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Case 80: RIF pain and vomiting

A 63 year old man is admitted with 12 hours of abdominal pain. It began centrally with crampy pain and he now has constant right iliac fossa pain. He is unwell with vomiting, tachycardia and his abdomen is distended and guarded. A plain xray is shown below.

1. What is the likely diagnosis?

The xray shows caecal volvulus with significant dilatation of the obstructed caecum.

2. What complication would you suspect has occurred?

The change in the nature of this mans pain from colicky visceral pain to constant well localised somatic pain, associated with tachycardia and guarding on abdominal examination suggests the presence of strangulation of the caecum.

3. How would you manage this man?

He requires urgent laparotomy after appropriate fluid resuscitation. At laparotomy a non-viable caecum is resected and an anastomosis is usually able to be performed.
If the caecum is viable after de-torsion then there are other options. Caecopexy or fixing the caecum to the abdominal wall by suturing or peritoneal flap avoids the morbidity of resection and anastomosis. It is associated with significant recurrence however. A third option is caecostomy usually via a foley catheter. This is designed to fix the caecum to the anterior abdominal wall however it is frequently complicated by abdominal wall sepsis.