Imaging Sciences Interesting Cases
Case 205
Wade Hedegard, MD
Clinical Presentation: A 60-year-old female had sudden onset severe abdominal pain.
Imaging Findings: CT exam showed a large U-shaped distended bowel segment in the mid to right abdomen. No associated small bowel obstruction or signs of ischemia, such as mural thickening, infiltration of the mesenteric fat, or pneumatosis, were identified. A possible whirl sign was present with twisting at the base of the cecum and mesentery.
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| Figure 1: Axial CT shows massively dilated cecum in the right mid to lower abdomen. No signs of ischemia. |
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| Figure 2: Coronal CT shows a dilated, twisted cecum. |
Diagnosis: Cecal volvulus
Discussion: Cecal volvulus represents 1-3% of cases of intestinal obstruction in adults. In general, a partial malrotation is necessary for cecal volvulus to occur as the cecum and portions of the ascending colon are involved in the abnormal twisting. Partial malrotation or abnormal peritoneal fixation may be seen in up to 10% of the population. Cecal volvulus commonly presents as an acute abdomen with sudden onset of colicky abdominal pain. Cecal volvulus is a closed-loop obstruction with associated high rates of vascular compromise, ischemia and perforation. Therefore, early diagnosis is key in reducing the high mortality rate (20-40%) reported with this condition. There are two main types of cecal volvulus: axial torsion and cecal bascule. Clinically, there is no difference between the two types, however the radiographic appearances may be different. Axial torsion is the most common form and occurs with a 180-360 degree twist along the longitudinal axis of the ascending colon. There is a high rate of ischemia, gangrene, perforation and associated small bowel obstruction. The cecal bascule form occurs when the cecum folds upon itself anteromedial to the ascending colon creating an occlusion at the site of flexion. The dilated cecum is often displaced into the center of the abdomen and there may or may not be an associated small bowel obstruction.
The diagnosis of cecal volvulus may be made by plain abdominal radiographic findings, however CT or single-contrast barium enema examinations are often helpful in confirming that the dilated viscus is in fact a twisted/folded cecum. CT is also useful in identifying signs of ischemia, which include mural thickening, infiltration of the mesenteric fat, and pneumatosis. The treatment of cecal volvulus is primarily surgical, however reduction of the volvulus has been reported after barium enema examination or with colonoscopic decompression.
References:
- Perret RS, Kunberger LE. Case 4: Cecal volvulus. AJR Am J Roentgenol. 1998 Sep;171(3):855, 859, 860. [PubMed]
- Moore CJ, Corl FM, Fishman EK. CT of cecal volvulus: unraveling the image. AJR Am J Roentgenol. 2001 Jul;177(1):95-8. [PubMed]
- Delabrousse E, Sarliève P, Sailley N, Aubry S, Kastler BA. Cecal volvulus: CT findings and correlation with pathophysiology. Emerg Radiol. 2007 Nov;14(6):411-5. [PubMed]