CASE 17063 Published on 25.11.2020

The black swan among volvuli

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Dr. Aswathi A. S., Dr. Devarajan, Dr. P. Rajan, Dr. Naufal Perumpalath, Dr. Saanida M. P., Dr. Juvaina P., Dr. Rahul K. R.

Government Medical College, Kozhikode, Kerala, India

Patient

37 years, female

Categories
Area of Interest Abdomen, Anatomy, Colon ; No Imaging Technique
Clinical History

A 37-year-old female with history of abdominal pain, distension and constipation for 4 days duration. She is having intellectual disability. No other comorbidities.

Imaging Findings

Abdominal x-ray, erect view: showed dilated small bowel loops with multiple air-fluid levels (Fig. 1)

CT scanning was performed at 120kVp, and the amperage setting varied between 60 and 80mA. The CT images were reconstructed at 5mm section thickness

Tomogram: showed dilated caecum and small bowel loops, with multiple foreign bodies within the dilated caecum (Fig. 2)

Plain and Contrast-enhanced CT: showed closed-loop dilation of caecum. The two limbs of the looped obstruction noted gradually tapering and converging at the site of the torsion (Fig. 3).

At the torsion site, twisting of intestinal loops, vessels and mesenteric fat noted (whirl sign) in ante clockwise direction (Fig. 4)

 The dilated caecum showed air-fluid level and Multiple foreign bodies. The wall appeared edematous. Adjacent mesentery showed fat stranding and multiple enlarged lymph nodes. Ileal and jejunal loops appear dilated and large bowel loops appear collapsed (Fig. 5)

Discussion

Background

Caecal volvulus (CV) is the torsion of a mobile caecum around its mesentery, which often results in a closed-loop obstruction and a distended caecum. The terminal ileum is usually twisted along with the caecum.[1]

Three forms of CV have been described: a) axial-type, b) loop-type and c) caecal bascule [1]

The axial type in which the caecum rotates along its vertical axis, the distended caecum remains in the lower part of the abdomen, near the right side. The loop type in which the caecal rotation is associated with an inversion secondary to an anterior displacement. Furthermore, the distended caecum is found in the upper part of the abdomen, near the left side. Finally, the caecal bascule- no twist occurs in this case, but anterior folding of the caecum, without rotation, is observed and there is no whirl sign in any axis. The distended caecum is found in the upper part of the abdomen, but it remains on the right side. [1]

Clinical Perspective

Patients with this condition may present with highly variable clinical presentations ranging from intermittent, self-limiting abdominal pain to acute abdominal pain associated with intestinal strangulation and sepsis (determined by the pattern, severity, and duration of the intestinal obstruction). [2]

Imaging Perspective

Radiographic and CT Signs of Caecal Volvulus

Radiographic signs are:   

Severe caecal distention, Coffee bean sign, Caecal haustra, Caecal apex in LUQ, Distal colon decompression and Small-bowel distention 

 CT signs are:

Severe caecal distention, Caecal apex in LUQ, Distal colon decompression, Small-bowel distention, Whirl sign, Ileocaecal twist, Transition points, X-marks-the-spot sign and Split-wall sign. [4]   

Outcome

Optimal patient management consists of metabolic support, early diagnosis, and operative therapy[2]. If there is intestinal gangrene, resection is inevitable. In non-gangrenous cases, it is sufficient to simply untwist the cecum or additionally to perform a cecopexy by fixing it to the abdominal wall, and laparoscopic technique is preferred[3]. 

In our case –caecum twisted around its mesenteric axis for about one and a half turns, and the bowel loops were ischemic (fig.6) so patient underwent right hemicolectomy. 

Perioperative mortality of CV is approximately 0–40% depending on the bowel viability or gangrene, as well as the type of the therapeutic procedure. Early diagnosis is essential to reduce the high mortality rate. [3]

Differential Diagnosis List
Acute caecal volvulus, loop-type
Final Diagnosis
Acute caecal volvulus, loop-type
Case information
URL: https://www.eurorad.org/case/17063
ISSN: 1563-4086
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