01Approach to the Critical Patient/attcp57

Immediate priorities

›Airway and resuscitation

›Large bore IV access bilateral antecubital

›IV fluid resuscitation with crystalloid

›Lactated Ringer or normal saline bolus 1 to 2 L

›Supplemental oxygen to maintain SpO2 >= 94%

›High flow oxygen if septic shock

›Endotracheal intubation if vomiting with airway compromise

›Nasogastric tube placement for proximal decompression

›Reduces distension

›May reduce vomiting and aspiration risk

›Hemodynamic targets

›MAP >= 65 mmHg

›Vasopressors if refractory to fluids

›Norepinephrine first-line vasopressor

›Urine output >= 0.5 mL/kg/hour via Foley catheter

›Monitors resuscitation adequacy

›Dehydration common from vomiting

›Lactate clearance target

›Repeat lactate within 2 hours if elevated

›Persistent lactate >= 4 mmol/l indicates bowel ischemia

›Emergent surgical consultation

›Endoscopic decompression is not recommended for cecal volvulus

›Success rate only 14% and delays definitive care

›ASCRS guideline recommendation against endoscopy

›Operative resection is the definitive treatment

›No role for watchful waiting once diagnosis confirmed

›Mortality 10 to 40% depending on bowel viability

02History/hx75

Presenting symptoms

›Abdominal pain

›Often acute onset, colicky or constant

›May localize to right lower quadrant or be diffuse

›Typically rapid progression over hours

›Severity often severe and rapidly worsening

›Distinguishes from sigmoid volvulus which may be more indolent

›Prior episodes of spontaneous resolution suggest intermittent volvulus

›Abdominal distension

›Progressive bloating

›Asymmetric distension often present

›Tympanic to percussion

›Nausea and vomiting

›Common at presentation

›May be bilious or feculent

›Causes dehydration and electrolyte derangements

›Obstipation

›Inability to pass flatus or stool

›Cardinal feature of complete large bowel obstruction

›May alternate with diarrhea in early or intermittent presentation

Symptom context and timeline

›Duration and progression

›Cecal volvulus typically more acute than sigmoid volvulus

›Hours to days rather than insidious onset

›Rapid escalation of pain and distension is characteristic

›Prior similar episodes with spontaneous resolution

›Suggests intermittent volvulus or cecal bascule

›Important to identify recurrent pattern

›Last bowel movement and flatus

›Absence supports complete obstruction

›Duration since last defecation

›Distinguish from constipation without obstruction

Risk factors

›Anatomic predisposition

›Cecal hypermobility from incomplete peritoneal fixation

›Present in approximately 10 to 25% of the general population

›Primary anatomic prerequisite for volvulus to occur

›Long redundant colon with narrow mesenteric attachment

›Creates lever-arm for torsion

›Congenital developmental variant

›Prior abdominal surgery

›Adhesions alter cecal position and mobility

›Most significant acquired risk factor

›Any prior abdominal or pelvic operation relevant

›Chronic constipation and colonic dysmotility

›Chronic laxative dependence

›Neuropsychiatric disorders including dementia and Parkinson disease

›Psychiatric medications including antipsychotics

›Medications causing dysmotility

›Opioids, anticholinergics, calcium channel blockers

›Sedatives and antipsychotics

›Demographic risk factors

›Female sex: cecal volvulus has female predominance

›Unlike sigmoid volvulus which is predominantly male

›Pregnancy displaces mobile cecum by gravid uterus

›Younger age than sigmoid volvulus patients

›Cecal volvulus typically presents in younger adults

›Bimodal distribution reported in some series

›High fiber diet and geographic factors

›High fiber diet in endemic regions

›Volvulus belt: Africa, Middle East, South Asia

›Bulky stool propels mobile cecum

Past medical and surgical history

›Relevant medical history

›Prior episodes of abdominal obstruction or volvulus

›Intermittent torsion and spontaneous detorsion

›Prior imaging showing abnormal cecal position

›Neuropsychiatric conditions

›Dementia

›Parkinson disease

›Diabetes mellitus with autonomic neuropathy

›Contributes to colonic dysmotility

›Delayed gastric emptying overlap

›Pregnancy history

›Current pregnancy status

›Gravid uterus displaces cecum

›Third trimester highest risk period

›Prior pregnancy as exposure event

›May unmask pre-existing cecal hypermobility

03Physical Exam/exam55

Vital signs

›Hemodynamic stability assessment

›Heart rate

›Tachycardia > 100 bpm suggests ischemia or volume depletion

›Septic physiology marker

›Blood pressure

›SBP < 90 mmHg or MAP < 65 mmHg indicates shock

›Orthostatic changes from dehydration

›Temperature

›Fever suggests bowel compromise or peritonitis

›Hypothermia as marker of severe sepsis

›Respiratory rate

›Tachypnea from pain, sepsis, or diaphragmatic splinting

›Compensation for metabolic acidosis in advanced ischemia

Abdominal exam

›Inspection

›Asymmetric abdominal distension

›Dilated cecum may produce visible bulge in right or central abdomen

›General abdominal distension with advanced obstruction

›Surgical scars indicating prior operations

›Important risk factor to document

›May indicate adhesion-related cecal displacement

›Palpation and percussion

›Tympany to percussion

›Diffuse tympany from dilated gas-filled bowel

›Area of maximal distension

›Tenderness location and character

›Right lower quadrant tenderness early

04Differential Diagnosis/ddx57

Large bowel obstruction causes

›Sigmoid volvulus

›ICD-10 K56.2

›More common than cecal volvulus; 60 to 75% of colonic volvulus

›Older males with neuropsychiatric comorbidities

›Coffee bean sign points to left lower quadrant

›Cecal volvulus coffee bean more often right-sided or midline

›Endoscopic decompression effective for sigmoid but not cecal volvulus

›Obstructing colon cancer

›ICD-10 C18 series

›Most common cause of large bowel obstruction overall

›CT identifies mass lesion and adenopathy

›Older age group

›Weight loss and occult blood

›Gradual onset versus acute volvulus presentation

›Diverticular stricture

›ICD-10 K57 series

›Common cause of large bowel obstruction

›History of diverticulitis episodes

›CT shows colonic thickening at sigmoid colon

›No whirl sign

›Pericolonic fat stranding

Right-sided and small bowel mimics

›Small bowel obstruction

›ICD-10 K56.0 or K56.6

›Clinically difficult to distinguish from cecal volvulus

›CT essential for differentiation

›Multiple air-fluid levels on plain film

05Laboratory Tests/lt56

Core labs

›Complete blood count

›Leukocytosis suggests bowel ischemia or perforation

›WBC > 15 x 10^9/L associated with gangrenous bowel

›Leukopenia as severe sepsis marker

›Hemoglobin and hematocrit

›Baseline for surgical planning

›Hemoconcentration from dehydration

›Metabolic panel

›Electrolytes

›Hypokalemia from vomiting is common

›Hyponatremia and hypokalemia require correction before surgery

›Creatinine and BUN

›Acute kidney injury from dehydration and hypoperfusion

›Antibiotic dosing adjustment inputs

›Bicarbonate

›Low bicarbonate suggests metabolic acidosis from ischemia

›Anion gap elevation with lactic acidosis

Ischemia and perfusion markers

›Lactate

›Elevated lactate raises concern for bowel ischemia

›>= 2 mmol/l meets organ hypoperfusion threshold

›>= 4 mmol/l indicates severe ischemia and septic shock

›Normal lactate does not exclude bowel ischemia

›CT signs of ischemia correlate poorly with pathologic findings

›Clinical exam and CT remain primary assessment tools

›Arterial blood gas

›Metabolic acidosis in advanced ischemia

06Diagnostic Tests/dt93

Scoring Systems

›No validated cecal volvulus specific scoring system exists

›No single score replaces clinical assessment plus CT

›ASA physical status class used for surgical risk stratification

›Higher ASA class influences operative approach selection

›Severity stratification categories

›Uncomplicated: viable bowel, hemodynamically stable, urgent surgery

›Complicated: gangrenous bowel, perforation, peritonitis, septic shock, emergent surgery

›General acute abdomen and sepsis scoring adjuncts

›qSOFA for sepsis screening

›Respiratory rate >= 22 per minute

›SBP <= 100 mmHg

›Altered mental status

›Alvarado score not applicable but RLQ pain overlap may prompt its use

›CT is definitive and supersedes scoring in this context

MRI

›MRI abdomen role in cecal volvulus

›Not indicated in acute emergency setting

›CT is faster and more available

›Unstable patients cannot tolerate MRI acquisition time

›Possible problem-solving role in stable selected patients

›Suspected underlying malignancy masquerading as volvulus

›Complex mesenteric or vascular anatomy delineation

›Limitations in acute bowel obstruction

›Bowel motion artifact degrades image quality

›Metallic implant contraindications

›Not standard of care for this condition

CT

›CT abdomen and pelvis with IV contrast is the gold standard

›Near 100% sensitivity and greater than 90% specificity with multiplanar reconstruction

›ASCRS and ASGE guidelines support CT as primary diagnostic modality

›Identifies volvulus, ischemia, and alternative diagnoses

›Whirl sign

›Mesenteric torsion point on CT

›Sensitivity 91 to 96%; independent predictor of volvulus

›Ectopic cecal position

›Displaced cecum to left upper quadrant or midline

›Abnormal position highly specific for volvulus

›Bird beak sign

›Tapered point of obstruction at torsion site

›Visible on axial and coronal reconstructions

›Severe cecal distension

›Sensitivity 100% for obstruction

›Diameter often > 9 to 12 cm

›Central appendix sign

›Appendix displaced near midline

›Sensitivity approximately 93%

›Ileocolic vascular curvature

›Hook-like curvature of ileocolic vessels

›Specificity 100% for cecal volvulus

›Distal colon decompression

›Absence of distal colonic gas makes cecal volvulus very unlikely

›Collapsed distal colon supports mechanical obstruction diagnosis

›CT signs of bowel ischemia and perforation

›Pneumatosis intestinalis

›Gas within bowel wall

›High specificity for transmural ischemia

›Portal venous gas

›Indicates severe bowel necrosis

›Associated with high mortality

›Lack of bowel wall enhancement after IV contrast

›Ischemic bowel wall

›May indicate gangrenous segment

›Free intraperitoneal fluid

›Ascites or hemorrhagic fluid from vascular compromise

›Pneumoperitoneum indicates frank perforation

›Plain abdominal radiograph role

›Coffee bean or bent inner tube sign of dilated cecum

›Projecting toward upper abdomen

›Diagnostic in only 26 to 42% of cases

›Less reliable than sigmoid volvulus radiographic findings

›Single air-fluid level versus multiple in SBO

›Decompressed distal colon with haustra in dilated segment

›Upright CXR for pneumoperitoneum screening

›Rapid and readily available

›Free air under diaphragm confirms perforation

Ultrasound

›Point-of-care ultrasound role in cecal volvulus

›Limited diagnostic accuracy compared to CT

›Not reliable for definitive diagnosis

›Operator-dependent and bowel gas limits visualization

›Dilated bowel loops identification

›May show markedly distended right colon

›Cannot reliably identify whirl sign or cecal position

›Free fluid detection

›Free intraperitoneal fluid suggestive of ischemia or perforation

›Useful rapid screen at bedside in unstable patients

›POCUS adjunct applications

›Cardiac and hemodynamic assessment

›IVC collapsibility for volume status in shock

›LV function estimation

›Bladder and renal assessment

›Urine output monitoring support

›Hydronephrosis exclusion

›Thoracic assessment if respiratory compromise

›Pleural effusion screen

›Lung consolidation pattern

07Disposition/dispo40

Admission and operative urgency

›All patients with confirmed cecal volvulus require admission

›This is a surgical emergency without outpatient management role

›ASCRS clinical practice guidelines support operative intervention

›No role for discharge or outpatient surveillance

›Emergent OR criteria: within 1 to 2 hours

›Peritonitis on exam

›Hemodynamic instability not responding to resuscitation

›Perforation or pneumoperitoneum on imaging

›Signs of bowel necrosis: pneumatosis, portal gas

›Urgent OR criteria: same-day surgical intervention

›Hemodynamically stable with confirmed cecal volvulus

›No signs of gangrene or perforation

›Delay to surgery increases risk of bowel compromise

›ICU admission indications

›Septic shock requiring vasopressors

›Norepinephrine infusion initiated

›Multiple organ dysfunction

›Significant hemodynamic instability

›MAP < 65 mmHg despite initial resuscitation

›Vasopressor-dependent state

›High operative risk with postoperative monitoring needs

›High ASA class patients

›Elderly with multiple comorbidities

›Postoperative complicated resection

›End ileostomy creation requiring stoma management

›Anastomotic concern requiring monitoring

08Treatment/t96

Initial stabilization

›IV fluid resuscitation

›Normal saline or lactated Ringer 1 to 2 L bolus

›Reassess response with repeat clinical exam and lactate

›Avoid excessive fluid administration in cardiac comorbidity

›Electrolyte replacement

›IV potassium for hypokalemia

›Target serum potassium >= 3.5 mmol/l before surgery

›Nasogastric tube

›Decompression of proximal distension

›Reduces vomiting and aspiration risk

›Low intermittent suction

›Monitor output for bilious or feculent content

›High output indicates proximal obstruction severity

›Foley catheter

›Urine output monitoring during resuscitation

›Target >= 0.5 mL/kg/hour

›Oliguria indicates inadequate resuscitation or AKI

›Analgesia

›IV opioid analgesia for pain

›Morphine 2 to 4 mg IV or hydromorphone 0.2 to 0.4 mg IV

›Titrate to comfort while preserving exam reliability

›Antiemetics

›Ondansetron 4 mg IV for nausea and vomiting

›Metoclopramide 10 mg IV alternative

Antibiotics for peritonitis and sepsis

›Broad-spectrum IV antibiotics when peritonitis or sepsis suspected

›Piperacillin-tazobactam IV

›4.5 g IV every 6 hours

›Covers gram-negative, gram-positive, and anaerobic organisms

›Ceftriaxone plus metronidazole alternative

›Ceftriaxone 2 g IV every 24 hours

›Metronidazole 500 mg IV every 8 hours

›Meropenem for resistant organism risk or prior colonization

›1 g IV every 8 hours

›Reserve for high-resistance risk environments

›Add vancomycin if MRSA risk or healthcare-associated infection

›15 to 20 mg/kg IV every 8 to 12 hours

›AUC-guided dosing per local protocol

›Antibiotic timing

›Within 1 hour of diagnosis for septic shock

›Class I recommendation per Surviving Sepsis Campaign

›Do not delay for blood cultures if patient unstable

Surgical treatment

›Segmental resection is the gold standard and preferred treatment

›Ileocecectomy or right hemicolectomy

›ASCRS clinical practice guidelines recommend resection

›Zero recurrence rate with resection

›Preferred over nonresective options for all appropriate surgical candidates

›Primary ileocolic anastomosis when safe

›Anastomotic leak rate approximately 4.1% in NSQIP data

›Mortality approximately 3.3% in NSQIP data for uncomplicated cases

›Resection with end ileostomy and mucous fistula

›High-risk patients with nonviable bowel

›Septic shock state with bowel contamination

›Second-stage anastomosis possible after recovery

›Nonresective options for patients unfit for resection

›Cecopexy

›Surgical fixation of cecum without resection

›Recurrence rate 13%; lower morbidity 15% and mortality 10%

›Reserved for viable bowel and very high surgical risk patients only

›Cecostomy

›Highest complication rates: morbidity 52%, mortality 32%

›Generally discouraged by ASCRS guidelines

›Considered only when resection and cecopexy not feasible

›Detorsion alone without fixation

›Recurrence rate up to 75%

›Not recommended as definitive treatment

›Endoscopic reduction is not recommended

›Success rate only 14% for cecal volvulus

›Significantly lower than sigmoid volvulus endoscopic success

›ASGE and ASCRS guidelines advise against endoscopy for cecal volvulus

›Risk of perforation and delay to definitive surgical care

›Failed endoscopy worsens operative risk

›Proceed directly to operative management

Laparoscopic versus open surgery

›Approach selection

›Laparoscopic approach feasible in stable patients with viable bowel

›Conversion to open if difficult exposure or necrosis found

›Similar outcomes to open in experienced centers

›Open laparotomy for unstable, peritonitis, or perforation

›Faster access in emergent cases

›Better visualization for contaminated fields

›Surgical approach guided by individual patient and operative team factors

›Center experience and available equipment

›Degree of cecal distension affecting laparoscopic feasibility

Perioperative management

›Deep vein thrombosis prophylaxis

›Sequential compression devices preoperatively

›Low molecular weight heparin postoperatively when hemostasis secured

›Enoxaparin 40 mg subcutaneous once daily

›Colorectal surgery carries high VTE risk without prophylaxis

›Glycemic control perioperatively

›Target blood glucose 6 to 10 mmol/l

›Insulin infusion for persistent hyperglycemia

›Hypoglycemia avoidance

›Thromboprophylaxis and anticoagulation reversal

›Reversal of anticoagulation if emergent surgery required

›Vitamin K and fresh frozen plasma for warfarin

›Idarucizumab for dabigatran

›Andexanet alfa for factor Xa inhibitors if available

09Special Populations/sp75

Pregnancy

›Pregnancy considerations

›Cecal volvulus risk increased during pregnancy

›Gravid uterus displaces the mobile cecum superiorly

›Third trimester is highest risk period

›Incidence estimated at 1 in 66,000 pregnancies

›Diagnosis approach

›MRI preferred over CT when possible in stable patients

›Avoids ionizing radiation to fetus

›CT with abdominal shielding acceptable when MRI unavailable or patient unstable

›Fetal monitoring

›Continuous fetal heart rate monitoring if viable gestation (>= 24 weeks)

›Obstetric consultation required urgently

›Maternal resuscitation prioritized to maintain fetal perfusion

›Surgical management

›Surgical resection remains the treatment of choice regardless of gestational age

›Risk of maternal death from delay exceeds fetal risk from surgery

›Multidisciplinary approach: colorectal surgery, obstetrics, neonatology

›Antibiotic selection

›Piperacillin-tazobactam acceptable in pregnancy when benefit outweighs risk

›Avoid aminoglycosides due to fetal ototoxicity

›Metronidazole acceptable in second and third trimester

›Anesthesia considerations

›Regional anesthesia preferred when technically feasible

›Left uterine displacement during general anesthesia

›RSI for aspiration risk in late pregnancy

Geriatric

›Older adult features

›Increased surgical mortality risk

›Comorbidity burden: cardiac, renal, pulmonary disease

›Frailty scoring relevant for informed consent and surgical planning

›ASA class often higher in this group

›Atypical presentation patterns

›Diminished pain response may mask severity

›Confusion and delirium as dominant presenting symptom

›Afebrile despite peritonitis in frail and immunosuppressed patients

›Neuropsychiatric medication associations

›High antipsychotic and anticholinergic medication burden

›Opioid use contributing to colonic dysmotility

›Medication reconciliation important

›Fluid resuscitation caution

›Reduced cardiac reserve limits aggressive fluid bolusing

›Invasive hemodynamic monitoring may be needed perioperatively

›Loop diuretic availability if fluid overload

›Postoperative delirium prevention

›Avoid benzodiazepines where possible

›Maintain sleep-wake cycle

›Early mobilization

›Decision-making capacity and goals of care

›Assess capacity before surgery in confused patients

›Surrogate decision-maker identification

›Goals of care discussion when surgical risk is prohibitive

Pediatrics

›Pediatric differences

›Cecal volvulus is rare in children

›More often associated with intestinal malrotation

›Hirschsprung disease association in neonates

›Anatomic causes differ from adults

›Congenital malrotation with Ladd bands more common

›Incomplete intestinal rotation allows cecal hypermobility

›Presentation features

›Bilious vomiting in neonates is a surgical emergency

›Abdominal distension and obstipation

›Pain expression depends on age and developmental stage

›Imaging approach

›Upper GI contrast study to assess rotation in non-emergency cases

›CT with pediatric dose reduction protocols

›US as initial adjunct to reduce radiation exposure

›Surgical management

›Ladd procedure for malrotation with volvulus

›Right hemicolectomy for cecal volvulus similar to adult approach

›Weight-based IV fluid resuscitation

›20 mL/kg normal saline bolus for shock

›Reassess after each bolus

›Antibiotic dosing weight-based

›Piperacillin-tazobactam 100 mg/kg/dose of piperacillin component IV every 8 hours

›Maximum adult dose applies

›Ceftriaxone 50 to 75 mg/kg IV once daily for less severe infections

10Background/b75

Epidemiology

›Incidence and prevalence

›Second most common cause of colonic volvulus after sigmoid volvulus

›Represents 25 to 40% of all colonic volvulus cases

›Sigmoid volvulus accounts for 60 to 75% of colonic volvulus

›Large bowel obstruction contribution

›Cecal volvulus accounts for 1 to 3% of all large bowel obstructions

›Obstructing colon cancer remains most common cause of large bowel obstruction

›Age and sex distribution

›Female predominance unlike sigmoid volvulus

›Typically younger patients than sigmoid volvulus

›Bimodal age distribution reported in some series

›Geographic variation

›Higher incidence in the volvulus belt: Africa, Middle East, South Asia

›Western countries have lower overall incidence

›High fiber diets and long mobile colons implicated

›Mortality and morbidity

›Mortality ranges from 10 to 40% depending on bowel viability

›Gangrenous cecum present in 18 to 44% of cases at surgery

›Perforation with peritonitis carries highest mortality

›Viable bowel with prompt surgery carries favorable prognosis

›Anastomotic leak rate approximately 4.1% in recent NSQIP data

›Mortality approximately 3.3% for uncomplicated resection

Pathophysiology

›Anatomic basis

›Primary prerequisite: incomplete peritoneal fixation of right colon

›Present in approximately 10 to 25% of the population

›Normally cecum fixed to right parietal peritoneum during development

›Two anatomic variants of cecal volvulus

›True cecal volvulus: mesentero-axial axial torsion

›Approximately 80% of cecal volvulus cases

›Rotates around mesenteric vascular pedicle

›Cecal bascule: cephalad folding without true axial torsion

›Approximately 20% of cecal volvulus cases

›Both variants produce same functional closed-loop obstruction

›Mechanism of obstruction and ischemia

›Closed-loop large bowel obstruction

›Ileocecal valve competency prevents proximal decompression

›Cecum distends rapidly with gas and fluid

›Vascular compromise sequence

›Venous outflow obstructed first causing edema and congestion

›Arterial inflow compromised with progressive torsion

›Transmural ischemia leads to gangrene and perforation

›Perforation risk

›Cecal diameter > 12 cm associated with impending perforation

›Time to surgery directly influences bowel viability

›Contributing factors to torsion

›Long narrow mesenteric attachment as lever arm

›Redundant mobile cecum with adequate length to twist

›Precipitating events: immobilization, prior surgery, pregnancy, colonic dysmotility

Therapeutic Considerations

›Surgery versus endoscopy evidence

›Endoscopic decompression has only 14% success rate for cecal volvulus

›Markedly inferior to 80 to 95% success rate for sigmoid volvulus

›ASGE and ASCRS guidelines recommend against endoscopic management

›Operative resection carries zero recurrence rate

›Cecopexy carries 13% recurrence rate

›Detorsion alone carries up to 75% recurrence rate

›Early surgery prevents progression to gangrene and perforation

›Surgical delay associated with higher mortality

›Time from diagnosis to OR is a modifiable prognostic factor

›Resection versus nonresective strategy

›Resection preferred for all patients fit to undergo it

›ASCRS 2021 clinical practice guidelines recommend resection

›Primary anastomosis preferred when bowel viable and patient stable

›Nonresective options reserved for highest risk patients

›Cecopexy: 13% recurrence, 15% morbidity, 10% mortality

›Cecostomy: 52% morbidity, 32% mortality - generally discouraged

›Anastomosis versus stoma decision intraoperative

›Bowel viability, degree of contamination, patient hemodynamic stability

›Surgeon and center experience

›Prevention and risk reduction

›Dietary and lifestyle modification for colonic dysmotility

›High fiber intake and adequate hydration

›Avoid constipating medications where possible

›Review and minimize bowel motility-slowing medications in high-risk patients

›Opioids, anticholinergics, antipsychotics

›Calcium channel blockers

11Patient Discharge Instructions/pdi50

copy discharge instructions

›Post-operative home care after cecal volvulus surgery

›Wound care

›Keep incision clean and dry

›Dressing changes as instructed by surgeon

›No soaking wound in bath or pool until healed

›Activity restrictions

›No heavy lifting (greater than 5 kg) for 6 weeks

›Walking encouraged from day one post-discharge

›Return to driving when off narcotic pain medications and able to react normally

›Diet advancement

›Start with clear fluids, advance slowly to regular diet

›High fiber diet and adequate hydration for long-term bowel regularity

›Avoid foods that caused severe constipation before surgery

›Medications

›Take pain medications as prescribed; avoid driving or alcohol while on opioids

›Stool softeners such as docusate sodium 100 mg twice daily to prevent constipation

›Complete antibiotic course if prescribed

›Stoma care if end ileostomy was created

›Ostomy bag change technique and frequency

›Skin barrier protection and proper pouch seal

›Contact ostomy nurse for questions or skin breakdown

›Monitor stoma output

›High output ileostomy can cause dehydration

›Drink extra fluids and replace electrolytes

›Seek medical attention if output > 2 L/day

›Warning signs requiring immediate return to emergency department

›Fever above 38.5 C or chills

12References/r27

Guidelines and key sources

›Society guidelines

›American Society of Colon and Rectal Surgeons (ASCRS) Clinical Practice Guidelines for the Management of Colonic Volvulus and Acute Colonic Pseudo-Obstruction

›Alavi K, Poylin V, Davids JS, et al.; Diseases of the Colon and Rectum 2021

›Recommends segmental resection as preferred treatment

›Recommends against endoscopic management of cecal volvulus

›American Society for Gastrointestinal Endoscopy (ASGE) Guideline on the Role of Endoscopy in the Management of Acute Colonic Pseudo-Obstruction and Colonic Volvulus

›Naveed M, Jamil LH, Fujii-Lau LL, et al.; Gastrointestinal Endoscopy 2020

›Confirms low success rate of endoscopy for cecal volvulus

›Imaging and diagnostic evidence

›CT findings of cecal volvulus: whirl sign, bird beak sign, ileocolic vascular curvature

›Rosenblat JM, Rozenblit AM, Wolf EL, et al.; Radiology 2010

›Dane B, Hindman N, Johnson E, Rosenkrantz AB; AJR 2017

›Wong M, Brooke Jeffrey R, Rucker AN, Olcott EW; Abdominal Radiology 2020

›Plain radiograph sensitivity 26 to 42% for cecal volvulus

›Supports CT as primary imaging modality

›ACS Gastrointestinal Surgical Emergencies Textbook 2021

›Surgical outcomes data

›NSQIP data: anastomotic leak rate 4.1%, mortality 3.3% for resection

›Colonic Volvulus review; Surgical Clinics of North America 2026

›Pickron B, Di Nolfi J, Hall J, Hegeholz D

›Cecopexy recurrence 13% vs zero recurrence with resection

›Case series and registry data supporting resection preference

›ICD-10 coding

›ICD-10 K56.2 Volvulus of intestine

›Encompasses cecal and sigmoid volvulus

›ICD-10 K56.0 Paralytic ileus for pseudo-obstruction differential

›ICD-10 K63.1 Perforation of intestine (nontraumatic) for complications

Evidence & Review