Case of the Month March 2015, Page 4

Answer 3

B) CT abdomen pelvis is the next best test.  Given the rapidity of obtaining and interpreting the study, this test would help to confirm the diagnosis as well as aid in pre-operative planning.
Though a contrast enema would be an adequate exam for the diagnosis, it is a time consuming study and inconvenient/uncomfortable for a patient who is already in pain.

For larger images, please click on  Mrs. J. H. 3 and Mrs. J. H. 4 .

These coronal CT images performed with intravenous  and oral contrast demonstrate definite and extreme dilation of the cecum.  The normal diameter of the cecum is variable, however, most literature agrees that a luminal diameter above 9cm is abnormal.  CT allows the radiologist to definitively identify which segment of bowel is involved, thus leading us to more exact diagnosis.

For a larger image, please click on Mrs. J. H. No. 4 .

 

A finding often encountered is the ‘birds beak sign’ which represents tapering  of bowel  proximal to the dilated cecum.  Though a non specific finding, it further supports the diagnosis of volvulus (white arrow).
A second finding is the ‘whirl sign’, which refers to a spiraling of loops of collapsed bowel as well as of mesenteric fat and engorged vasculature (red arrow).

Discussion

  • Cecal volvulus represents twisting or torsion of the cecum around its own mesentery, which often results in bowel obstruction.  It is a clinical and often surgical emergency, resulting in bowel perforation and peritonitis if unrecognized.
  • Often, patients with cecal volvulus have a past medical history of abdominal surgery or an abdominal or pelvic mass (such as a neoplasm). 
  • The clinical presentation of cecal volvulus is that of proximal large bowel obstruction.   Common clinical histories include colicky abdominal pain, vomiting and abdominal distension.
  • Treatment may include colonoscopic decompression if patient is unfit for surgery. However, surgery more often than not indicated. 
  • In Mrs. J.H’s case, an exploratory laparotomy was immediately performed after the results of the CT scan were conveyed to the surgical team.   A right hemi-colectomy was performed.  The patient’s post operative course was uncomplicated.  She returned home on post operative day 3.

 

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