Southern Illinois University School of Medicine Springfield, IL
Tharani Sundararajan, MD1, Madhusudhanan Jegadeesan, MBBS, MS, MCh2, Kevin J. Coakley, MD1, Abdul Swied, MD1, Zafar Quader, MD1, Ramprasad Jegadeesan, MD1; 1Southern Illinois University School of Medicine, Springfield, IL; 2Apollo Hospitals, Madurai, Tamil Nadu, India
Introduction: Cecal volvulus constitute 25-40% of all the colonic volvulus. Anatomical predispositions such as embryogenic failure of parietal fixation of ileocolonic region, pelvic surgery, chronic constipation, pregnancy are commonly recognized etiologies. We report a case of cecal volvulus in a patient with irritable bowel syndrome-constipation (IBS-C) associated with linaclotide use with no predisposing surgical or anatomical risk factors.
Methods: 50 year female with a past medical history of COPD, GERD, IBS-C, migraine, chronic back pain and depression presented to the emergency department with an acute onset of abdominal pain, nausea and vomiting for the past 24 hours. She denied any hematochezia, melena or hematemesis. She denied any recent trauma or abdominal surgery. She denied any recent alcohol or illicit drug usage. She was an active smoker and used prescription marijuana daily. She was on linaclotide 145 mcg twice daily for the past 10 months for IBS-C and no other significant new medications were noted. On examination, she was afebrile and vitals were stable. Abdominal palpation revealed diffuse tenderness with guarding concerning for peritonitis. CT abdomen/pelvis revealed cecal volvulus with high grade small bowel obstruction along with bowel wall thickening and small bowel ischemia. Patient was taken for emergent exploratory laparotomy which reveled cecal volvulus and a right hemicolectomy with ileo-colonic anastomosis was performed. Peri-operative and post-operative period was uneventful and the patient was discharged safely in four days. Discussion: Linaclotide is a selective guanylate cyclase-C agonist approved for IBS-C and chronic idiopathic constipation. It improves gut motility by increasing luminal fluid secretion and accelerating transit of intestinal contents. Based on a clinical review from centers for drug evaluation and research, a case of cecal volvulus was associated with linaclotide use. We report a second case of cecal volvulus with possible association with linaclotide use in our patient. She did not have any other predisposing anatomical or surgical risk factors for cecal volvulus other than IBS-C. Patient was informed about the possible association with linaclotide use and was advised to stop the medication to prevent any possible recurrence. Clinicians should be aware of this possible association with linaclotide use given that it can cause catastrophic complications.
Image 1: CT abdomen and Pelvis showing dilated malpositioned cecum secondary to volvulus (red arrow), compressed transverse colon (yellow arrow) and dilated small bowel (pink mark).
Disclosures: Tharani Sundararajan indicated no relevant financial relationships. Madhusudhanan Jegadeesan indicated no relevant financial relationships. Kevin Coakley indicated no relevant financial relationships. Abdul Swied indicated no relevant financial relationships. Zafar Quader indicated no relevant financial relationships. Ramprasad Jegadeesan indicated no relevant financial relationships.