Hospital: Hospital General Universitario Jose María Morales Meseguer.
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Aut@r o Autores: I. Herves Escobedo, A. Blanco Barrio, G. Pérez Hernández, I. García Tuells, J. Plasencia Martínez, B. Márquez Argente Del Castillo.,
Presentación:
A 35-year-old woman presented with constipation for the last 4 days, abdominal pain and distension. She was institutionalized due to cognitive impairment, alcoholism and eating behavior disorder. She had a surgical history for obstruction due to adhesions. As bowel obstruction was the main concern, an abdominal X-ray was performed followed by an abdominopelvic CT with intravenous contrast. On radiography, there was dilation of the colonic frame with fecal content, distended small bowel loops and a large air bubble in the left upper quadrant. On CT, a voluminous intraperitoneal collection with no clearly defined walls and an air-fluid level could be seen occupying the left abdomen, mimicking an abscess. The colonic frame was distended and full of feces – a very unusual finding in a cecal volvulus setting. There was small bowel dilation with some loops showing a lack of wall enhancement. Extensive ascites was also evident. On a second-reading, the transition points (bird beak sign) and small pneumatosis in the cecal apex were depicted. At surgery, a cecal volvulus with extensive wall necrosis and ischemic ileal loops were found.
Discusión:
Cecal volvulus is an infrequent cause of intestinal obstruction (1%), usually manifesting in the 30-40 age group. Possible causes include defects in the peritoneal fixation of the ascending colon, which allow the proximal colon to be free and mobile, and adhesions that provide a fulcrum for rotation. It manifests with abdominal pain, distension, vomiting and/or constipation. On abdominal radiographs, marked distension of a loop of large bowel can be seen more frequently extending from the right lower quadrant to the epigastrium or left upper quadrant, consistent with the twisted cecum. In most patients (not in our case), obstruction is almost complete with the distal colon usually empty and the small bowel frequently distended. CT has high sensitivity and specificity for the diagnosis. Findings include: abnormally displaced cecum with an air-fluid level, the whirl sign due to the twisting of the mesentery, the bird beak sign (the two limbs of the loop gradually taper and converge at the site of the torsion), and mesenteric engorgement. In case of ischemia, theeffacement of the cecal wall can mimic an abscess. Pneumatosis intestinalis and free air are highly specific signs.
Conclusión:
Cecal volvulus is an infrequent cause of intestinal obstruction (1%), usually manifesting in the 30-40 age group. Possible causes include defects in the peritoneal fixation of the ascending colon, which allow the proximal colon to be free and mobile, and adhesions that provide a fulcrum for rotation. It manifests with abdominal pain, distension, vomiting and/or constipation. On abdominal radiographs, marked distension of a loop of large bowel can be seen more frequently extending from the right lower quadrant to the epigastrium or left upper quadrant, consistent with the twisted cecum. In most patients (not in our case), obstruction is almost complete with the distal colon usually empty and the small bowel frequently distended. CT has high sensitivity and specificity for the diagnosis. Findings include: abnormally displaced cecum with an air-fluid level, the whirl sign due to the twisting of the mesentery, the bird beak sign (the two limbs of the loop gradually taper and converge at the site of the torsion), and mesenteric engorgement. In case of ischemia, theeffacement of the cecal wall can mimic an abscess. Pneumatosis intestinalis and free air are highly specific signs.
Bibliografía:
– Rosenblat JM, Rozenblit AM, Wolf EL, DuBrow RA, Den EL, Levsky JM. Findings of cecal volvulus at CT. Radiology, 2010,256:169–75 – Lee SY, Bhaduri M. Cecal volvulus. CMAJ. 2013,185:684.