SPR Unknown # 78 -- FINAL

Esben Vogelius, M.D.


Publication Date: 2012-10-26

History

19 year old-female with Rett syndrome and chronic constipation presents with abdominal pain and distention.

Findings

Scout radiograph demonstrate a distended large bowel extending to the left upper quandrant. Axial and coronal CT images without contrast demonstrate a distended cecum in the left hemiabdomen with beaking at the site of the mesenteric twist in the mid abdomen. The appendix is seen ectopically located the left upper quadrant. Additionally, there are associated signs of bowel ischemia of the cecum including pneumatosis and interloop mesenteric fluid.

Diagnosis

Cecal Volvulus

Surgical Findings: Cecal volvulus with transmural ischemia of the right colon. A right hemicolectomy was performed with primary anastomosis of the distal illeum to the viable transverse colon.

Discussion

Cecal volvulus is relatively common cause of large bowel obstruction in adults accounting for 20-40% of cases of colonic volvulus. In children it is very rare with only 9 cases described in the literature. There appears to be an association with neurological impairment, chronic constipation and surgical adhesions.

The described imaging findings are similar to those seen in adults. There is marked dilitation of the proximal large bowel with the cecum typically ectopically located in the left upper quadrant. There may be associated findings of small bowel obstruction or signs of ischemia such as pneumatosis. Contrast enema and CT can demonstrate the typical tapering/beaking of the cecum at the site of the mesenteric twist. While non-operative reduction was attempted in the past (either by endoscopy or contrast enema), currently early surgical reduction is recommended due to the high incidence of recurrence and bowel ischemia. If the cecum is viable, cecopexy is performed, alternatively the gangranous segment of bowel is resected and either ileostomy or primary small-bowel large bowel anastomosis is performed.

Files

References

  1. Kirks DR, Swischuk LE, Merten D, Filston H. Cecal volvulus in children. Am J Roentgenol 1981;136(2):419-422.
  2. Mellor M, Drake D. Colonic volvulus in children: value of barium enema for diagnosis and treatment in 14 children. Am J Roentgenol 1994;162(5):1157-1159.
  3. SHAH SS, LOUIE JP, FEIN JA. Cecal volvulus in childhood. Pediatr Emerg Care 2002;18(4):300-302

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