Primary cecal pathologies presenting as acute abdomen and critical appraisal of their current management strategies in emergency settings with review of literature

Abstract

Background: The importance of cecal pathologies lie in the fact that being the first part of the large intestine, any disease involving the cecum affects the overall functioning of the large bowel. Primary cecal pathologies presenting as acute abdomen have not been described in any previous study in terms of presentation, management, and outcome.

Objectives: The objective of this study was to identify the reported causes of primary cecal pathologies presenting as acute abdomen and the various causes presenting in our setting, the to discuss morbidity and mortality associated with cecal pathologies, and to critically analyze the various management modalities employed in an emergency setting.

Materials and methods: This is a retrospective analysis of a prospectively collected data of all adult patients admitted to our unit in the last 10 years for acute abdomen, in whom cecal pathology was identified as the primary offending agent.

Results: Our analysis of 43 patients revealed cecal perforation secondary to amebic colitis along with the simultaneous presence of liver abscess to be the most common primary cecal entity met in practice as acute abdomen. Other pathologies that were encountered included volvulus, diverticulitis, and idiopathic typhlitis. Primary acute cecal pathologies are associated with high mortality rates (≈42%). Delay in diagnosis seems to be the most important factor contributing to high mortality as these conditions are commonly misdiagnosed as appendicular pathology. Most of our patients were managed by conservative colonic resection with proximal diversion. This seems to be a more plausible option in current practice in an emergency setting (mortality rate ≈ 36%) as hemicolectomy is associated with proportionately higher mortality rates (67%).

Conclusion: A high index of suspicion, timely and adequate pre-operative workup, optimal resuscitation, and surgical conservatism with proximal diversion might help in early accurate identification of these conditions and possibly improved outcome.

Keywords: Amebic typhlitis; cecal diverticulitis; conservative colonic resection; emergency laparotomy; fulminant amebic colitis; idiopathic typhlitis; ileoascending anastomosis; ileocecal resection; ileotransverse anastomosis; primary cecal pathology; right hemicolectomy; ruptured liver abscess.

Figure 1

Flowchart depicting the outcome of patients by procedures performed and final diagnosis

Figure 2

Intra-operative image of a patient who was erroneously presumed to be having ruptured liver abscess with suspected cecal perforation while it was found that liver abscess was intact and pyoperitoneum was due to cecal perforation only

Figure 3

A case of perforated cecal diverticulitis who was initially suspected to be having perforated appendicitis

Figure 4

Pre-operative provisional diagnosis of patients on the basis of clinical judgment and available radiological modalities

Figure 5

Distribution of patients by final diagnosis