Cecal volvulus

Case contributed by Michael P. Hartung
Diagnosis certain

Presentation

Sudden onset of abdominal pain.

Patient Data

Age: 17
Gender: Male
x-ray
Frontal
Frontal
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Dilated and redundant loops of large bowel in the left and mid abdomen. Distortion of the gastric bubble. No small bowel obstruction. Findings suggestive of volvulus or colonic obstruction. 

ct
This study is a stack
Axial C+ portal
venous phase
This study is a stack
Coronal C+ portal
venous phase
This study is a stack
Sagittal C+ portal
venous phase
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Moderately distended stomach. Dilated, volvulized redundant cecum malpositioned in the left and mid abdomen, with mass effect. No malrotation. No small bowel obstruction. Mesenteric adenopathy. Small amount of free fluid. 

Fusion anomaly left kidney with few areas of scarring of the lower pole moiety. No hydronephrosis. 

Annotated coronal series

ct
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Annotated coronal series following the path of volvulus. Ascending colon, appendix, and terminal ileum are annotated for reference. 

Case Discussion

Unusual case of cecal volvulus in a pediatric patient. Operative note describes redundant cecum which had volvulized 3 turns. This likely occurred due to congenital lack of peritoneal fixation of the cecum, resulting in increased mobility. A few "flimsy adhesions" were noted in the operative note which may have served as a fulcrum for rotation. The annotated coronal images help to identify the relevant anatomy. Evaluating all three planes can be helpful as the key findings can be more apparent in one than another. 

Mesenteric adenopathy can frequently occur when there is congestion/ischemia due to volvulus, as in this case. However, sampling of the lymph nodes was recommended at the time of surgery, as lymphoproliferative disorder is in the differential (final pathology was benign reactive lymphoid hyperplasia). 

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