Cecal bascule with a mesenteric band acting as a ‘point of basculation’

CASE REPORT A 72­year­old female with a past history of cesarean section presented with a three day history of right­sided abdominal pain and distension. She had a low­grade fever, was normotensive, and without leukocytosis or metabolic acidosis. Her exam revealed moderate abdominal distension with rebound tenderness localized to the right lower quadrant. An abdominal X­ray showed significant cecal distension without small bowel dilatation (Figure 1). Given her worrisome clinical picture, the patient was emergently taken for an exploratory laparotomy. There was anteromedial folding of a massively distended cecum about a mesenteric band traversing the terminal ileum extending to the ascending colon (Figure 2; arrow). This created a closed­loop obstruction of the ascending colon. There was no axial torsion of the cecal mesentery. There was no colonic perforation or feculent spillage noted. After lysis of this band, inspection of the cecum demonstrated that it was not only severely dilated but also tethered in its abnormal anteromedial position by multiple adhesions. These adhesions were lysed and a right hemicolectomy with primary anastomosis was performed. The patient had an uneventful postoperative course, with return of bowel function prior to discharge.