OmarPardesi,HMSIII

GillianLieberman,MD

August2011

CecalVolvulus:CasePresentation
andReviewofCTFindings
OmarPardesi,HarvardMedicalSchoolYearIII
GillianLieberman,MD

OmarPardesi,HMSIII
GillianLieberman,MD

OurPatientLD:History&Physical
HPI:
28y.o.femalepresentswithdiffuseabdominal
pain;begansuddenlythisAM,worstinLLQ.
Beganmensesyesterday
HadnormalBMwithoutrelief
Deniesfever,chills,vaginaldischarge,
hematuria,dysuria,diarrhea,melena,or
hematochezia.

OmarPardesi,HMSIII
GillianLieberman,MD

PatientLD:History&Physical(cont.)
PMH:Rupturedovariancyst
Meds:Oralcontraceptives
Social:Notcurrentlysexuallyactive
Pertinentexamfindings:abdomensoftand
mildlydistended,moderatelytenderinall
quadrantswithoutreboundorguarding;
normalbowelsounds.

OmarPardesi,HMSIII
GillianLieberman,MD

InitialDifferential:BroadCategories
Gynecologic(ovariantorsion,ectopic
pregnancy,menstrual,etc.)
Infection(gastroenteritis,pyelonephritis,etc.)
Primaryabdominalpathology(diverticulitis,
ischemicbowel,intussusception,etc.)

OmarPardesi,HMSIII
GillianLieberman,MD

PatientLD:InitialLabs

CBC:WBC5.2,Hct39.9,Plt223
HCGnegative
AST26,ALT16,AlkPhos78,Tbili0.2,Lipase32
UAnegative

OmarPardesi,HMSIII
GillianLieberman,MD

PatientLD:InitialImaging
LDhadanabdominal+pelvicultrasound
Showednormalovaries,butlargeamountof
freefluidintherightpelvis
Nextimagingtesttoworkupabdominalpain
andfreefluid:CToftheabdomen.
WewillbrieflyviewimagesfromthisCTnow,but
willrevisitthefindingsinmoredetaillaterinthis
presentation.
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OmarPardesi,HMSIII
GillianLieberman,MD

PatientLD:AbdominalCTScan1

Dilatedcecum,
locatedinLUQ
BlueBox:Transition
point

C CTabdomen,axialview
7
PACS,BIDMC

OmarPardesi,HMSIII
GillianLieberman,MD

LD:AbdominalCTScan2

WhirlSign

C CTabdomen,sagittalview
PACS,BIDMC

OmarPardesi,HMSIII
GillianLieberman,MD

ThesefindingsonCTarediagnosticofcecal
volvulus;wewillnowproceedtobrieflyreview
theanatomyofcecalvolvulus.

Wewillthenrevisittheseimagesinorderto
reviewimportantCTfindingsofcecalvolvulus.

OmarPardesi,HMSIII
GillianLieberman,MD

CecalVolvulus:Definitionand
Illustration
Definedastorsionof
thebowelaroundits
ownmesentery
Thisimageshows
cecumtwistingand
invertingupward,
tanglingwithileum.
MooreCJetal.CTofCecalVolvulus:UnravelingtheImage.AJR. 2001;177:9598.
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OmarPardesi,HMSIII
GillianLieberman,MD

SitesofVolvulusintheBowel
Cecumaccountsfor1140%
ofintestinalvolvulus
Cecalvolvulususuallyonly
occursinpatientswitha
developmentalfailureof
fixationofproximalright
colontoperitoneum
Morecommoninyounger
patients
Sigmoidcolonismost
commonsiteofvolvulus
Caplan,GeralynM.DigestiveSystemStudyGuide.OwensboroCommunity&TechnicalCollege:Anatomy&PhysiologyII.
http://legacy.owensboro.kctcs.edu/gcaplan/anat2/Study%20Guides/APII%20Study%20Guide%20K%20Digestive%20Anatomy.htm.

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OmarPardesi,HMSIII
GillianLieberman,MD

PriortoreviewingCTfindingsofcecalvolvulus,
wewillviewanabdominalplainfilmfroma
companionpatientanddiscussthediagnostic
utilityoftheplainfilmforcecalvolvulus.

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OmarPardesi,HMSIII
GillianLieberman,MD

CompanionPt1:AbdominalPlainFilm

Majorfindings:
Focalloopofairdistended
bowel
Prominentsmallbowel
(2.82.9cm)

SupineAbdominalPlainFilm
PACS,BIDMC

13

OmarPardesi,HMSIII
GillianLieberman,MD

PlainFilms:DiagnosticUtility
Inonelargeseries,plainfilmsuggested
diagnosisofcecalvolvulus<50%ofthetime.
1/3ofcaseswerethoughttobesmallbowel
obstruction.
Whymightthisbe?Letusbrieflyconsidera
differentialdiagnosisbasedontheseplainfilm
findings.
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OmarPardesi,HMSIII
GillianLieberman,MD

PartialDifferentialDiagnosis
SuggestedbyPlainFilmFindings
Massivelydilatedloopof(large)
bowel:
Distalobstruction
Functionalobstruction
Paralyticileus(nonobstructive
distention)
Scleroderma,dermatomyositis
Toxicmegacolon
Congenital/pediatric

Fordistendedsmallbowel,add:
Drugeffect
Mesentericischemia
Postvagotomy
Celiacsprue
Othermalabsorptivesyndromes

Inpartbecauseofthisbroaddifferential,plain
filmsareoflimitedutilityindiagnosingvolvulus,
andCTispreferable.
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OmarPardesi,HMSIII
GillianLieberman,MD

ImportantCTFindingsofVolvulus
Severececaldistention(>10cm)
Whirlsign,transitionpoint(s)
Dilationandfecalizationofsmallbowel
Decompressionofcolon
Splitwallsign

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OmarPardesi,HMSIII
GillianLieberman,MD

PtLD:WhirlSignonCT
WhirlSign/HurricaneSign
Animportantdefiningsignof
volvulus
Twistedloopsofboweland
branchingmesentericvessels
createswirlingstrandsofsoft
tissueattenuationwithina
backgroundofmesentericfat
attenuation.
KhuranaB,Radiology(2003);
226:6970.
C CTabdomen,sagittalview
PACS,BIDMC

17

OmarPardesi,HMSIII
GillianLieberman,MD

PACS,BIDMC

PtLD:TransitionPoints

PACS,BIDMC

SequentialaxialC CTimagesshowingtransitionpointsinsmallandlargebowel.
Left(arrow):proximaldilatedcecumtransitioningtonarrowed,collapseddistalcolon.
Right:proximalsmallbowel(arrow)enteringintotwist(box)withlargebowel.

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OmarPardesi,HMSIII
GillianLieberman,MD

CompanionPt1:WhirlSign(AxialView)

Dilatedcecum,seen
hereclosertomidline
BlueBox:WhirlSign

Ourcompanionpatientprovides
anotherexampleofthewhirlsign.

C CTabdomen,axialview
PACS,BIDMC

19

OmarPardesi,HMSIII
GillianLieberman,MD

CompanionPt1:WhirlSign(Coronal
View)
Thiscoronalviewof
ourcompanion
patientclearly
demonstratesthe
whirlsign,with
distendedlarge
bowelenteringinto
thetwist.
C CTabdomen,coronalview
PACS,BIDMC

20

OmarPardesi,HMSIII
GillianLieberman,MD

ImportantCTFindingsofVolvulus:
Progress
Severececaldistention(>10cm)
Whirlsign,transitionpoint(s)
Dilationandfecalizationofsmallbowel
Decompressionofcolon
Splitwallsign

21

OmarPardesi,HMSIII
GillianLieberman,MD

CompanionPt1:FecalizedSmallBowel

FecalizedSmallBowel,suggesting
distalobstruction

C CTabdomen,coronalview
PACS,BIDMC

22

OmarPardesi,HMSIII
GillianLieberman,MD

CompanionPt2:DecompressedColon
Here,wesee
decompressedright
colondistaltothe
pointofvolvulus.
Oralcontrasthasnot
reachedthisloop,
anditappears
collapsed.
RosenblatJM,AMRozenblit,ELWolf,etal.FindingsofCecalVolvulusatCT.
Radiology.2010;256:169175.

23

OmarPardesi,HMSIII
GillianLieberman,MD

CompanionPt3:SplitWallSign
SplitWallSign:
Apparentsplittingof
colonwallby
mesentericfat.
Causedbyadjacent
mesentericfat
invaginationina
twistedloopof
bowel.
RosenblatJM,AMRozenblit,ELWolf,etal.FindingsofCecalVolvulusatCT.
Radiology.2010;256:169175.

24

OmarPardesi,HMSIII
GillianLieberman,MD

ImportantCTFindingsofVolvulus:
Complete
Severececaldistention(>10cm)
Whirlsign,transitionpoint(s)
Dilationandfecalizationofsmallbowel
Decompressionofcolon
Splitwallsign

25

OmarPardesi,HMSIII
GillianLieberman,MD

OurPatientLD:ClinicalOutcome
LDhadanemergent
exploratorylaparotomy,
withnosignsofbowel
ischemia
Ileocolectomywas
performedwithout
complication
LDrecoveredwelland
wasdischargedonpost
operativeday4.

Companionpatientssurgicalspecimen

Habre J,NSautotVial,CMarcotte etal.Caecal Volvulus.AmJSurg.2008;196:e48e49.

26

OmarPardesi,HMSIII
GillianLieberman,MD

References

Caplan,Geralyn M.DigestiveSystemStudyGuide.OwensboroCommunity&Technical
College:Anatomy&PhysiologyII.
http://legacy.owensboro.kctcs.edu/gcaplan/anat2/Study%20Guides/APII%20Study%20G
uide%20K%20Digestive%20Anatomy.htm.Accessed8/20/11.
Habre J,NSautotVial,CMarcotte etal.Caecal Volvulus.AmJSurg.2008;196:e48e49.
KatzDS,BYam,JJHinesetal.UncommonandUnusualGastrointestinalCausesofthe
AcuteAbdomen:ComputedTomographic Diagnosis.SeminarsinUltrasoundCTandMRI.
2008;29:386398.
Khurana B.TheWhirlSign.Radiology.2003;226:6970.
MooreCJ,FCorl,EFishman.CTofCecal Volvulus:UnravelingtheImage.AJR. 2001;
177:9598.
PetersonC,JAnderson,AKHaraetal.Volvulus oftheGastrointestinalTract:Appearance
atMultimodalityImaging.RadioGraphics.2009;29:12811293.
Reeder,MauriceM.ReederandFelsons Gamuts inRadiology:ComprehensiveListsof
ImagingDifferentialDiagnoses.Fourthedition.NewYork:Springer;2003.
http://rfs.acr.org/gamuts/data/index.html.Accessed8/20/11.
Rosenblat JM,AMRozenblit,ELWolf,etal.FindingsofCecal Volvulus atCT.Radiology.
2010;256:169175.
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OmarPardesi,HMSIII
GillianLieberman,MD

Acknowledgements
GillianLieberman,MD
Samir Shah,MD
EmilyHanson

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