Sigmoid volvulus complicated by bowel ischemia

Case contributed by RMH Core Conditions
Diagnosis certain

Presentation

Small bowel obstruction.

Patient Data

Age: 80
Gender: Male

There is extensive distension of the colon, which measures up to 10 cm in diameter at the cecum. This extends to just distal to the rectosigmoid anastomosis, where there is a swirled appearance to the residual rectum suggesting volvulus.

No pneumoperitoneum or free fluid. Gas outlining the bowel wall of the cecum to hepatic flexure represents gas against fecal matter. No portal venous gas.

W hilst the majority of the colon, including the cecum demonstrates normal mural enhancement the distal sigmoid colon and immediately proximal to the rectosigmoid anastomosis ( for a length of approximately 5 cm ) shows no or minimal mural enhancement raising the possibility of distal sigmoid ischemia.

There is mild fecalization of the distal small bowel, otherwise the small bowel is normal. A nasogastric tube has been inserted, with the tip in the mid duodenum.

A 2.5 x 1.5 cm water density subcutaneous lesion is seen just superior to the umbilicus, possibly a seroma related to the previous laparotomy incision. Bilateral renal cysts again noted, the largest measuring 7.5 cm and the right kidney lower pole. The prostate is enlarged, measuring 6.1 x 5.5 x 6.0 cm. The liver, spleen, pancreas, gallbladder and adrenals are unremarkable.

Conclusion:

Large bowel obstruction just distal to the rectosigmoid anastomosis secondary to rectosigmoid volvulus. The cecum is at risk of ischemia given and it is distended to 10 cm. There are imaging findings suggestive of ischemia of the distal portion of the sigmoid immediately proximal to the rectosigmoid anastomosis, as outlined above. No evidence of perforation.

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