1. A Review of Cecal Pathology Presenting as Acute Abdomen and Critical Appraisal of its Management Strategies : Our Experience & Review of Literature
Prof Afzal Anees
Prof M. A. Khan
Dr Shehtaj Khan
Dr Kaushal Deep Singh
Department Of Surgery
JNMCH, AMU

2. INTRODUCTION
Disease involving the cecum affects overall functioning of the large bowel
Commonly misdiagnosed
High morbidity and mortality
Can have myriad of causes
Importance lies in the fact that being
the first part of large intestine,
Those presenting with acute abdomen require attention, as being

3. AIMS & OBJECTIVES
To appreciate various causes of cecal pathology presenting as acute abdomen
To identify the pattern of common pathologies in Indian setup
To discuss morbidity and mortality associated with cecal
pathologies
To critically analyze the various management modalities available for cecal pathologies presenting as acute abdomen

4. STUDY DESIGN
Retrospective analysis of prospectively collected data

5. MATERIALS & METHODS
Retrospective analysis of the prospectively collected data of patients admitted to our unit in last 7 years for acute abdomen in whom cecal pathology was the prime culprit
Total number of patients included in study - 19

6. INCLUSION CRITERIA EXCLUSION CRITERIA
Adult patients presenting in emergency department with acute abdomen
Identification of cecal pathology as the cause of acute abdomen per-operatively or on HPE or on imaging
Patients identified with cecal perforation who had symptoms for few days but who didn’t presented immediately due to various reasons(Guven et al., 1) but in whom severe pain abdomen was the first symptom
EXCLUSION CRITERIA
Patients with sub-acute, intermittent or chronic pain
Pain is not due to cecal pathology
Predominant pathology is not cecal
Patients with cecal pathology operated as an elective case

7. RESULTS

8. Age Distribution
38.1 ± 17.4 yrs (Range 15-70)
AGE (yrs)
Patient Name

9. Sex Distribution
Males - 15
Females - 4

10. Distribution by Diagnosis
In 11 (57.9%) patients, provisional diagnosis was different from the final daignosis
Most common cecal pathology presenting as acute abdomen was amoebic perforation of cecum in association with a ruptured/intact
liver abscess 8 (42.1%), followed by ileocecal TB 3 (18.2%)

11. Treatment
5 (26.3%) patients were managed conservatively & 14 (73.7%) operated

12. PROCEDURES PERFORMED Expired Discharged
Right hemicolectomy with proximal diversion - 3 (21.4%)
2 expired (66.7% mortality)
Primary repair of cecal pathology with/without proximal diversion - 10 (71.4%)
4 expired (40% mortality)
1 (7.1%) undergone simple appendectomy which on subsequent biopsy showed normal appendix with non-specific inflammation of cecum
Expired
Discharged

13. Final Outcome
6 (42.9%) of 14 operated patients expired

14. Massive hepatomegaly with intact liver abscess
FIGURE
Patient was erroneously diagnosed as ruptured liver abscess with perforation peritonitis
Massive hepatomegaly with intact liver abscess
Cecal Perforation

15. REVIEW OF LITERATURE

16. Causes of cecal pathology presenting with acute abdomen described in literature
Cecal perforation(Albers et al, 2)
I. Trauma
Penetrating
Non-Penetrating
Surgical
Foreign body
II. Obstruction
Distal malignancy
Distal stricture
Volvulus of cecum
Volvulus of sigmoid
Adhesions
Hernia
Vascular accident
III. Inflammatory
Perforation of base of appendix
Blowout of appendiceal stump
Idiopathic typhlitis
Ulcerating enteric disease
Diverticulitis of cecum
IV. Tumors
Carcinoma
Sarcoma
Lymphoma
Miscellaneous

17. Causes of cecal perforation presenting as acute abdomen
Neutropenic enterocolitis/Typhilitis(20,21)
Amyloidosis(22)
Crohn’s disease(23,24)
Ulcerative colitis(25)
Dermatomyositis(26)
Ascariasis(27)
Pancreatic carcinoma(28)
Polyarteritis nodosa(29)
Appendicular perforation at the base of the caecum(30)
Secondary to amebic colitis(3) with or without ruptured/intact liver abscess(4,5,6,7)
Tuberculosis(8,9,10)
Ogilvie’s syndrome(11)
Non-steroidal anti-inflammatory drug (NSAID)-induced(12)
Iatrogenic (Upper GI Endoscopy(13), Lower GI Endoscopy(14))
Antiphospholipid syndrome(15)
Behçet's disease(16)
Foreign body(17,18,19,20)

18. Ileocecal tuberculosis(31)
Cecal volvulus(32,33)
Cecal diverticulitis(34,35)
Perforated cecal diverticulum(36,37)
Isolated cecal necrosis/Spontaneous non-occlusive ischemic colitis(38)
Suppuration of a cecal cyst(39)
Ileocecal xanthogranulomatosis(40)
Cecal carcinoma(41)
Ileocecal intussusception(42)
Fibromatosis(43)
Mobile caecum and ascending colon syndrome(44)
Epiploic appendagitis of caecum(45)
Cecal endometriosis(46)
Neutropenic enterocolitis/Typhilitis(47,48)
Idiopathic typhilitis(49)

19. DISCUSSION

20. Evolution of Management of Cecal Pathologies
Certain common cecal pathologies have a very poor outcome in emergency settings -
Fulminant amoebic colitis (with/without cecal perforation & with/without a ruptured/intact liver abscess)(50)
Neutropenic enterocolitis(51)
Cecal Volvulus(33)

21. Various treatment options in such patients(52)
Conservative
Tube cecostomy
Right hemicolectomy with or without proximal diversion
Primary repair or limited colonic resection with/without proximal diversion.

22. Conservative Management
Indicated in only certain group of patients
Indicated in conditions like
Ileocecal tuberculosis
Localized abscess
Idiopathic typhilitis responding to medications
Amoebic colitis
Certain cases of cecal diverticulitis
Old debilitated patients in whom surgical outcome is expected to be very poor
specially those who are hemodynamically stable in whom a sinister pathology is not suspected

23. Tube Cecostomy Almost an obsolete procedure in adults
Benacci et al.(53) in 1995 defined the use of cecostomy in practice at that time with following indications-
colonic pseudo-obstruction,
distal colonic obstruction,
cecal perforation,
cecal volvulus,
preanastomotic decompression, and
miscellaneous usage
No longer used for any of the above mentioned indications
in current practice
However in today’s era of safer and better procedures like ileostomy, it is

24. Intractable fecal incontinence
Only frequently required indication of cecostomy(open/laparoscopic) today are in children(54)
Intractable fecal incontinence
Myelomeningocele
Anorectal malformations
Caudal regression syndrome
Hirschsprung disease with encephalopathy with convulsions;
Constipation with encopresis
Sacrococcygeal teratoma
Cerebral palsy and acquired megarectum with psychiatric and social disorders

25. Right Hemicolectomy
Still the most commonly practiced procedure by most surgeons even in emergency settings
Gold standard procedure for malignancies of right side of colon
Can also be used in suspicious lesions
Preferred procedure for cecal volvulus(55)
Review of literature suggests that it is
in patients with cecal pathology

26. In emergency setting, a right hemicolectomy with proximal fecal diversion is a wise choice
However, even proximal fecal diversion is associated with high morbidity and mortality
One contributing factor can be the increased operative duration and increased blood loss in already compromised patients

27. Primary Repair/Limited Right Colectomy/Ileocecal Resection with or without Proximal Diversion
Guven et al.(1) writes “Most inflammatory masses are caused by benign pathologies, and usually ileocecal resection is the procedure of choice. Rarely, when surgeons can not determine the pathology clearly and suspect malignancy they can prefer to perform right hemicolectomy or ileocecal resection……Careful intraoperative assessment including examination of the resected specimen is essential to exclude malignancy, which would require right hemicolectomy ”
In their study, 12 patients underwent right hemicolectomy on suspicion basis but none of their biopsy came out to be malignant

28. Singh et al.(57) reports a good survival with conservative surgical resection even in patients with fulminant amoebic colitis which generally have a poor outcome.
Sarkar et al.(56) evaluated the use of ileocecal resection for infection and inflammatory condition of right iliac fossa and found it to be safe option even without proximal diversion

29. Conservative cecal resection with proximal diversion in our experience has a favourable outcome
Seems to be a more plausible option in emergency settings
Shorter operative time
Less loss of bowel
Lesser mortality and better patient outcome

30. CONCLUSION
Fulminant amoebic colitis in association with a ruptured/intact liver abscess seems to be the most common clinical cecal entity presenting as acute abdomen met in our setting
In recent times a paradigm shift has occurred with increased usage of more conservative surgical procedures and we strongly support their usage in emergency settings
Inflammatory and/or infectious conditions should be managed by a more conservative resection or simple primary repair

31. Even in dubious situations, a conservative approach with wide enough clear margins seems to be a smart move if patient is young
However, right hemicolectomy remains the procedure of choice for malignant conditions and cecal volvulus

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38. THANK YOU