Cecal volvulus with pneumatosis coli

Case contributed by Dr Yair Glick


Right lower abdominal pain - appendicitis?

Patient Data

Age: 50 years
Gender: Female

Scout view
Grossly dilated bowel loop arising from the right lower abdomen, projected onto the lumbar spine and leftwards. Dilated contiguous small bowel loop (terminal ileum?). Picture suggestive of cecal volvulus.

The patient is most probably a smoker, as evidenced by a lighter in her right trouser (pants) pocket.

CT abdomen
Torsed cecum pulling a normal gas-filled appendix into the "whirlpool". The cecum is dilated, reaches the level of T12 and contains a copious amount of intramural gas. The terminal ileum is dilated. Thickened wall/prominent valvulae conniventes of the proximal jejunum.

Polycystic kidneys (known ADPKD), left kidney enlarged with cortical thinning.
Numerous tiny hypodense foci throughout the liver; in light of the ADPKD, most probably cysts.

Case Discussion

The patient was promptly ushered to the operating room, where she underwent a right hemicolectomy.

From the surgical report: Cecal volvulus. Signs of ischemia in the terminal ileum and ascending colon.

The surgeon told the radiologist that he felt and heard crepitations when handling the cecum, thereby confirming pneumatosis coli.

Pathology report:

Colon (right colectomy): ischemic necrosis involving the entire wall thickness, with edema and congestion. Fresh hemorrhages in the submucosa and periserosal fat. Viable proximal and distal resection margins.
Appendix: no remarkable changes seen.
Lymph nodes (pericolonic): Fifteen lymph nodes, hyperplasia, congestion.
Omentum: congestion of blood vessels, fresh hemorrhages.

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