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 Table of Contents  
LETTER TO THE EDITOR
Year : 2013  |  Volume : 3  |  Issue : 3  |  Page : 256-257

An unusual cause of intestinal obstruction in an elderly patient with multiple myeloma


1 Department of Hematology and Oncology, St. Michael's Medical Center, Newark, NJ, USA
2 Department of Gastroenterology, St. Joseph's Regional Medical Center, Paterson, NJ, USA
3 Department of Internal Medicine, St. Michael's Medical Center, Newark, NJ, USA
4 Department of Hematology and Oncology, St. Joseph's Regional Medical Center, Paterson, NJ, USA

Date of Web Publication28-Mar-2014

Correspondence Address:
Hamid Shaaban
Department of Hematology and Oncology, St. Michael's Medical Center, 111 Central Avenue, Newark, NJ 07102
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.129584

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How to cite this article:
Shaaban H, Shaikh S, Chamarthy S, Layne T. An unusual cause of intestinal obstruction in an elderly patient with multiple myeloma. Arch Int Surg 2013;3:256-7

How to cite this URL:
Shaaban H, Shaikh S, Chamarthy S, Layne T. An unusual cause of intestinal obstruction in an elderly patient with multiple myeloma. Arch Int Surg [serial online] 2013 [cited 2019 Aug 24];3:256-7. Available from: http://www.archintsurg.org/text.asp?2013/3/3/256/129584

Sir,

Cecal bascule is a rare type of cecal volvulus in which the cecum folds anteriorly and its posterior surface comes anterior and the appendix is displaced to the right upper quadrant. [1] Although patients with cecal bascule usually present with colon obstruction, the diagnosis is not easily made pre-operatively and is usually made at laparotomy. This is an abdominal surgical emergency and gangrene or perforation due to prolonged strangulation is the main cause of mortality. [2] We present the first case of cecal bascule in a patient with multiple myeloma.

An 81-year-old African American female with recently diagnosed multiple myeloma presented at our institution with the complaints of abdominal pain and distension of 4 days duration associated with constipation. She also complained of nausea, vomiting and poor appetite. She denied any hematemesis, melena or hematochezia, recent viral illness, smoking or alcohol use and had no prior abdominal surgeries. The systems review was otherwise unremarkable. Other than tachycardia, vital signs were normal. Initial abdominal exam revealed diffuse tenderness to deep palpation especially in the right lower quadrant. However, there were no signs of acute peritonitis. Digital rectal examination was normal and stools tested heme-negative. Laboratory results included a normal complete blood cell count. The lactic acid level was 2.1 mmol/L. The electrolytes were normal except for hypercalcemia of 10.4 mmol/L. Chest X-ray revealed elevation of right hemidiaphragm secondary to marked distension of loop of bowel in right upper quadrant. Subsequent computed tomography scan of abdomen [Figure 1] revealed cecal distension that measured 9 cm in maximum diameter with an air-fluid level within. A clinical diagnosis of large bowel obstruction secondary to cecal volvulus was made. The patient was hydrated aggressively and the calcium level successfully decreased to normal values. On day 2, the patient then started to experience increased abdominal pain and physical exam revealed a remarkable acute abdomen with peritoneal signs. With a diagnosis of acute abdomen due to large bowel obstruction, the patient underwent open laparotomy and a cecal bascule [Figure 2] was found with the cecum folded up onto the ascending colon into the right upper quadrant so that the posterior surface was anterior and the appendix was uppermost. The cecum was completely obstructed at the fold and the proximal portion of ascending colon showed patchy areas of necrosis. A right hemicolectomy was performed and she had an uneventful recovery. She is currently being treated for mutiple myeloma without any complications.
Figure 1: Computed tomography scan of abdomen revealed cecal distension with distended loop of bowel measuring 9 cm in maximum diameter

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Figure 2: Gross images of cecal bascule which was resected with the cecum folded up onto the ascending colon into the right upper quadrant

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Cecal bascule classically occurs in the setting of colonic pseudo-obstruction or distal mechanical large bowel obstruction. [3] We believe that the patient first developed ileus secondary to the multiple myeloma-related hypercalcemia. The intestinal obstruction then progressively evolved into a cecal bascule. Cecal volvulus must be suspected in patients who present with abdominal pain and distension. Marked mobility of the cecum is found in 20% of the general population and may be asymptomatic or give rise to recurrent bouts of abdominal distension and chronic periumbilical or right lower quadrant pain. [4] The diagnosis of this "mobile cecum syndrome" is usually made with a barium enema and the radiologist can manipulate the patient on the X-ray table to demonstrate mobility. Non-operative management involves reduction with barium enema or colonoscopy but can be done only when the cecum is not perforated. Surgical management includes right hemicolectomy as in our patient and decompression, detorsion and cecopexy when there is no gangrene or perforation. [5]

 
  References Top

1.Ferguson L, Higgs Z, Brown S, McCarter D, McKay C. Intestinal volvulus following laparoscopic surgery: A literature review and case report. J Laparoendosc Adv Surg Tech A 2008;18:405-10.  Back to cited text no. 1
    
2.Feliciano DV. Special feature: Image of the month. Arch Surg 2001;136:475-7.  Back to cited text no. 2
[PUBMED]    
3.Ulloa SA, Ramírez LO, Ortíz VN. Cecal volvulus after laparoscopic liver biopsy. Bol Asoc Med P R 1997;89:195-6.  Back to cited text no. 3
    
4.Rabinovici R, Simansky DA, Kaplan O, Mavor E, Manny J. Cecal volvulus. Dis Colon Rectum 1990;33:765-9.  Back to cited text no. 4
    
5.Hogan BA, Brown CJ, Brown JA. Cecal volvulus in pregnancy: Report of a case and review of the safety and utility of medical diagnostic imaging in the assessment of the acute abdomen during pregnancy. Emerg Radiol 2008;15:127-31.  Back to cited text no. 5
    


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