminated, damage control surgery is always a consideration with the patient left in discontinuity after the object has been removed and further contamination has been controlled.

Intervention upon retained foreign object is largely dependent on the characteristics of the patient, the object, the time course and the presentation, as well as the resources available at the facility. As the majority of foreign objects pass without injury through the gastrointestinal tract, it is relatively rare for ingestion to result in surgical intervention. A clear trend towards the most minimally invasive approach has been forming, and we anticipate that the future guidelines will reflect this. The basic principles of bowel obstruction and perforation are still the most important factors to consider when planning your method of management and should be adhered to.

#### **4. Complications**

#### **4.1 Perforation**

Foreign body ingestion resulting in perforation is a rare but dreaded complication. It is reported to occur following only 1% of foreign body ingestions [18]. Some studies in the literature report that the average time from ingestion to evaluation at a medical facility was 10.4 ± 9.3 days with a wide range of 3 to 60 days [19]. The most common presenting symptom at the time of presentation is abdominal pain, with many patients having peritonitis on exam. Once a diagnosis of perforation is suspected, operative exploration is warranted. The most common locations found intra-operatively are the distal ileum and colon. Other less common locations are the duodenum and jejunum. Reports in the literature support that longer objects often result in more proximal intestinal perforation at the second and third portion of the duodenum as foreign bodies are unable to pass through the physiological angulation [20].

Although emergent surgical intervention is often the first line treatment for perforation, there are case reports in the literature that discuss endoscopic management [18]. Simunic et al. discussed the successful endoscopic retrieval of a sharp foreign body from the cecum that caused a localized perforation [18]. Their report emphasizes that clinically stable patients with localized findings on CT scan are more likely to be successfully managed using this technique. Despite case reports discussing the management of localized perforations, foreign body ingestions that present as perforations do not usually manifest with minimal symptoms and clinical stability. Consideration of endoscopic management should be on a case by

**47**

*Foreign Bodies and Bowel Obstructions DOI: http://dx.doi.org/10.5772/intechopen.92170*

complications.

**4.2 Obstruction**

encountered [21].

**4.3 Bleeding**

nostic tool but also as potentially therapeutic.

case basis if the appropriate qualified personnel are available to assist in treatment. Overall, surgical treatment is still the recommended course of treatment for such

The literature regarding foreign body ingestion causing obstruction is relatively

As mentioned previously, delayed presentation following foreign body ingestion increases the risks for complications, such as intestinal obstruction. In patients who present in a delayed fashion after ingestion of superabsorbent polymers, as the time increases following ingestion, both the length of passage and amount of water absorbed by the foreign body increases. These factors increase the likelihood of intestinal obstruction and decrease the chance that the foreign body will pass without either endoscopic or surgical intervention [2]. The key to preventing intestinal obstruction is to pursue endoscopic intervention early when ingestion is highly suspected but not witnessed. If obstruction is not identified in a timely fashion, then it can lead to intestinal perforation, which has its own associated morbidity.

Most complications reported in the literature associated with foreign body ingestion are related to perforation, obstruction, or fistula formation. Bleeding is another complication that can result from foreign body ingestion. Hemorrhage can result from direct mucosal injury from sharp objects. Bleeding may also occur due to erosion of the mucosa caused by blunt objects. In patients who are hemodynamically stable and present with gastrointestinal bleeding with a history of foreign body ingestion, endoscopic intervention should be considered not only as a diag-

The ESGE recommends that endoscopy be performed within 24 hours for sharp and long objects that are in the stomach to prevent complications such as bleeding, perforation, and obstruction. In the pediatric population it is well documented that button batteries, if ingested, may lead to all the above complications [1]. Although, they are most commonly lodged in the esophagus, if they do pass into the stomach and then into the small intestine, they may cause obstruction leading to mucosal erosion and subsequently perforation. A patient may present with hematemesis or lower GI bleed depending on where the object is causing mucosal erosion. It is estimated that the risk of complications can be as high as 35% once these objects leave the stomach [1]. With regards to adult literature, case reports have been published showing that ingestion of sharp foreign bodies can cause life-threatening gastrointestinal bleeding. Gattai et al. reported on a patient who had ingested glass, which caused lacerations in the fourth portion of the duodenum that led to a severe gastrointestinal bleed. During operative intervention the patient was found to have a segment of jejunal diverticulum; however, the source of bleeding was not found in the resected portion of bowel. Following small bowel resection, the patient continued to hemorrhage and was found to have active bleeding from lacerations found in the duodenum. This case report demonstrates the severity of foreign body ingestion and appropriate surgical management [22]. If bleeding is unable to be controlled endoscopically, then surgical intervention is mandated. Although gastrointestinal hemorrhage is a rare complication, its morbidity should not be underestimated.

limited to case series at single institutions and published case reports. Review of the available literature supports that intestinal perforation is the most common presenting complication with obstruction being the second most frequently case basis if the appropriate qualified personnel are available to assist in treatment. Overall, surgical treatment is still the recommended course of treatment for such complications.

#### **4.2 Obstruction**

*Intestinal Obstructions*

**3.6 Open surgical management**

contamination has been controlled.

adhered to.

**4. Complications**

**4.1 Perforation**

angulation [20].

Laparotomy is still recommended for management of the unstable patient with suspected or confirmed perforation or obstruction that is threatening life or bowel. This presentation secondary to foreign body obstruction is rare, but it is important to consider. As the management trend has shifted towards minimally invasive, with endoscopic management often attempted first and laparoscopy considered if available, open surgical management is often reserved for emergency or for those facilities that do not have the resources the previously mentioned approaches [8, 9, 16, 17]. As with the laparoscopic management, the area of obstruction, perforation or abscess formation should be localized and an enterotomy made for retrieval. If the bowel is viable and can be repaired primarily this is recommended. If bowel injury is greater than 50% of its circumference, resection and anastomosis is recommended. If the patient is unstable and requires further resuscitation, or the abdomen is grossly contaminated, damage control surgery is always a consideration with the patient left in discontinuity after the object has been removed and further

Intervention upon retained foreign object is largely dependent on the characteristics of the patient, the object, the time course and the presentation, as well as the resources available at the facility. As the majority of foreign objects pass without injury through the gastrointestinal tract, it is relatively rare for ingestion to result in surgical intervention. A clear trend towards the most minimally invasive approach has been forming, and we anticipate that the future guidelines will reflect this. The basic principles of bowel obstruction and perforation are still the most important factors to consider when planning your method of management and should be

Foreign body ingestion resulting in perforation is a rare but dreaded complication. It is reported to occur following only 1% of foreign body ingestions [18]. Some studies in the literature report that the average time from ingestion to evaluation at a medical facility was 10.4 ± 9.3 days with a wide range of 3 to 60 days [19]. The most common presenting symptom at the time of presentation is abdominal pain, with many patients having peritonitis on exam. Once a diagnosis of perforation is suspected, operative exploration is warranted. The most common locations found intra-operatively are the distal ileum and colon. Other less common locations are the duodenum and jejunum. Reports in the literature support that longer objects often result in more proximal intestinal perforation at the second and third portion of the duodenum as foreign bodies are unable to pass through the physiological

Although emergent surgical intervention is often the first line treatment for perforation, there are case reports in the literature that discuss endoscopic management [18]. Simunic et al. discussed the successful endoscopic retrieval of a sharp foreign body from the cecum that caused a localized perforation [18]. Their report emphasizes that clinically stable patients with localized findings on CT scan are more likely to be successfully managed using this technique. Despite case reports discussing the management of localized perforations, foreign body ingestions that present as perforations do not usually manifest with minimal symptoms and clinical stability. Consideration of endoscopic management should be on a case by

**46**

The literature regarding foreign body ingestion causing obstruction is relatively limited to case series at single institutions and published case reports. Review of the available literature supports that intestinal perforation is the most common presenting complication with obstruction being the second most frequently encountered [21].

As mentioned previously, delayed presentation following foreign body ingestion increases the risks for complications, such as intestinal obstruction. In patients who present in a delayed fashion after ingestion of superabsorbent polymers, as the time increases following ingestion, both the length of passage and amount of water absorbed by the foreign body increases. These factors increase the likelihood of intestinal obstruction and decrease the chance that the foreign body will pass without either endoscopic or surgical intervention [2]. The key to preventing intestinal obstruction is to pursue endoscopic intervention early when ingestion is highly suspected but not witnessed. If obstruction is not identified in a timely fashion, then it can lead to intestinal perforation, which has its own associated morbidity.

#### **4.3 Bleeding**

Most complications reported in the literature associated with foreign body ingestion are related to perforation, obstruction, or fistula formation. Bleeding is another complication that can result from foreign body ingestion. Hemorrhage can result from direct mucosal injury from sharp objects. Bleeding may also occur due to erosion of the mucosa caused by blunt objects. In patients who are hemodynamically stable and present with gastrointestinal bleeding with a history of foreign body ingestion, endoscopic intervention should be considered not only as a diagnostic tool but also as potentially therapeutic.

The ESGE recommends that endoscopy be performed within 24 hours for sharp and long objects that are in the stomach to prevent complications such as bleeding, perforation, and obstruction. In the pediatric population it is well documented that button batteries, if ingested, may lead to all the above complications [1]. Although, they are most commonly lodged in the esophagus, if they do pass into the stomach and then into the small intestine, they may cause obstruction leading to mucosal erosion and subsequently perforation. A patient may present with hematemesis or lower GI bleed depending on where the object is causing mucosal erosion. It is estimated that the risk of complications can be as high as 35% once these objects leave the stomach [1]. With regards to adult literature, case reports have been published showing that ingestion of sharp foreign bodies can cause life-threatening gastrointestinal bleeding. Gattai et al. reported on a patient who had ingested glass, which caused lacerations in the fourth portion of the duodenum that led to a severe gastrointestinal bleed. During operative intervention the patient was found to have a segment of jejunal diverticulum; however, the source of bleeding was not found in the resected portion of bowel. Following small bowel resection, the patient continued to hemorrhage and was found to have active bleeding from lacerations found in the duodenum. This case report demonstrates the severity of foreign body ingestion and appropriate surgical management [22]. If bleeding is unable to be controlled endoscopically, then surgical intervention is mandated. Although gastrointestinal hemorrhage is a rare complication, its morbidity should not be underestimated.

#### **5. Special considerations**

Bezoars are uncommon masses formed from indigestible ingested substances in the gastrointestinal system. They were named in 1854 by Quain, after a mass of intragastric food residue was found during autopsy [23]. They are reported to contribute to up to 4% of small bowel obstructions [23–25]. Many are diagnosed post-operatively as they do not have a clinically significant difference in presentation from other causes of small bowel obstruction [24]. There are different forms of bezoars that are classified based on the content that forms the mass.

#### **5.1 Classification**

There are five types of bezoars: phytobezoars, trichobezoars, polybezoars, pharmacobezoars, and lactobezoars [23, 25]. Phytobezoars are made of vegetable and fruit residues, trichobezoars consist of hair, a lactobezoar is formed from dairy products, polybezoars are caused by ingested foreign bodies, and a pharmacobezoar is caused by medications [23]. The most common type of bezoar is the phytobezoar, which typically consists of cellulose and hemicellulose from indigestible food residue [23]. Trichobezoars are generally seen in individuals with trichophagia, a psychiatric disorder that causes the compulsive eating of hair after pulling (trichotillomania), usually seen in young adults and during childhood [23, 26, 27]. Most cases of trichobezoars are reported in females, which may be attributed to the tendency to have longer hair [26]. These bezoars are generally located in the stomach, but prolonged or unrecognized ingestion can cause a process known as Rapunzel syndrome, where the hair extends from the stomach into the small intestine [23, 26, 27]. Treatment of the underlying psychiatric illness is paramount to prevent recurrence and further complication. Trichobezoar with Rapunzel syndrome is an uncommon diagnosis in children, with fewer than 100 cases reported [26].

#### **5.2 Presentation**

The symptoms of bezoars can differ according to size, location and the level of obstruction. Gastric bezoars will usually present with vomiting, upper abdominal pain and distention, which are common symptoms of obstruction [23, 24]. The most common symptom has been reported as upper abdominal pain [24]. It is often difficult to differentiate small bowel obstruction (SBO) secondary to bezoar from adhesive obstruction in a patient who has had previous abdominal surgery.

The history portion of the clinical exam is often the most important in this patient population as past surgical history and medical conditions can raise suspicion for a bezoar. Predisposing factors of bowel obstruction due to bezoar are ingestion of a high-fiber diet, abnormal chewing, diminished gastric secretion and motility, diabetics, patients with myotonic dystrophy and many other less common factors [23–25]. High-fiber foods such as celery, pumpkins, grape skins, prunes and especially persimmons, are a risk factor for formation [23]. Bezoars are prevalent among patients with delayed gastric emptying such as after a gastrectomy or a vagotomy, or secondary to diabetic autonomic neuropathy and hypothyroidism [23–25]. Bezoar causing SBO in patients with previous gastric surgery is well known as a late complication, although rare [25]. Incidence of post-gastrectomy bezoar has been reported to be between 5 and 15%, and the time it takes a bezoar to form after gastric surgery ranges from 9 months to 30 years [23, 25]. Bezoars can also be formed primarily in the small intestine when a mechanical factor alters the small intestinal lumen such as a diverticulum, tumor or stricture [23]. Pharmacobezoars are usually caused by Kayexalate (sodium polystyrene sulfonate), cholestyramine

**49**

ingestion.

**Acknowledgements**

*Foreign Bodies and Bowel Obstructions DOI: http://dx.doi.org/10.5772/intechopen.92170*

**5.3 Imaging**

**5.4 Treatment**

**6. Conclusions**

and antacid medications [23]. Lactobezoars typically occur in low-birth-weight

An accurate preoperative diagnosis is often difficult due to lack of specific symptoms, and clinical presentation of an acute surgical abdomen is very rare, occurring in 1.1% of cases [24, 25]. Most bezoars in the small bowel are found approximately 50 to 70 cm above the ileocecal valve because of narrowing with slower intestinal motility and significant water absorption that hardens the bezoar [24]. The most

Computed-tomography is the gold standard imaging modality for diagnosing small bowel obstruction due to bezoar [23, 24]. Contrast-enhanced CT imaging is the most valuable method for determining the location and etiology of intestinal obstructions [23]. The history provided by the patient in conjunction with CT imaging findings will likely give the most complete picture. As many bezoars can be radiolucent, plain film radiographs may have less utility. Other imaging modalities that can be considered are abdominal ultrasound, which has a reportedly high diagnostic rate of 88–93%, but this is user dependent and can be limited by patient's

Treatment is identical to that previously described for other forms of small bowel obstruction due to foreign body ingestion. The minimally invasive approach of endoscopy, including double-balloon enteroscopy, may be used as a first line if the patient is stable without perforation. Case reports have described the use of endoscopic fragmentation, gastric lavage, enzymatic therapy or combination of these approaches [26, 27]. Bezoars like Rapunzel syndrome require surgical removal. Laparoscopic enterotomy and retrieval should be considered for any obstructions not amenable to endoscopic treatment. Open surgical management should be reserved for patients in extremis, with perforation and contamination, or based on the availability of experienced endoscopic and laparoscopic surgeons and resources.

Foreign body ingestion can be a challenge to manage. It creates diagnostic as well as treatment dilemmas for clinicians. Evaluation should be initiated with a basic history and physical exam, and further imaging studies should be obtained based on the information gathered. After appropriate work-up has been completed, clinicians can determine the next step in management. Most foreign body ingestions may be managed non-operatively; however, in some situations, management may be a multidisciplinary approach that includes gastroenterologists and surgeons. Ultimately, the patient's clinical stability and examination should determine the best course in management to prevent complications associated with foreign body

We would like to express our thanks to Dr Brian Daley for his guidance. We appreciate his patience and time. We would also like to thank the University of

body habitus, gas accumulation and location of the obstruction [24].

newborns as a result of concentrated baby formulas [23].

common site of obstruction is the terminal ileum [25].

#### *Foreign Bodies and Bowel Obstructions DOI: http://dx.doi.org/10.5772/intechopen.92170*

and antacid medications [23]. Lactobezoars typically occur in low-birth-weight newborns as a result of concentrated baby formulas [23].

An accurate preoperative diagnosis is often difficult due to lack of specific symptoms, and clinical presentation of an acute surgical abdomen is very rare, occurring in 1.1% of cases [24, 25]. Most bezoars in the small bowel are found approximately 50 to 70 cm above the ileocecal valve because of narrowing with slower intestinal motility and significant water absorption that hardens the bezoar [24]. The most common site of obstruction is the terminal ileum [25].

#### **5.3 Imaging**

*Intestinal Obstructions*

**5.1 Classification**

**5.2 Presentation**

**5. Special considerations**

Bezoars are uncommon masses formed from indigestible ingested substances in the gastrointestinal system. They were named in 1854 by Quain, after a mass of intragastric food residue was found during autopsy [23]. They are reported to contribute to up to 4% of small bowel obstructions [23–25]. Many are diagnosed post-operatively as they do not have a clinically significant difference in presentation from other causes of small bowel obstruction [24]. There are different forms of

There are five types of bezoars: phytobezoars, trichobezoars, polybezoars, pharmacobezoars, and lactobezoars [23, 25]. Phytobezoars are made of vegetable and fruit residues, trichobezoars consist of hair, a lactobezoar is formed from dairy products, polybezoars are caused by ingested foreign bodies, and a pharmacobezoar is caused by medications [23]. The most common type of bezoar is the phytobezoar, which typically consists of cellulose and hemicellulose from indigestible food residue [23]. Trichobezoars are generally seen in individuals with trichophagia, a psychiatric disorder that causes the compulsive eating of hair after pulling (trichotillomania), usually seen in young adults and during childhood [23, 26, 27]. Most cases of trichobezoars are reported in females, which may be attributed to the tendency to have longer hair [26]. These bezoars are generally located in the stomach, but prolonged or unrecognized ingestion can cause a process known as Rapunzel syndrome, where the hair extends from the stomach into the small intestine [23, 26, 27]. Treatment of the underlying psychiatric illness is paramount to prevent recurrence and further complication. Trichobezoar with Rapunzel syndrome is an uncommon

The symptoms of bezoars can differ according to size, location and the level of obstruction. Gastric bezoars will usually present with vomiting, upper abdominal pain and distention, which are common symptoms of obstruction [23, 24]. The most common symptom has been reported as upper abdominal pain [24]. It is often difficult to differentiate small bowel obstruction (SBO) secondary to bezoar from adhesive obstruction in a patient who has had previous abdominal surgery. The history portion of the clinical exam is often the most important in this patient population as past surgical history and medical conditions can raise suspicion for a bezoar. Predisposing factors of bowel obstruction due to bezoar are ingestion of a high-fiber diet, abnormal chewing, diminished gastric secretion and motility, diabetics, patients with myotonic dystrophy and many other less common factors [23–25]. High-fiber foods such as celery, pumpkins, grape skins, prunes and especially persimmons, are a risk factor for formation [23]. Bezoars are prevalent among patients with delayed gastric emptying such as after a gastrectomy or a vagotomy, or secondary to diabetic autonomic neuropathy and hypothyroidism [23–25]. Bezoar causing SBO in patients with previous gastric surgery is well known as a late complication, although rare [25]. Incidence of post-gastrectomy bezoar has been reported to be between 5 and 15%, and the time it takes a bezoar to form after gastric surgery ranges from 9 months to 30 years [23, 25]. Bezoars can also be formed primarily in the small intestine when a mechanical factor alters the small intestinal lumen such as a diverticulum, tumor or stricture [23]. Pharmacobezoars are usually caused by Kayexalate (sodium polystyrene sulfonate), cholestyramine

bezoars that are classified based on the content that forms the mass.

diagnosis in children, with fewer than 100 cases reported [26].

**48**

Computed-tomography is the gold standard imaging modality for diagnosing small bowel obstruction due to bezoar [23, 24]. Contrast-enhanced CT imaging is the most valuable method for determining the location and etiology of intestinal obstructions [23]. The history provided by the patient in conjunction with CT imaging findings will likely give the most complete picture. As many bezoars can be radiolucent, plain film radiographs may have less utility. Other imaging modalities that can be considered are abdominal ultrasound, which has a reportedly high diagnostic rate of 88–93%, but this is user dependent and can be limited by patient's body habitus, gas accumulation and location of the obstruction [24].

#### **5.4 Treatment**

Treatment is identical to that previously described for other forms of small bowel obstruction due to foreign body ingestion. The minimally invasive approach of endoscopy, including double-balloon enteroscopy, may be used as a first line if the patient is stable without perforation. Case reports have described the use of endoscopic fragmentation, gastric lavage, enzymatic therapy or combination of these approaches [26, 27]. Bezoars like Rapunzel syndrome require surgical removal. Laparoscopic enterotomy and retrieval should be considered for any obstructions not amenable to endoscopic treatment. Open surgical management should be reserved for patients in extremis, with perforation and contamination, or based on the availability of experienced endoscopic and laparoscopic surgeons and resources.

#### **6. Conclusions**

Foreign body ingestion can be a challenge to manage. It creates diagnostic as well as treatment dilemmas for clinicians. Evaluation should be initiated with a basic history and physical exam, and further imaging studies should be obtained based on the information gathered. After appropriate work-up has been completed, clinicians can determine the next step in management. Most foreign body ingestions may be managed non-operatively; however, in some situations, management may be a multidisciplinary approach that includes gastroenterologists and surgeons. Ultimately, the patient's clinical stability and examination should determine the best course in management to prevent complications associated with foreign body ingestion.

#### **Acknowledgements**

We would like to express our thanks to Dr Brian Daley for his guidance. We appreciate his patience and time. We would also like to thank the University of

Tennessee Graduate School of Medicine for providing us with the resources to compile the research used in the content of this manuscript. No source of funding was used in the production of this manuscript.

### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Jessica Elizabeth Taylor\* and Devin Clegg University of Tennessee Graduate School of Medicine, Knoxville, TN, United States

\*Address all correspondence to: jtaylor4@utmck.edu

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**51**

*Foreign Bodies and Bowel Obstructions DOI: http://dx.doi.org/10.5772/intechopen.92170*

[1] Birk M, Bauerfeind P, Deprez PH, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy. 2016;**48**:489-496. DOI:

Principles & Practice. 6th ed. Philadelphia: Lippincott Williams &

Wilkins; 2016. p. 1904-1914

DOI: 10.1515/pjs-2015-0006

10.1155/2015/658602

s11695-014-1271-5

[12] Nakamura M, Hirooka Y,

Science. 2015;**77**(1-2):189-194

Techniques in Gastrointestinal Endoscopy. 2013;**15**(1):9-17. DOI:

10.1016/j.tgie.2012.09.005

INTSURG-D-14-00238.1

[15] Mohamed Aboulkacem B, Ghalleb M, Khemir A, et al. Laparoscopic assisted foreign body

[13] Kay M, Wyllie R. Foreign body ingestions in the pediatric population and techniques of endoscopic removal.

[14] Chia DKA, Wijaya R, Wong A, Tan S-M. Laparoscopic management of complicated foreign body ingestion: A case series. International Surgery. 2015;**100**(5):849-853. DOI: 10.9738/

Watanabe O, et al. Minimally invasive extraction of a foreign body from the small intestine using double-balloon endoscopy. Nagoya Journal of Medical

[10] Yao C-C, Wu I-T, Lu L-S, et al. endoscopic management of foreign bodies in the upper gastrointestinal tract of adults. BioMed Research International. 2015;**2015**:1-6. DOI:

[11] Di Saverio S, Bianchini Massoni C, Boschi S, et al. Complete small-bowel obstruction from a migrated intragastric balloon: Emergency laparoscopy for retrieval via enterotomy and intracorporeal repair. Obesity Surgery. 2014;**24**(10):1830-1832. DOI: 10.1007/

[9] Wnęk B, Łożyńska-Nelke A, Karoń J. Foreign body in the gastrointestinal tract leading to small bowel obstruction— Case report and literature review. Polish Journal of Surgery. 2015;**86**(12):549-597.

[2] Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: A clinical report of the NASPGHAN endoscopy committee. Journal of Pediatric Gastroenterology and Nutrition. 2015;**60**:562-574. DOI: 10.1097/MPG.0000000000000729

[3] Ikenberry SO, Jue TL, Anderson MA,

[4] Arshad M, Jeelani SM, Salim A, et al. Multiple magnet ingestion leading to bowel perforation: A relatively sinister foreign body. Cureus. 2019;**11**:e5866.

[5] Kozaci N, Avci M, Pinarbasili T, et al. Ingested foreign body imaging using point-of-care ultrasonography: A case series. Pediatric Emergency Care. 2019;**35**:807-810. DOI: 10.1097/

[6] Taylor JE, Campbell M, Daley B. The management of small bowel obstruction caused by ingested gastrostomy tube. The American Surgeon. 2019;**85**(8):e372-e373

[7] Eisen GM, Baron TH, Dominitz JA, et al. Guideline for the management of ingested foreign bodies. Gastrointestinal Endoscopy. 2002;**55**(7):802-806. DOI: 10.1016/s0016-5107(02)70407-0

[8] Mulholland MW, Lillemoe KD, Doherty GM, Upchurch GR Jr, Alam HB, Pawlik TM, editors. Other childhood gastrointestinal disorders. In: Greenfield's Surgery: Scientific

et al. Management of ingested foreign bodies and food impactions. Gastrointestinal Endoscopy. June 2011;**73**:1085-1091. DOI: 10.1016/j.

DOI: 10.7759/cureus.5866

PEC.0000000000001971

gie.2010.11.010

10.1055/s-0042-100456

**References**

*Foreign Bodies and Bowel Obstructions DOI: http://dx.doi.org/10.5772/intechopen.92170*

#### **References**

*Intestinal Obstructions*

**Conflict of interest**

was used in the production of this manuscript.

The authors declare no conflict of interest.

**50**

**Author details**

Jessica Elizabeth Taylor\* and Devin Clegg

provided the original work is properly cited.

\*Address all correspondence to: jtaylor4@utmck.edu

University of Tennessee Graduate School of Medicine, Knoxville, TN, United States

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Tennessee Graduate School of Medicine for providing us with the resources to compile the research used in the content of this manuscript. No source of funding

> [1] Birk M, Bauerfeind P, Deprez PH, et al. Removal of foreign bodies in the upper gastrointestinal tract in adults: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy. 2016;**48**:489-496. DOI: 10.1055/s-0042-100456

[2] Kramer RE, Lerner DG, Lin T, et al. Management of ingested foreign bodies in children: A clinical report of the NASPGHAN endoscopy committee. Journal of Pediatric Gastroenterology and Nutrition. 2015;**60**:562-574. DOI: 10.1097/MPG.0000000000000729

[3] Ikenberry SO, Jue TL, Anderson MA, et al. Management of ingested foreign bodies and food impactions. Gastrointestinal Endoscopy. June 2011;**73**:1085-1091. DOI: 10.1016/j. gie.2010.11.010

[4] Arshad M, Jeelani SM, Salim A, et al. Multiple magnet ingestion leading to bowel perforation: A relatively sinister foreign body. Cureus. 2019;**11**:e5866. DOI: 10.7759/cureus.5866

[5] Kozaci N, Avci M, Pinarbasili T, et al. Ingested foreign body imaging using point-of-care ultrasonography: A case series. Pediatric Emergency Care. 2019;**35**:807-810. DOI: 10.1097/ PEC.0000000000001971

[6] Taylor JE, Campbell M, Daley B. The management of small bowel obstruction caused by ingested gastrostomy tube. The American Surgeon. 2019;**85**(8):e372-e373

[7] Eisen GM, Baron TH, Dominitz JA, et al. Guideline for the management of ingested foreign bodies. Gastrointestinal Endoscopy. 2002;**55**(7):802-806. DOI: 10.1016/s0016-5107(02)70407-0

[8] Mulholland MW, Lillemoe KD, Doherty GM, Upchurch GR Jr, Alam HB, Pawlik TM, editors. Other childhood gastrointestinal disorders. In: Greenfield's Surgery: Scientific

Principles & Practice. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2016. p. 1904-1914

[9] Wnęk B, Łożyńska-Nelke A, Karoń J. Foreign body in the gastrointestinal tract leading to small bowel obstruction— Case report and literature review. Polish Journal of Surgery. 2015;**86**(12):549-597. DOI: 10.1515/pjs-2015-0006

[10] Yao C-C, Wu I-T, Lu L-S, et al. endoscopic management of foreign bodies in the upper gastrointestinal tract of adults. BioMed Research International. 2015;**2015**:1-6. DOI: 10.1155/2015/658602

[11] Di Saverio S, Bianchini Massoni C, Boschi S, et al. Complete small-bowel obstruction from a migrated intragastric balloon: Emergency laparoscopy for retrieval via enterotomy and intracorporeal repair. Obesity Surgery. 2014;**24**(10):1830-1832. DOI: 10.1007/ s11695-014-1271-5

[12] Nakamura M, Hirooka Y, Watanabe O, et al. Minimally invasive extraction of a foreign body from the small intestine using double-balloon endoscopy. Nagoya Journal of Medical Science. 2015;**77**(1-2):189-194

[13] Kay M, Wyllie R. Foreign body ingestions in the pediatric population and techniques of endoscopic removal. Techniques in Gastrointestinal Endoscopy. 2013;**15**(1):9-17. DOI: 10.1016/j.tgie.2012.09.005

[14] Chia DKA, Wijaya R, Wong A, Tan S-M. Laparoscopic management of complicated foreign body ingestion: A case series. International Surgery. 2015;**100**(5):849-853. DOI: 10.9738/ INTSURG-D-14-00238.1

[15] Mohamed Aboulkacem B, Ghalleb M, Khemir A, et al. Laparoscopic assisted foreign body extraction from the small bowel: A case report. International Journal of Surgery Case Reports. 2017;**41**:283-286. DOI: 10.1016/j.ijscr.2017.08.047

[16] Mulholland MW, Lillemoe KD, Doherty GM, Upchurch GR Jr, Alam HB, Pawlik TM, editors. Mechanical obstruction of the intestines. In: Greenfield's Surgery: Scientific Principles & Practice. 6th ed. pp. 782-798

[17] Alsharief AN, Blackmore C, Schmit P. Small bowel obstruction due to ingestion of rubber balls. Pediatric Radiology. 2017;**47**(11):1539-1541. DOI: 10.1007/s00247-017-3894-x

[18] Simunic M, Zaja I, Ardalic Z, et al. Case report: Successful endoscopic treatment of a large bowel perforation caused by chicken bone ingestion. Medicine. 2019;**98**:e18111. DOI: 10.1097/ MD.0000000000018111

[19] Rodríguez-Hermosa JI, Codina-Cazador A, Sirvent JM, et al. Surgically treated perforations of the gastrointestinal tract caused by ingested foreign bodies. Colorectal Disease. 2008;**10**:701-707

[20] Li C, Yong CC, Encarnacion DD. Duodenal perforation nine months after accidental foreign body ingestion, a case report. BMC Surgery. 2019;**19**:132. DOI: 10.1186/s12893-019-0594-5

[21] Shao F, Shen N, Hong Z, et al. Injuries due to foreign body ingestion and insertion in children: 10 years of experience at a single institution. Journal of Paediatrics and Child Health. 2019;**56**:537-541. DOI: 10.1111/jpc.14677

[22] Gattai R, Pantalone D, Migliaccio ML, Bonizzoli M, Peris A, Bechi P. Upper G.I. hemorrhage from glass fragments' ingestion in a patient with jejunal diverticula—Case report. International Journal of Surgery

Case Reports. 2015;**6C**:191-193. DOI: 10.1016/j.ijscr.2014.11.069

[23] Dikicier E. Intestinal obstruction due to phytobezoars: An update. World Journal of Clinical Cases. 2015;**3**(8):721. DOI: 10.12998/wjcc.v3.i8.721

[24] Oh SH, Namgung H, Park MH, Park D-G. Bezoar-induced small bowel obstruction. Journal of the Korean Society of Coloproctology. 2012;**28**(2):89. DOI: 10.3393/ jksc.2012.28.2.89

[25] Nasri B, Calin M, Shah A, Gilchrist B. A rare cause of small bowel obstruction due to bezoar in a virgin abdomen. International Journal of Surgery Case Reports. 2016;**19**:144-146. DOI: 10.1016/j.ijscr.2015.12.039

[26] Gonuguntla V, Joshi D-D. Rapunzel syndrome: A comprehensive review of an unusual case of trichobezoar. Clinical Medicine & Research. 2009;**7**(3):99-102. DOI: 10.3121/cmr.2009.822

[27] Al-Janabi IS, Al-Sharbaty MA, Al-Sharbati MM, Al-Sharifi LA, Ouhtit A. Unusual trichobezoar of the stomach and the intestine: A case report. Journal of Medical Case Reports. 2014;**8**(1):79. DOI: 10.1186/1752-1947-8-79

**53**

**Chapter 5**

**Abstract**

**1. Introduction**

world [4, 5].

**2. Epidemiology**

volvulus increased by 5% per year.

*Paul K. Okeny*

Caecal Volvulus

associated with better postoperative outcomes.

Colonic volvulus is the third leading cause of large bowel obstruction. About 35% of these are located in the caecum. Though, relatively, a rare cause of obstruction, the incidence of caecal volvulus is steadily increasing at a rate of about 5% per year. Mortality due to caecal volvulus may be as high as 40% especially in the presence of gangrene and sepsis. Clinical presentation may be acute and fulminant or as a mobile caecum syndrome with intermittent abdominal pain. "Whirl," "Coffee bean," and "bird beak" signs seen on computed tomography are pathognomonic. Colectomy is the preferred treatment as it obviates any chance of recurrence. A conservative approach to colectomy such as limited ileocaecal resection and ileostomy formation in critically ill patients or in those with poor physiological reserve may be

**Keywords:** caecum, volvulus, obstruction, mobile caecum, management

There are records of volvulus as far back as 1550 BC and by Hippocrates who first described treatment options such as injection of a large quantity of air or insertion of a 10 digit suppository through the anus [1]. In modern day literature, it was first described by Austrian pathologist Rokitansky in 1837 as an important cause of intestinal strangulation [2]. Colonic volvulus or twisting of the large bowel is the third leading cause of large bowel obstruction world-wide [3]. It mainly occurs in the 'Volvulus belt' of Africa, Middle East, India and Russia where it may affect a slightly younger age group compared to the rest of the

Although the incidence of caecal volvulus as a cause of colonic volvulus appears

Caecal volvulus in itself is rare but an associated mortality of nearly 40% warrants prompt diagnosis and treatment [6]. It has an incidence of 2.8–7.1 per million people, is responsible for 1–1.5% of intestinal obstructions, and 25–40% of all colonic volvulus and affects females more than males [7]. The presence of a volvulus belt has already been discussed. In a large epidemiological study done by Halabi et al. [8] over a period covering 9 years in the United States, the incidence of caecal

to be increasing, the commonest sites for colonic volvulus still include sigmoid −60%, caecum −35%, transverse colon −4%, and splenic flexure −1% [1]. This

chapter reviews the current management of caecal volvulus.

## **Chapter 5** Caecal Volvulus

*Paul K. Okeny*

### **Abstract**

*Intestinal Obstructions*

pp. 782-798

10.1016/j.ijscr.2017.08.047

extraction from the small bowel: A case report. International Journal of Surgery Case Reports. 2017;**41**:283-286. DOI:

Case Reports. 2015;**6C**:191-193. DOI:

[23] Dikicier E. Intestinal obstruction due to phytobezoars: An update. World Journal of Clinical Cases. 2015;**3**(8):721.

[24] Oh SH, Namgung H, Park MH, Park D-G. Bezoar-induced small bowel obstruction. Journal of the Korean Society of Coloproctology. 2012;**28**(2):89. DOI: 10.3393/

10.1016/j.ijscr.2014.11.069

DOI: 10.12998/wjcc.v3.i8.721

[25] Nasri B, Calin M, Shah A,

DOI: 10.1016/j.ijscr.2015.12.039

DOI: 10.3121/cmr.2009.822

10.1186/1752-1947-8-79

[27] Al-Janabi IS, Al-Sharbaty MA, Al-Sharbati MM, Al-Sharifi LA, Ouhtit A. Unusual trichobezoar of the stomach and the intestine: A case report. Journal of Medical Case Reports. 2014;**8**(1):79. DOI:

Gilchrist B. A rare cause of small bowel obstruction due to bezoar in a virgin abdomen. International Journal of Surgery Case Reports. 2016;**19**:144-146.

[26] Gonuguntla V, Joshi D-D. Rapunzel syndrome: A comprehensive review of an unusual case of trichobezoar. Clinical Medicine & Research. 2009;**7**(3):99-102.

jksc.2012.28.2.89

[16] Mulholland MW, Lillemoe KD, Doherty GM, Upchurch GR Jr, Alam HB, Pawlik TM, editors. Mechanical obstruction of the intestines. In: Greenfield's Surgery: Scientific Principles & Practice. 6th ed.

[17] Alsharief AN, Blackmore C, Schmit P. Small bowel obstruction due to ingestion of rubber balls. Pediatric Radiology. 2017;**47**(11):1539-1541. DOI:

[18] Simunic M, Zaja I, Ardalic Z, et al. Case report: Successful endoscopic treatment of a large bowel perforation caused by chicken bone ingestion. Medicine. 2019;**98**:e18111. DOI: 10.1097/

[19] Rodríguez-Hermosa JI, Codina-Cazador A, Sirvent JM, et al.

Surgically treated perforations of the gastrointestinal tract caused by ingested foreign bodies. Colorectal Disease.

[20] Li C, Yong CC, Encarnacion DD. Duodenal perforation nine months after accidental foreign body ingestion, a case report. BMC Surgery. 2019;**19**:132. DOI:

10.1186/s12893-019-0594-5

[22] Gattai R, Pantalone D,

Migliaccio ML, Bonizzoli M, Peris A, Bechi P. Upper G.I. hemorrhage from glass fragments' ingestion in a patient with jejunal diverticula—Case report. International Journal of Surgery

[21] Shao F, Shen N, Hong Z, et al. Injuries due to foreign body ingestion and insertion in children: 10 years of experience at a single institution. Journal of Paediatrics and Child Health. 2019;**56**:537-541. DOI: 10.1111/jpc.14677

10.1007/s00247-017-3894-x

MD.0000000000018111

2008;**10**:701-707

**52**

Colonic volvulus is the third leading cause of large bowel obstruction. About 35% of these are located in the caecum. Though, relatively, a rare cause of obstruction, the incidence of caecal volvulus is steadily increasing at a rate of about 5% per year. Mortality due to caecal volvulus may be as high as 40% especially in the presence of gangrene and sepsis. Clinical presentation may be acute and fulminant or as a mobile caecum syndrome with intermittent abdominal pain. "Whirl," "Coffee bean," and "bird beak" signs seen on computed tomography are pathognomonic. Colectomy is the preferred treatment as it obviates any chance of recurrence. A conservative approach to colectomy such as limited ileocaecal resection and ileostomy formation in critically ill patients or in those with poor physiological reserve may be associated with better postoperative outcomes.

**Keywords:** caecum, volvulus, obstruction, mobile caecum, management

#### **1. Introduction**

There are records of volvulus as far back as 1550 BC and by Hippocrates who first described treatment options such as injection of a large quantity of air or insertion of a 10 digit suppository through the anus [1]. In modern day literature, it was first described by Austrian pathologist Rokitansky in 1837 as an important cause of intestinal strangulation [2]. Colonic volvulus or twisting of the large bowel is the third leading cause of large bowel obstruction world-wide [3]. It mainly occurs in the 'Volvulus belt' of Africa, Middle East, India and Russia where it may affect a slightly younger age group compared to the rest of the world [4, 5].

Although the incidence of caecal volvulus as a cause of colonic volvulus appears to be increasing, the commonest sites for colonic volvulus still include sigmoid −60%, caecum −35%, transverse colon −4%, and splenic flexure −1% [1]. This chapter reviews the current management of caecal volvulus.

#### **2. Epidemiology**

Caecal volvulus in itself is rare but an associated mortality of nearly 40% warrants prompt diagnosis and treatment [6]. It has an incidence of 2.8–7.1 per million people, is responsible for 1–1.5% of intestinal obstructions, and 25–40% of all colonic volvulus and affects females more than males [7]. The presence of a volvulus belt has already been discussed. In a large epidemiological study done by Halabi et al. [8] over a period covering 9 years in the United States, the incidence of caecal volvulus increased by 5% per year.

#### **3. Aetiology**

The aetiology of caecal volvulus can be attributed to an interplay between anatomical and other predisposing factors.

In normal embryological development, the mesentery of the right colon gets fixed on the right posterior abdominal wall (retroperitoneum) during the counter clockwise rotation of the caecum from left to right lower quadrant. Abnormal fixation may lead to an excessively mobile caecum in an anatomical anomaly called "messenterium commune" [9]. In an autopsy examination of 125 cadavers, 11.2% had freely mobile colons with a 36.8% total risk of caecal volvulus [3, 10].

Including previous surgery – adhesions acting as fulcrum for rotation of the mobile caecum [11], other predisposing factors include chronic constipation, distal obstruction, prior colonoscopy, high fibre diet, psychotropic drugs, ileus and late term pregnancy [7, 10, 12–14].

The commonest features in the aetiology of caecal volvulus are therefore caecal displacement, hyperperistalsis/dysmotility and colonic distension. It may also be associated with other congenital malformations such as Cornelia de Lange in children [15] and situs inversus [16].

#### **4. Pathophysiology**

Caecal volvulus occurs when the caecum which forms the first part of the large bowel undergoes an axial twist about its mesenteric pedicle leading to a closed loop intestinal obstruction [7, 17]. Also involved in this process are the ascending colon and terminal ileum. This should be differentiated from caecal bascule in which the caecum folds anteriorly along a horizontal plane [7, 18, 19]. See **Figures 1**–**3**.

**55**

**Figure 3.**

*Caecal Volvulus*

**Figure 2.**

*DOI: http://dx.doi.org/10.5772/intechopen.91311*

Many scholars report three types of caecal volvulus [20–22]:

*illustrates 'whirl sign' at the point of obstruction/torsion as seen in CT images.*

*Caecal bascule. Upward fold along horizontal plane. Adapted from Consorti and Liu [7].*

It results in a characteristically empty right iliac fossa [23].

the right lower quadrant.

• Type 1 in which a clockwise axial twist results in the volvulus being located in

*Pictorial illustration of loop type caecal volvulus with entangled terminal ileum from Moore et al. [22] inset* 

• Type 2 in which both the caecum and terminal ileum get involved and ectopically located in the Left upper quadrant in an inverted position. Here, the caecum both twists and inverts and this twist may sometimes be counter clockwise [22]. This type is also referred to as the 'loop type' of caecal volvulus.

#### *Caecal Volvulus DOI: http://dx.doi.org/10.5772/intechopen.91311*

*Intestinal Obstructions*

anatomical and other predisposing factors.

The aetiology of caecal volvulus can be attributed to an interplay between

In normal embryological development, the mesentery of the right colon gets fixed on the right posterior abdominal wall (retroperitoneum) during the counter clockwise rotation of the caecum from left to right lower quadrant. Abnormal fixation may lead to an excessively mobile caecum in an anatomical anomaly called "messenterium commune" [9]. In an autopsy examination of 125 cadavers, 11.2% had freely mobile colons with a 36.8% total risk of caecal

Including previous surgery – adhesions acting as fulcrum for rotation of the mobile caecum [11], other predisposing factors include chronic constipation, distal obstruction, prior colonoscopy, high fibre diet, psychotropic drugs, ileus and late

The commonest features in the aetiology of caecal volvulus are therefore caecal displacement, hyperperistalsis/dysmotility and colonic distension. It may also be associated with other congenital malformations such as Cornelia de Lange in

Caecal volvulus occurs when the caecum which forms the first part of the large bowel undergoes an axial twist about its mesenteric pedicle leading to a closed loop intestinal obstruction [7, 17]. Also involved in this process are the ascending colon and terminal ileum. This should be differentiated from caecal bascule in which the caecum folds anteriorly along a horizontal plane [7, 18, 19]. See **Figures 1**–**3**.

*Caecal volvulus with axial twist causing closed loop obstruction. Adapted from Consorti and Liu [7].*

**3. Aetiology**

volvulus [3, 10].

term pregnancy [7, 10, 12–14].

**4. Pathophysiology**

children [15] and situs inversus [16].

**54**

**Figure 1.**

**Figure 2.** *Caecal bascule. Upward fold along horizontal plane. Adapted from Consorti and Liu [7].*

**Figure 3.** *Pictorial illustration of loop type caecal volvulus with entangled terminal ileum from Moore et al. [22] inset illustrates 'whirl sign' at the point of obstruction/torsion as seen in CT images.*

Many scholars report three types of caecal volvulus [20–22]:


• Type 3 caecal volvulus also known as caecal bascule, is characterised by absence of axial twist.

In all these types, there is potential for intestinal obstruction and strangulation [11, 24] with the risk higher in types 1 and 2 which constitute about 80% of caecal volvulus. Caecal volvulus may sometimes coexist with a synchronous splenic flexure volvulus [25] and/or sigmoid volvulus [26].

Baumann et al. [27] propose a mathematical model based on the physics of a spring to explain the mechanism of occurrence of exercise related caecal volvulus in long distance runners and aggressive walkers. Repetitive vertical stretching of caecum and ascending colon leads to loss of elastic recoil and a laxed mesentery which predisposes to volvulus.

#### **5. Clinical presentation**

The clinical presentation of caecal volvulus can be divided into separate but interrelated clinical syndromes that is, mobile caecum syndrome, acute obstruction and acute fulminant obstruction [7].

#### **5.1 Mobile caecum syndrome**

This may be associated with caecal bascule and occurs due to increased mobility of the caecum. It is characterised by recurrent, intermittent abdominal pain and distension which typically resolves on passage of flatus [18, 28]. Vomiting may occur in only 30% of the patients [18]. It may be associated with some functional colon diseases such as chronic constipation and irritable bowel syndrome.

Gomes et al. [29] propose a laparoscopic grading system for mobile caecum syndrome depending on the degree of mobility of the ileocaecal and appendiceal unit:


Caecopexy is advised for Grades II and III.

Due to the quick resolution of symptoms, diagnosis of the mobile cecum syndrome can be difficult. Cesaretti et al. [28] advise performing computed tomography in Trendelenburg position and propose use of virtual colonoscopy to aid diagnosis of mobile caecum syndrome.

Up to 50% of patients with acute obstructive caecal volvulus tend to initially present with features of mobile caecum syndrome [30, 31].

#### **5.2 Acute obstructive pattern**

This may be simple – no ischaemia, or fulminant obstruction – bowel ischaemia, sepsis and peritonitis.

These patients present with classical features of acute intestinal obstruction that is, abdominal pain, distension, constipation and vomiting. Being the first part of

**57**

*Caecal Volvulus*

*DOI: http://dx.doi.org/10.5772/intechopen.91311*

of acute small bowel obstruction.

exceeding mucosal capillary pressure.

and in metabolic acidosis.

**6. Evaluation**

**7. Laboratory workup**

**8.1 Plain abdominal radiography (AXR)**

**8. Radiology**

abdominal radiographs.

**8.2 Barium Enema (BE)**

large bowel clinical features of caecal volvulus may be indistinguishable from those

In simple obstruction, patients may present with dehydration and electrolyte imbalance due to persistent vomiting. Prolonged obstruction may result in strangulation, gangrene and perforation. At this point patients are toxic, peritonitic, septic

The sepsis is associated with translocation of bacteria due to a damaged caecal/ colonic mucosal layer. This damage is due to mechanical cut off of arterial blood supply or severe caecal distension −>10 cm with intraluminal pressure greatly

Nearly 30% of the acute obstructive pattern occurs in hospitalised patients [32, 33]. This may be attributed to bowel distension and dysmotility. Symptoms in these patients may be masked by the signs and symptoms of concurrent medical illness. High index of suspicion and early diagnostic imaging are therefore paramount [7].

Following a thorough history and physical examination, a laboratory workup and appropriate diagnostic imaging should be planned while resuscitation is on-going. The surgeon should be sure to take medication history and ascertain pre-existing comorbidities to ensure they are under control. It is important at this point to pass a urethral catheter and monitor fluid input/output, pass a nasogastric tube if there is excessive distension with vomiting and administer antiemetics and analgesics.

These are usually non-specific. However, a complete blood count (CBC) with differential, metabolic panel, lactic acid, urea and electrolytes should be done. Fluid and electrolyte imbalance may be found in patients who have had prolonged

In many limited resource settings, this may be the only available radiological investigation. However, the plain AXR is diagnostic in less than 20% of the cases [11, 34] and sometimes the surgeon's only option is to perform an emergency exploratory celiotomy. In cases where AXR is diagnostic or suggestive of caecal volvulus, the typical findings include caecal distension in over 98%, absence of gas in distal colon in 82%, a distended small bowel in 55% that is pushed lateral to the caecum and a single air-fluid level in the right lower quadrant [11]. In contrast to sigmoid volvulus, haustrations are nearly always visible in caecal volvulus. James and Kelly [35] provide an extensive account on how to perform and interpret

This was traditionally used for diagnosis and treatment of colonic volvulus including caecal volvulus [11]. It had the advantage of being 88% accurate and the

obstruction with vomiting, bowel ischaemia, peritonitis or systemic sepsis.

#### *Caecal Volvulus DOI: http://dx.doi.org/10.5772/intechopen.91311*

large bowel clinical features of caecal volvulus may be indistinguishable from those of acute small bowel obstruction.

In simple obstruction, patients may present with dehydration and electrolyte imbalance due to persistent vomiting. Prolonged obstruction may result in strangulation, gangrene and perforation. At this point patients are toxic, peritonitic, septic and in metabolic acidosis.

The sepsis is associated with translocation of bacteria due to a damaged caecal/ colonic mucosal layer. This damage is due to mechanical cut off of arterial blood supply or severe caecal distension −>10 cm with intraluminal pressure greatly exceeding mucosal capillary pressure.

Nearly 30% of the acute obstructive pattern occurs in hospitalised patients [32, 33]. This may be attributed to bowel distension and dysmotility. Symptoms in these patients may be masked by the signs and symptoms of concurrent medical illness. High index of suspicion and early diagnostic imaging are therefore paramount [7].

#### **6. Evaluation**

*Intestinal Obstructions*

absence of axial twist.

which predisposes to volvulus.

and acute fulminant obstruction [7].

**5.1 Mobile caecum syndrome**

**5. Clinical presentation**

flexure volvulus [25] and/or sigmoid volvulus [26].

iliac fossa and does not cross the midline.

Caecopexy is advised for Grades II and III.

present with features of mobile caecum syndrome [30, 31].

diagnosis of mobile caecum syndrome.

**5.2 Acute obstructive pattern**

sepsis and peritonitis.

• Type 3 caecal volvulus also known as caecal bascule, is characterised by

In all these types, there is potential for intestinal obstruction and strangulation [11, 24] with the risk higher in types 1 and 2 which constitute about 80% of caecal volvulus. Caecal volvulus may sometimes coexist with a synchronous splenic

Baumann et al. [27] propose a mathematical model based on the physics of a spring to explain the mechanism of occurrence of exercise related caecal volvulus in long distance runners and aggressive walkers. Repetitive vertical stretching of caecum and ascending colon leads to loss of elastic recoil and a laxed mesentery

The clinical presentation of caecal volvulus can be divided into separate but interrelated clinical syndromes that is, mobile caecum syndrome, acute obstruction

This may be associated with caecal bascule and occurs due to increased mobility of the caecum. It is characterised by recurrent, intermittent abdominal pain and distension which typically resolves on passage of flatus [18, 28]. Vomiting may occur in only 30% of the patients [18]. It may be associated with some functional

Gomes et al. [29] propose a laparoscopic grading system for mobile caecum syndrome depending on the degree of mobility of the ileocaecal and appendiceal unit:

• Grade I – The peritoneal attachments are intact and the unit is within the right

• Grade II – The ileocaecal and appendiceal unit can easily be moved across the

• Grade III – The ileocaecal and appendiceal unit can easily be moved up to the left upper quadrant. No fixation hence axial twist about its own axis is possible.

Due to the quick resolution of symptoms, diagnosis of the mobile cecum syndrome can be difficult. Cesaretti et al. [28] advise performing computed tomography in Trendelenburg position and propose use of virtual colonoscopy to aid

Up to 50% of patients with acute obstructive caecal volvulus tend to initially

This may be simple – no ischaemia, or fulminant obstruction – bowel ischaemia,

These patients present with classical features of acute intestinal obstruction that is, abdominal pain, distension, constipation and vomiting. Being the first part of

midline. No fixation hence axial twist about its own axis is possible.

colon diseases such as chronic constipation and irritable bowel syndrome.

**56**

Following a thorough history and physical examination, a laboratory workup and appropriate diagnostic imaging should be planned while resuscitation is on-going. The surgeon should be sure to take medication history and ascertain pre-existing comorbidities to ensure they are under control. It is important at this point to pass a urethral catheter and monitor fluid input/output, pass a nasogastric tube if there is excessive distension with vomiting and administer antiemetics and analgesics.

#### **7. Laboratory workup**

These are usually non-specific. However, a complete blood count (CBC) with differential, metabolic panel, lactic acid, urea and electrolytes should be done. Fluid and electrolyte imbalance may be found in patients who have had prolonged obstruction with vomiting, bowel ischaemia, peritonitis or systemic sepsis.

#### **8. Radiology**

#### **8.1 Plain abdominal radiography (AXR)**

In many limited resource settings, this may be the only available radiological investigation. However, the plain AXR is diagnostic in less than 20% of the cases [11, 34] and sometimes the surgeon's only option is to perform an emergency exploratory celiotomy. In cases where AXR is diagnostic or suggestive of caecal volvulus, the typical findings include caecal distension in over 98%, absence of gas in distal colon in 82%, a distended small bowel in 55% that is pushed lateral to the caecum and a single air-fluid level in the right lower quadrant [11]. In contrast to sigmoid volvulus, haustrations are nearly always visible in caecal volvulus. James and Kelly [35] provide an extensive account on how to perform and interpret abdominal radiographs.

#### **8.2 Barium Enema (BE)**

This was traditionally used for diagnosis and treatment of colonic volvulus including caecal volvulus [11]. It had the advantage of being 88% accurate and the possibility of visualising the distal colon for any obstructive causes of volvulus. The "bird beak sign" in the efferent limb is diagnostic [36]. However, it has now been abandoned due to time needed to perform and potential for extravasation of contrast. Currently, a water soluble contrast such as gastrograffin enema may be used [37]. It is absolutely contraindicated in critically ill patients and in suspected perforation or strangulation.

#### **8.3 Computed tomography (CT) scan**

Abdominopelvic CT scan is currently the imaging of choice for diagnosis of caecal volvulus. Rosenblatt et al. [38] and later Dane et al. [39] provide an extensive discussion on the utility of CT findings in the diagnosis of caecal volvulus. The CT findings more common in caecal volvulus included severe caecal distension ≥10 cm, whirl sign, abnormal caecal position, central appendix – at or close to the midline, split wall, coffee bean sign and distal colonic decompression. In the study conducted by Dane et al., [39] the whirl sign was an independent predictor of caecal volvulus. The "whirl," "coffee bean" and "bird beak" signs are considered pathognomonic for caecal volvulus although a gas filled appendix is also a common finding especially in the loop type of caecal volvulus [22]. Findings of pneumatosis intestinalis and portal venous gas are suggestive of bowel ischaemia.

#### **8.4 Colonoscopy**

In contrast to sigmoid volvulus, the role of colonoscopy in diagnosis and treatment of caecal volvulus is very limited and has a reported success rate of less than 30%. It is associated with delay in definitive operative treatment and high risk for perforation hence not generally recommended [24, 40].

Despite all the above investigations and the high sensitivity and specificity of CT scan for diagnosis of caecal volvulus, diagnosis can sometimes only be made intraoperatively in about 10% of the cases [24, 39, 41].

#### **9. Treatment**

Definitive treatment should be sought as soon as the patient has been adequately resuscitated. The surgeon has to decide between non-operative and operative treatment.

#### **9.1 Non-operative treatment**

Absolute contraindications to non-operative treatment include pneumoperitoneum, bowel ischaemia, peritonitis or clinically confirmed tenderness over the distended caecum. In very elderly, frail patients with multiple comorbidities and advanced obstruction, the risks of an operation may outweigh the benefits. In such situations, the surgical team may decide to offer palliation. This decision must be reached after consideration of availability of resources for peri and postoperative care and in conjunction with the patient and/or family.

As stated earlier, the role of colonoscopy is generally limited and more than 90% of patients will require surgical treatment. There have been a few reports of successful detorsion of caecal volvulus especially in children albeit with recurrence as early as 6 weeks after colonoscopy [42, 43].

Barium enema is currently not recommended for treatment of caecal volvulus.

**59**

*Caecal Volvulus*

options are:

wall.

right colon.

**9.2 Operative treatment**

*DOI: http://dx.doi.org/10.5772/intechopen.91311*

only a Grade I Clavien-Dindo classification [45].

• Detorsion and/or caecopexy

some of these patients may require postoperative care in the ICU.

The surgical approach may be open – midline laparotomy, or laparoscopic depending on availability of resources, surgeon's expertise and patient factors. A laparoscopic approach is currently considered safe in both the acute and elective setting [28, 37]. In a series of 15 patients with mobile caecum syndrome who underwent laparoscopic caecopexy, Gomes et al. [29] report a very favourable outcome with 84% achieving a modified Visick score [44] of 1 while up to 92% had

Most of the time, an emergency laparotomy may be needed especially in fulminant cases even precluding diagnostic imaging. In all cases, an honest discussion needs to be held preoperatively with the patient and their family regarding possible outcomes given available resources. The surgical team will need to be proactive and invite the intensive care team (ICU) for peri and postoperative care planning as

At laparotomy, the decision regarding definitive treatment relies heavily on the operating surgeon and their experience [7]. The factors affecting these decisions are mainly the patient's physiological reserve and state of the bowel. The surgical

• Caecostomy – decompresses caecum and fixes it on to the anterior abdominal

• Resection and primary anastomosis – this may be the traditional right hemicolectomy or a more limited ileocaecal resection with or without colopexy of the

There are no randomized controlled trials comparing these treatment options. However, in the presence of gangrene – which occurs about 23 to nearly 100% of the time [24], overly distended and stretched caecum, resection is mandatory. It is advisable not to untwist the gangrenous portion in order not to release toxins into

Overall mortality with resectional procedures is up to 32% [24]. In patients with poor physiological reserve, a conservative approach such as limited ileocaecal resection or formation of an ileostomy may reduce intraoperative time and result in better postoperative outcome [47]. In synchronous caecal and sigmoid volvulus, a

of detorsion and caecopexy greatly reduces this recurrence rate to less than 15% with a mortality of about 10% [11]. The technique of caecopexy involves placing two to three knots to attach the lateral taenia coli of the caecum or right colon in colopexy to the right paracolic gutter approximately along the level of the axillary line [29]. This may be achieved by initially raising a peritoneal flap at this level as in the Dixon and Meyer's approach [48]. Sakamoto et al. [49] report a successful case

Caecostomy alone is associated with a mortality of 22% and a recurrence rate of 14–20% [11]. It is advised as a temporary measure or in very high-risk surgical candidates. The technique involves catheter or tube decompression of the caecum

Detorsion alone is associated with a recurrence of up to 75% [24]. A combination

• Resection and temporary ileostomy or ileostomy with mucus fistula.

the blood circulation that would lead to worsening of septic shock [46].

total colectomy with ileostomy may sometimes be necessary [26].

of percutaneous endoscopic colopexy in caecal volvulus.

#### **9.2 Operative treatment**

*Intestinal Obstructions*

**8.4 Colonoscopy**

**9. Treatment**

treatment.

**9.1 Non-operative treatment**

as 6 weeks after colonoscopy [42, 43].

perforation or strangulation.

**8.3 Computed tomography (CT) scan**

possibility of visualising the distal colon for any obstructive causes of volvulus. The "bird beak sign" in the efferent limb is diagnostic [36]. However, it has now been abandoned due to time needed to perform and potential for extravasation of contrast. Currently, a water soluble contrast such as gastrograffin enema may be used [37]. It is absolutely contraindicated in critically ill patients and in suspected

Abdominopelvic CT scan is currently the imaging of choice for diagnosis of caecal volvulus. Rosenblatt et al. [38] and later Dane et al. [39] provide an extensive discussion on the utility of CT findings in the diagnosis of caecal volvulus. The CT findings more common in caecal volvulus included severe caecal distension ≥10 cm, whirl sign, abnormal caecal position, central appendix – at or close to the midline, split wall, coffee bean sign and distal colonic decompression. In the study conducted by Dane et al., [39] the whirl sign was an independent predictor of caecal volvulus. The "whirl," "coffee bean" and "bird beak" signs are considered pathognomonic for caecal volvulus although a gas filled appendix is also a common finding especially in the loop type of caecal volvulus [22]. Findings of pneumatosis

In contrast to sigmoid volvulus, the role of colonoscopy in diagnosis and treatment of caecal volvulus is very limited and has a reported success rate of less than 30%. It is associated with delay in definitive operative treatment and high risk for

Despite all the above investigations and the high sensitivity and specificity of CT scan for diagnosis of caecal volvulus, diagnosis can sometimes only be made

Definitive treatment should be sought as soon as the patient has been adequately

Absolute contraindications to non-operative treatment include pneumoperitoneum, bowel ischaemia, peritonitis or clinically confirmed tenderness over the distended caecum. In very elderly, frail patients with multiple comorbidities and advanced obstruction, the risks of an operation may outweigh the benefits. In such situations, the surgical team may decide to offer palliation. This decision must be reached after consideration of availability of resources for peri and postoperative

As stated earlier, the role of colonoscopy is generally limited and more than 90% of patients will require surgical treatment. There have been a few reports of successful detorsion of caecal volvulus especially in children albeit with recurrence as early

Barium enema is currently not recommended for treatment of caecal volvulus.

resuscitated. The surgeon has to decide between non-operative and operative

intestinalis and portal venous gas are suggestive of bowel ischaemia.

perforation hence not generally recommended [24, 40].

intraoperatively in about 10% of the cases [24, 39, 41].

care and in conjunction with the patient and/or family.

**58**

The surgical approach may be open – midline laparotomy, or laparoscopic depending on availability of resources, surgeon's expertise and patient factors.

A laparoscopic approach is currently considered safe in both the acute and elective setting [28, 37]. In a series of 15 patients with mobile caecum syndrome who underwent laparoscopic caecopexy, Gomes et al. [29] report a very favourable outcome with 84% achieving a modified Visick score [44] of 1 while up to 92% had only a Grade I Clavien-Dindo classification [45].

Most of the time, an emergency laparotomy may be needed especially in fulminant cases even precluding diagnostic imaging. In all cases, an honest discussion needs to be held preoperatively with the patient and their family regarding possible outcomes given available resources. The surgical team will need to be proactive and invite the intensive care team (ICU) for peri and postoperative care planning as some of these patients may require postoperative care in the ICU.

At laparotomy, the decision regarding definitive treatment relies heavily on the operating surgeon and their experience [7]. The factors affecting these decisions are mainly the patient's physiological reserve and state of the bowel. The surgical options are:


There are no randomized controlled trials comparing these treatment options. However, in the presence of gangrene – which occurs about 23 to nearly 100% of the time [24], overly distended and stretched caecum, resection is mandatory. It is advisable not to untwist the gangrenous portion in order not to release toxins into the blood circulation that would lead to worsening of septic shock [46].

Overall mortality with resectional procedures is up to 32% [24]. In patients with poor physiological reserve, a conservative approach such as limited ileocaecal resection or formation of an ileostomy may reduce intraoperative time and result in better postoperative outcome [47]. In synchronous caecal and sigmoid volvulus, a total colectomy with ileostomy may sometimes be necessary [26].

Detorsion alone is associated with a recurrence of up to 75% [24]. A combination of detorsion and caecopexy greatly reduces this recurrence rate to less than 15% with a mortality of about 10% [11]. The technique of caecopexy involves placing two to three knots to attach the lateral taenia coli of the caecum or right colon in colopexy to the right paracolic gutter approximately along the level of the axillary line [29]. This may be achieved by initially raising a peritoneal flap at this level as in the Dixon and Meyer's approach [48]. Sakamoto et al. [49] report a successful case of percutaneous endoscopic colopexy in caecal volvulus.

Caecostomy alone is associated with a mortality of 22% and a recurrence rate of 14–20% [11]. It is advised as a temporary measure or in very high-risk surgical candidates. The technique involves catheter or tube decompression of the caecum through the anterior abdominal wall. The catheters may regularly get blocked due to the viscid faeces and may require regular flushing. Alternatively, a wider more rigid size 8–9 mm endotracheal tube may be ballooned, sutured in place and attached to an ordinary urinary bag [50]. The approach to caecostomy may be percutaneous – endoscopic or needle [51, 52], or during formal laparotomy.

### **10. Conclusion**

Caecal volvulus is a rare but important cause of intestinal obstruction. It is both organ and life threatening especially if advanced and fulminant. Abdominopelvic CT scan is the preferred imaging and the "whirl sign" is an independent predictor of caecal volvulus. The choice of surgical option hugely depends on the operating surgeon. Current advances favour a multidisciplinary approach and colectomy as the choice of treatment following adequate resuscitation. The surgeon should work closely with the intensive care team as some of these patients may require postoperative mechanical ventilation. Both patient and/or family preferences need to be considered during the course of management.

### **Conflict of interest**

None.

### **Author details**

Paul K. Okeny School of Postgraduate Studies, Royal College of Surgeons in Ireland, Dublin, Ireland

\*Address all correspondence to: PaulOkeny@rcsi.ie; okenykpaul@yahoo.ca

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**61**

*Caecal Volvulus*

**References**

*DOI: http://dx.doi.org/10.5772/intechopen.91311*

[1] Ballantyne GH. Review of sigmoid volvulus: History and results of treatment. Diseases of the Colon and

[11] Rabinovici R, Simansky DA, Kaplan O, Mavor E, Manny J. Cecal volvulus. Diseases of the Colon and

[12] Montes H, Wolf J. Cecal volvulus in pregnancy. The American Journal of Gastroenterology. 1999;**94**:2554-2555

[13] Tejler G, Jiborn H. Volvulus of the cecum. Report of 26 cases and review of the literature. Diseases of the Colon and

[14] Viney R, Fordan SV, Fisher WE, Ergun G. Cecal volvulus after colonoscopy. The American Journal of Gastroenterology. 2002;**97**(12):3211-3212

[15] Miura da Costa K, Saxena AK. A systematic review of the management and outcomes of cecal and appendiceal volvulus in children. Acta Paediatrica.

[16] Elsharif M, Basu I, Phillips D. A case of triple volvulus. Annals of the Royal College of Surgeons of England.

[17] Majeski J. Operative therapy for cecal volvulus combining resection with colopexy. American Journal of Surgery.

[18] Lung BE, Yelika SB, Murthy AS, Gachabayov M, Denoya P. Cecal bascule: A systematic review of the literature. Techniques in Coloproctology.

[19] Park J-S, Ng K-S, Young CJ. Caecal bascule: A case series and literature review. ANZ Journal of Surgery.

[20] Le CK, Qaja E. Caecal Volvulus Treasure Island: StatPearls; 2019 [updated 28 February 2019]

Rectum. 1990;**33**(9):765-769

Rectum. 1988;**31**:445-449

2018;**107**(12):2054-2058

2012;**94**(2):e62-ee4

2005;**189**(2):211-213

2018;**22**(2):75-80

2018;**88**(5):E386-E3E9

Rectum. 1982;**25**(5):494-501

[2] Rokitansky C. Intestinal

of Surgery. 1985;**202**(1):83-92

[4] Heis HA, Bani-Hani KE,

Surgery. 2008;**32**(3):459-464

[5] Bruusgaard C. Volvulus of the sigmoid colon and its treatment. Surgery. 1947;**22**(3):466-478

[6] Renzulli P, Maurer CA, Netzer P, Büchler MW. Preoperative colonoscopic

derotation is beneficial in acute colonic volvulus. Digestive Surgery.

[7] Consorti ET, Liu TH. Diagnosis and treatment of caecal volvulus. Postgraduate Medical Journal.

[8] Halabi WJ, Jafari MD, Kang CY, Nguyen VQ, Carmichael JC, Mills S, et al. Colonic volvulus in the United States: Trends, outcomes, and predictors

of mortality. Annals of Surgery.

[9] Moritz AR. Mesenterium commune with intestinal obstruction. The American Journal of Pathology.

[10] Gingold D, Murrell Z. Management of colonic volvulus. Clinics in Colon and Rectal Surgery. 2012;**25**(4):236-244

2002;**19**:223-229

2005;**81**:772-776

2014;**259**(2):293-301

1932;**8**(6):735-744.1

strangulation. Archives of General Internal Medicine. 1837;**14**:202-204

[3] Ballantyne GH, Brandner MD, Beart RW Jr, Ilstrup DM. Volvulus of the colon. Incidence and mortality. Annals

Rabadi DK, Elheis MA, Bani-Hani BK, Mazahreh TS, et al. Sigmoid volvulus in the Middle East. World Journal of

### **References**

*Intestinal Obstructions*

**10. Conclusion**

**Conflict of interest**

None.

**60**

**Author details**

School of Postgraduate Studies, Royal College of Surgeons in Ireland,

\*Address all correspondence to: PaulOkeny@rcsi.ie; okenykpaul@yahoo.ca

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

through the anterior abdominal wall. The catheters may regularly get blocked due to the viscid faeces and may require regular flushing. Alternatively, a wider more rigid size 8–9 mm endotracheal tube may be ballooned, sutured in place and attached to an ordinary urinary bag [50]. The approach to caecostomy may be percutaneous –

Caecal volvulus is a rare but important cause of intestinal obstruction. It is both organ and life threatening especially if advanced and fulminant. Abdominopelvic CT scan is the preferred imaging and the "whirl sign" is an independent predictor of caecal volvulus. The choice of surgical option hugely depends on the operating surgeon. Current advances favour a multidisciplinary approach and colectomy as the choice of treatment following adequate resuscitation. The surgeon should work closely with the intensive care team as some of these patients may require postoperative mechanical ventilation. Both patient and/or family preferences need to be

endoscopic or needle [51, 52], or during formal laparotomy.

considered during the course of management.

Paul K. Okeny

Dublin, Ireland

provided the original work is properly cited.

[1] Ballantyne GH. Review of sigmoid volvulus: History and results of treatment. Diseases of the Colon and Rectum. 1982;**25**(5):494-501

[2] Rokitansky C. Intestinal strangulation. Archives of General Internal Medicine. 1837;**14**:202-204

[3] Ballantyne GH, Brandner MD, Beart RW Jr, Ilstrup DM. Volvulus of the colon. Incidence and mortality. Annals of Surgery. 1985;**202**(1):83-92

[4] Heis HA, Bani-Hani KE, Rabadi DK, Elheis MA, Bani-Hani BK, Mazahreh TS, et al. Sigmoid volvulus in the Middle East. World Journal of Surgery. 2008;**32**(3):459-464

[5] Bruusgaard C. Volvulus of the sigmoid colon and its treatment. Surgery. 1947;**22**(3):466-478

[6] Renzulli P, Maurer CA, Netzer P, Büchler MW. Preoperative colonoscopic derotation is beneficial in acute colonic volvulus. Digestive Surgery. 2002;**19**:223-229

[7] Consorti ET, Liu TH. Diagnosis and treatment of caecal volvulus. Postgraduate Medical Journal. 2005;**81**:772-776

[8] Halabi WJ, Jafari MD, Kang CY, Nguyen VQ, Carmichael JC, Mills S, et al. Colonic volvulus in the United States: Trends, outcomes, and predictors of mortality. Annals of Surgery. 2014;**259**(2):293-301

[9] Moritz AR. Mesenterium commune with intestinal obstruction. The American Journal of Pathology. 1932;**8**(6):735-744.1

[10] Gingold D, Murrell Z. Management of colonic volvulus. Clinics in Colon and Rectal Surgery. 2012;**25**(4):236-244

[11] Rabinovici R, Simansky DA, Kaplan O, Mavor E, Manny J. Cecal volvulus. Diseases of the Colon and Rectum. 1990;**33**(9):765-769

[12] Montes H, Wolf J. Cecal volvulus in pregnancy. The American Journal of Gastroenterology. 1999;**94**:2554-2555

[13] Tejler G, Jiborn H. Volvulus of the cecum. Report of 26 cases and review of the literature. Diseases of the Colon and Rectum. 1988;**31**:445-449

[14] Viney R, Fordan SV, Fisher WE, Ergun G. Cecal volvulus after colonoscopy. The American Journal of Gastroenterology. 2002;**97**(12):3211-3212

[15] Miura da Costa K, Saxena AK. A systematic review of the management and outcomes of cecal and appendiceal volvulus in children. Acta Paediatrica. 2018;**107**(12):2054-2058

[16] Elsharif M, Basu I, Phillips D. A case of triple volvulus. Annals of the Royal College of Surgeons of England. 2012;**94**(2):e62-ee4

[17] Majeski J. Operative therapy for cecal volvulus combining resection with colopexy. American Journal of Surgery. 2005;**189**(2):211-213

[18] Lung BE, Yelika SB, Murthy AS, Gachabayov M, Denoya P. Cecal bascule: A systematic review of the literature. Techniques in Coloproctology. 2018;**22**(2):75-80

[19] Park J-S, Ng K-S, Young CJ. Caecal bascule: A case series and literature review. ANZ Journal of Surgery. 2018;**88**(5):E386-E3E9

[20] Le CK, Qaja E. Caecal Volvulus Treasure Island: StatPearls; 2019 [updated 28 February 2019]

[21] Delabrousse E, Sarliève P, Sailley N, Aubry S, Kastler BA. Cecal volvulus: CT findings and correlation with pathophysiology. Emergency Radiology. 2007;**14**(6):411-415

[22] Moore CJ, Corl FM, Fishman EK. CT of cecal volvulus. American Journal of Roentgenology. 2001;**177**(1):95-98

[23] Zabeirou AA, Belghali H, Souiki T, Ibn Majdoub K, Toughrai I, Mazaz K. Acute cecal volvulus: A diagnostic and therapeutic challenge in emergency: A case report. Annals of Medicine and Surgery. 2019;**48**:69-72

[24] Madiba TE, Thomson SR. The management of cecal volvulus. Diseases of the Colon and Rectum. 2002;**45**(2):264-267

[25] Islam S, Hosein D, Harnarayan P, Naraynsingh V. Synchronic volvulus of splenic flexure and caecum: A very rare cause of large bowel obstruction. BMJ Case Reports. 2016;**2016**:bcr2015-213029

[26] Roy SP, Tay YK, Kozman D. Very rare case of synchronous volvulus of the sigmoid colon and caecum causing large-bowel obstruction. BML Case Reports. 2019;**12**(1):bcr-2018-227375

[27] Bauman BD, Witt JE, Vakayil V, Anwer S, Irwin ED, Kwaan MR, et al. Cecal volvulus in long-distance runners: A proposed mechanism. The American Journal of Emergency Medicine. 2019;**37**(3):549-552

[28] Cesaretti M, Trotta M, Leale I, Minetti GA, Cittadini G, Montecucco F, et al. Surgery to treat symptomatic mobile cecum syndrome is safe and associated with good recovery outcomes. Case Reports in Gastrointestinal Medicine. 2018;**2018**:4718406

[29] Gomes CA, Soares C Jr, Catena F, Di Saverio S, Sartelli M, Gomes CC,

et al. Laparoscopic Management of Mobile Cecum. JSLS. 2016;**20**(4):e2016.00076

[30] Rogers RL, Harford FJ. Mobile cecum syndrome. Diseases of the Colon and Rectum. 1984;**27**(6):399-402

[31] Printen KJ. Mobile cecal syndrome in the adult. The American Surgeon. 1976;**42**(3):204-205

[32] Theuer C, Cheadle WG. Volvulus of the colon. The American Surgeon. 1991;**57**(3):145-150

[33] Friedman JD, Odland MD, Bubrick MP. Experience with colonic volvulus. Diseases of the Colon and Rectum. 1989;**32**(5):409-416

[34] Rakinic J. Colonic volvulus. In: Beck DE, Roberts PL, Saclarides TJ, Senagore AJ, Stamos MJ, Wexner SD, editors. The ASCRS Textbook of Colon and Rectal Surgery. New York, NY: Springer; 2011. pp. 395-406

[35] James B, Kelly B. The abdominal radiograph. The Ulster Medical Journal. 2013;**82**(3):179-187

[36] Young WS. Further radiological observations in caecal volvulus. Clinical Radiology. 1980;**31**(4):479-483

[37] Kelly MD, Bunni J, Pullyblank AM. Laparoscopic assisted right hemicolectomy for caecal volvulus. World Journal of Emergency Surgery. 2008;**3**(1):4

[38] Rosenblat JM, Rozenblit AM, Wolf EL, DuBrow RA, Den EI, Levsky JM. Findings of cecal volvulus at CT. Radiology. 2010;**256**(1):169-175

[39] Dane B, Hindman N, Johnson E, Rosenkrantz AB. Utility of CT findings in the diagnosis of cecal volvulus. American Journal of Roentgenology. 2017;**209**(4):762-766

**63**

*Caecal Volvulus*

*DOI: http://dx.doi.org/10.5772/intechopen.91311*

[40] Anderson MJ, Okike N, Spencer RJ. The colonoscope in cecal volvulus: Report of three cases. Diseases of the Colon and Rectum. 1978;**21**(1):71-74

of literature. International Journal of Critical Illness and Injury Science.

[48] Dixon CF, Meyer AC. Volvulus of the cecum. The Surgical Clinics of North America. 1948;**28**(Mayo Clinic

[49] Sakamoto Y, Hiyoshi Y, Sakata K, Toyama E, Takata N, Yoshinaka I, et al. Case of cecal volvulus successfully treated with endoscopic colopexy. Asian Journal of Endoscopic Surgery.

[50] Ingoldby CJ, Dawson A, Addison NV. A new technique of caecostomy using endotracheal tubes. Annals of the Royal College of Surgeons of England.

2018;**8**(2):90-99

Number):953-963

2018;**11**(4):402-404

1989;**71**(4):211-212

[51] Koundouris C, Thivaios I,

of Surgery. 2016;**88**(2):93-96

[52] Limmer AM, Clement Z. Percutaneous emergency needle Caecostomy for prevention of Caecal perforation. Case Reports in Surgery.

2017;**2017**:1090769

Chrysoulas G, Manisali A, Avitidou E, Sofos G, et al. Percutaneous endoscopic colostomy/caecostomy - A minimally invasive approach to certain colonic disorders: Report of five cases and review of the literature. Hellenic Journal

[41] Pulvirenti E, Palmieri L, Toro A, Carlo ID. Is laparotomy the unavoidable step to diagnose caecal volvulus? Annals of the Royal College of Surgeons of

[42] van de Lagemaat M, Blink M, Bakx R, de Meij TG. Cecal volvulus in children: Is there place for colonoscopic decompression? Journal of Pediatric Gastroenterology and Nutrition.

[43] Shahramian I, Bazil A, Ebadati D,

Draaisma WA, Smout AJ, Broeders IA, Gooszen HG. The Visick score: A good measure for the overall effect of antireflux surgery? Scandinavian Journal of Gastroenterology.

Rostami K, Delaramnasab M. Colonoscopic decompression of childhood sigmoid and cecal volvulus. The Turkish Journal of Gastroenterology. 2018;**29**(2):221-225

[44] Rijnhart-De Jong HG,

[45] Dindo D, Demartines N,

Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Annals of Surgery. 2004;**240**(2):205-213

[46] Tuech JJ, Becouarn G, Cattan F, Arnaud JP. Volvulus of the right colon. Plea for right hemicolectomy. Apropos of a series of 23 cases. J Chir (Paris).

[47] Kaushal-Deep SM, Anees A, Khan S, Khan MA, Lodhi M. Primary cecal pathologies presenting as acute abdomen and critical appraisal of their current management strategies in emergency settings with review

2008;**43**(7):787-793

1996;**133**(6):267-269

England. 2010;**92**:e27-e29

2018;**66**(2):e59-e60

#### *Caecal Volvulus DOI: http://dx.doi.org/10.5772/intechopen.91311*

*Intestinal Obstructions*

2007;**14**(6):411-415

[21] Delabrousse E, Sarliève P, Sailley N, Aubry S, Kastler BA. Cecal volvulus: CT findings and correlation with pathophysiology. Emergency Radiology. et al. Laparoscopic Management

[30] Rogers RL, Harford FJ. Mobile cecum syndrome. Diseases of the Colon and Rectum. 1984;**27**(6):399-402

[31] Printen KJ. Mobile cecal syndrome in the adult. The American Surgeon.

[32] Theuer C, Cheadle WG. Volvulus of the colon. The American Surgeon.

[33] Friedman JD, Odland MD, Bubrick MP. Experience with colonic volvulus. Diseases of the Colon and Rectum. 1989;**32**(5):409-416

[34] Rakinic J. Colonic volvulus. In: Beck DE, Roberts PL, Saclarides TJ, Senagore AJ, Stamos MJ, Wexner SD, editors. The ASCRS Textbook of Colon and Rectal Surgery. New York, NY:

[35] James B, Kelly B. The abdominal radiograph. The Ulster Medical Journal.

[36] Young WS. Further radiological observations in caecal volvulus. Clinical

[37] Kelly MD, Bunni J, Pullyblank AM.

hemicolectomy for caecal volvulus. World Journal of Emergency Surgery.

[38] Rosenblat JM, Rozenblit AM, Wolf EL, DuBrow RA, Den EI,

Levsky JM. Findings of cecal volvulus at CT. Radiology. 2010;**256**(1):169-175

[39] Dane B, Hindman N, Johnson E, Rosenkrantz AB. Utility of CT findings in the diagnosis of cecal volvulus. American Journal of Roentgenology.

2017;**209**(4):762-766

Radiology. 1980;**31**(4):479-483

Laparoscopic assisted right

Springer; 2011. pp. 395-406

2013;**82**(3):179-187

2008;**3**(1):4

of Mobile Cecum. JSLS. 2016;**20**(4):e2016.00076

1976;**42**(3):204-205

1991;**57**(3):145-150

[22] Moore CJ, Corl FM, Fishman EK. CT of cecal volvulus. American Journal of Roentgenology. 2001;**177**(1):95-98

[23] Zabeirou AA, Belghali H, Souiki T, Ibn Majdoub K, Toughrai I, Mazaz K. Acute cecal volvulus: A diagnostic and therapeutic challenge in emergency: A case report. Annals of Medicine and Surgery. 2019;**48**:69-72

[24] Madiba TE, Thomson SR. The management of cecal volvulus. Diseases of the Colon and Rectum.

[25] Islam S, Hosein D, Harnarayan P, Naraynsingh V. Synchronic volvulus of splenic flexure and caecum: A very rare cause of large bowel obstruction. BMJ Case Reports. 2016;**2016**:bcr2015-213029

[26] Roy SP, Tay YK, Kozman D. Very rare case of synchronous volvulus of the sigmoid colon and caecum causing large-bowel obstruction. BML Case Reports. 2019;**12**(1):bcr-2018-227375

[27] Bauman BD, Witt JE, Vakayil V, Anwer S, Irwin ED, Kwaan MR, et al. Cecal volvulus in long-distance runners: A proposed mechanism. The American Journal of Emergency Medicine.

[28] Cesaretti M, Trotta M, Leale I, Minetti GA, Cittadini G, Montecucco F, et al. Surgery to treat symptomatic

[29] Gomes CA, Soares C Jr, Catena F, Di Saverio S, Sartelli M, Gomes CC,

mobile cecum syndrome is safe and associated with good recovery outcomes. Case Reports in Gastrointestinal Medicine.

2002;**45**(2):264-267

2019;**37**(3):549-552

2018;**2018**:4718406

**62**

[40] Anderson MJ, Okike N, Spencer RJ. The colonoscope in cecal volvulus: Report of three cases. Diseases of the Colon and Rectum. 1978;**21**(1):71-74

[41] Pulvirenti E, Palmieri L, Toro A, Carlo ID. Is laparotomy the unavoidable step to diagnose caecal volvulus? Annals of the Royal College of Surgeons of England. 2010;**92**:e27-e29

[42] van de Lagemaat M, Blink M, Bakx R, de Meij TG. Cecal volvulus in children: Is there place for colonoscopic decompression? Journal of Pediatric Gastroenterology and Nutrition. 2018;**66**(2):e59-e60

[43] Shahramian I, Bazil A, Ebadati D, Rostami K, Delaramnasab M. Colonoscopic decompression of childhood sigmoid and cecal volvulus. The Turkish Journal of Gastroenterology. 2018;**29**(2):221-225

[44] Rijnhart-De Jong HG, Draaisma WA, Smout AJ, Broeders IA, Gooszen HG. The Visick score: A good measure for the overall effect of antireflux surgery? Scandinavian Journal of Gastroenterology. 2008;**43**(7):787-793

[45] Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Annals of Surgery. 2004;**240**(2):205-213

[46] Tuech JJ, Becouarn G, Cattan F, Arnaud JP. Volvulus of the right colon. Plea for right hemicolectomy. Apropos of a series of 23 cases. J Chir (Paris). 1996;**133**(6):267-269

[47] Kaushal-Deep SM, Anees A, Khan S, Khan MA, Lodhi M. Primary cecal pathologies presenting as acute abdomen and critical appraisal of their current management strategies in emergency settings with review

of literature. International Journal of Critical Illness and Injury Science. 2018;**8**(2):90-99

[48] Dixon CF, Meyer AC. Volvulus of the cecum. The Surgical Clinics of North America. 1948;**28**(Mayo Clinic Number):953-963

[49] Sakamoto Y, Hiyoshi Y, Sakata K, Toyama E, Takata N, Yoshinaka I, et al. Case of cecal volvulus successfully treated with endoscopic colopexy. Asian Journal of Endoscopic Surgery. 2018;**11**(4):402-404

[50] Ingoldby CJ, Dawson A, Addison NV. A new technique of caecostomy using endotracheal tubes. Annals of the Royal College of Surgeons of England. 1989;**71**(4):211-212

[51] Koundouris C, Thivaios I, Chrysoulas G, Manisali A, Avitidou E, Sofos G, et al. Percutaneous endoscopic colostomy/caecostomy - A minimally invasive approach to certain colonic disorders: Report of five cases and review of the literature. Hellenic Journal of Surgery. 2016;**88**(2):93-96

[52] Limmer AM, Clement Z. Percutaneous emergency needle Caecostomy for prevention of Caecal perforation. Case Reports in Surgery. 2017;**2017**:1090769

**65**

**Chapter 6**

**Abstract**

sigmoid volvulus

**1. Introduction**

Latin America [1].

ary ischemia.

conditions and at birth.

Disease

*Víctor Hugo García Orozco*

receives adequate diagnosis and complete treatment.

Sigmoid Volvulus Due Chagas

American Trypanosomiasis, also known as Chagas disease, is a parasitic disease caused by *Trypanosoma cruzi* and transmitted by hematophagous vectors, occupies the fourth place as a cause of loss of potential years of life between infectious and parasitic diseases, and has an acute presentation form and chronic, in which it can present complications at cardiac and digestive levels, among others. The development of megacolon with subsequent development of volvulus is an important cause of acute abdomen and intestinal obstruction that requires urgent treatment, as it presents an axial rotation of the intestinal loop with obstruction in a closed loop and subsequent ischemia. According to the World Health Organization, there are between 16 and 18 million infected people in the world, of which the majority is located in Latin American territory, and it is estimated that approximately only 1%

**Keywords:** Chagas disease, megacolon, intestinal occlusion, trypanosomiasis,

Infections and exposure to *Trypanosoma cruzi* occupy the fourth place due to loss

of potential years of life between parasitic and infectious diseases [1]. American Trypanosomiasis, also known as Chagas disease, is a parasitic infection transmitted by hematophagous vectors [2] with acute clinical presentation and silent chronic. According to the World Health Organization (WHO), there are between 16 and 18 million infected people in the world, of which the majority is located in Latin American territory, and only 1% receives adequate diagnosis and complete treatment. For the World Health Organization and the Pan American Health Organization, Trypanosomiasis is considered the most serious parasitic disease in

Transmission can also be done vertically through women infected during pregnancy, which would lead to a congenital disease with intrauterine clinical

One of the main complications of the chronic form of Chagas disease is the development of the Chagasic megacolon, which causes alterations in the neurosensory system of the colon. Colon volvulus is described as torsion of the large intestine on its mesenteric axis, thus causing a picture of intestinal obstruction and second-

The development of intestinal volvulations secondary to megacolon [3] is considered as the most severe complication of megacolon syndromes, regardless of

#### **Chapter 6**
