eP591 - Rare Case of Cecal Bascule Presenting as Intestinal Obstruction and Its Management

Purpose/Background: Cecal bascule is a rare condition where the cecum becomes folded beneath the ascending colon, resulting in a high-grade colonic obstruction. We present a case of cecal bascule in a 62-year-old female, emphasizing the importance of timely diagnosis and surgical intervention.Methods/Interventions: A 62 year-old female, with a history of laparoscopic gastric bypass, appendectomy and cholecystectomy presented to the emergency department with a one-day history of severe right lower quadrant abdominal pain. Physical examination focal peritonitis in the right lower quadrant, and anemia (Hbg/HCT 8.2/27). Of note, the patient had multiple prior colonoscopies in the past, all normal. Due to the severity of her condition, emergent diagnostic laparoscopy was performed, revealing a cecal bascule. The cecum was trapped beneath the ascending colon, causing significant distention and pressure on adjacent structures. Given the complexity of the situation, the procedure was converted to an exploratory laparotomy. To examine the peritoneal cavity adhesions were lysed. The cecum was retracted medially to slowly dissect off its lateral peritoneal attachments and superiorly along the ascending colon. Ileocolic vascular bundle was skeletonized and clamped and ligated with vicryl suture. An end-to-end ileostomy was created using a GIA stapler. Good perfusion was established. Fascia and skin were closed appropriately. Post-operatively course was uncomplicated. Patient diet was slowly advanced and post-operative pain was well controlled. By hospital day 3, the patient was having return of bowel function, ambulating independently, tolerating regular diet, and was safely discharged home.Results/Outcomes: Cecal bascule is the rarest type of cecal volvulus accounting for 5-20% of cases1. It is characterized by an excessively mobile cecum folding anterior over the ascending colon causing a mechanical obstruction. The formation of a cecal bascule can be caused from an embryologic failure of fixation of the cecum to the RLQ during rotation, but given this patient's extensive surgical history the cause is most likely from adhesions. What differentiates a cecal bascule is the feature of no vascular compromise.
The presentation of a cecal bascule can present with nonspecific symptoms such as abdominal pain, nausea, vomiting and inability to tolerate po diet. The use of abdominal plain films and CT scan play a crucial role in establishing a diagnosis. While an abdominal film is faster to obtain, it is less specific in confirming the diagnosis. Characteristic signs of a cecal bascule on CT scan include dilation of the cecum, displacement of the cecum to the upper/central abdomen, or transition zone between the cecum and ascending colon.
The treatment of this condition in the majority of patients is operative management ranging from cecopexy with possibly cecostomy, cecectomy , or right colectomy. A right hemicolectomy is considered the standard operative option for this condition, with cecopexy with cecostomy more commonly performed in unstable patients.Conclusion/

Discussion: Cecal bascule can present as a challenging surgical condition, especially in older patients. Timely diagnosis and surgical intervention, whether through laparoscopy or laparotomy, are crucial in achieving successful outcomes and preventing future complications."Image 1

Coronal View of CT abdomen pelvis with IV contrast revealing dilated loops of small bowel with transition point at dilated cecum
Image 2

Intra-operative image of eviscerated cecal bascule "