Presentation
Five day history of abdominal pain and lack of bowel action.
Patient Data
The x-rays taken in the ED show a distended loop of large bowel with a liquid-air level between the right diaphragm and the liver. Furthermore they demonstrate some distended loops of the distal small bowel.
There is dilated gas-filled bowel in the right upper quadrant. Bowel gas cannot be seen in the rest of the colon.
The axial CT-slices clearly reveal a small bowel obstruction due to a cecal volvulus. Notice the classic "whirl sign".
Case Discussion
The first x-rays were misinterpreted in the ED as free abdominal air.
During subsequent laparascopy the surgeons couldn't find any site of perforation but did identify a distended loop of large bowel between the right lateral diaphragm and the liver. They suggested a stenosing process of the transverse colon.
The CT reveals, as the main finding, a cecal volvulus with the classic "whirl sign" and some distended, fluid filled small bowel loops with air-fluid levels, consistent with an obstructive small bowel ileus.
The free abdominal air on the CT is attributable to the recent laparascopy.
Incidental findings include:
- cosolidation in the middle lobe
- atelectasis of the right lower lobe
- partial duplication of the right collecting system (ureter fissus)