Cecal volvulus

1. Abdomen Case 4

2. 56 year old female with acute onset of severe abdominal pain and nausea . Also complaining of distended right sided abdomen. She has no medical history, otherwise healthy female. History & Physical T 98.6 P 100 R 16 BP 120/80 Gen: normal appearing female who appears to be in pain HEENT: PERRLA, oropharynx clear, NC/AT head CV: RRR no m/r/g Pulm: CTAB Abd: distended in Right abd > Left abdomen, TTP diffusely, greater in Right abdomen, Ext: 2+ pulses, no c/c/e

3. Abdominal X-Ray

4. Cecal Volvulus Maintain Haustral Markings Can usually see haustra Arise in RLQ and point toward LUQ Kidney-shaped distended cecum Greater than 9cm Caput cecum usually rotates into mid abdomen or left upper quadrant Air-filled appendix Little gas in rest of colon

5. IV Fluid Resuscitation NPO Only 10-15% can be detorsed with Colonoscopy Surgical Consultation for definitive management Broad Spectrum Antibiotics if signs of peritonitis, ischemic bowel, or sepsis ED Management

6. Misnomer: It does not just involve the cecum . the entire ascending colon lacks normal fusion of mesentery to posterior abdominal wall and you get cecocolonic twisting around the ileocolic vascular pedicle. Depending on the initial position and the length of mobile right colon, the cecum can be found anywhere in the abdomen but often found in LUQ. >9 cm is considered a dilated cecum . >12cm concern for impending perforation. Conservative management (No surgery) approaches 100% mortality rate; vascular compromise occurs early. Pearls

7. Additional Images Point of torsion may be identified by an area of cone like narrowing, outlined by gas. Cecal Volvulus

8. http://radiopaedia.org/articles/caecal_volvulus http://www.learningradiology.com/archives05/COW%20152-Cecal%20Volvulus/cecalvolvuluscorrect.htm Schwartz, David. Emergency Radiology. 2000. pg 527-529. Tintanelli’s Emergency Medicine: A Comprehensive Study Guide. Chapter 79 Intestinal Obstruction References