Images in Emergency Medicine
Article Outline
A 31-year-old woman presented with acute onset of crampy suprapubic and lower abdominal pain associated with vomiting and loose brown stools. She denied hematemesis, urinary symptoms, or fever. The patient had no medical problems and no previous surgeries. She appeared extremely uncomfortable. Vital signs and physical examination results were normal, except for mild tenderness to palpation over the lower half of her abdomen bilaterally, with no peritoneal signs. She was sent for computed tomography (CT) of the abdomen and pelvis.
Diagnosis
Cecal volvulus
The CT revealed a markedly dilated right colon with a thickened, irregular wall and a small amount of free fluid and free air (Figure 1, Figure 2). Cecal volvulus was confirmed during surgery, and ileocectomy was performed. The patient recovered well. Unlike sigmoid volvulus, which occurs more often in elderly patients, incidence of cecal volvulus peaks at age 25 to 35 years. It is associated with hypofixation of the cecum and other parts of the intestine to the posterior abdominal wall,1 which results in hypermobility, often around the ileocecal artery's mesenteric pedicle, and can be provoked by neoplasms, inflammation, or previous surgery. Marathon runners seem to have higher rates of cecal volvulus, possibly because of a thin elastic mesentery. The characteristic “coffee bean” finding is not always seen on plain radiograph. Expeditious evaluation is essential because mortality is 10% to 15% if the bowel is viable and up to 40% if the bowel has infarcted. Although successful reduction by barium enema has been reported, there are higher rates of perforation, and the standard of care is almost always operative, with either cecopexy or right-sided colectomy.2
Figure 1.
Anteroposterior scout film of CT abdomen and pelvis.
Figure 2.
Transverse CT image of abdomen showing dilated right colon with thickened wall. Used with permission of Joanna Law Courter, MD, Emergency Department, Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA.
References
PII: S0196-0644(06)00693-7
doi:10.1016/j.annemergmed.2006.04.020
© 2007 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
