Clinical presentation: 65 year old male presented to the emergency department with abdominal pain. Abdominal series and CT of the abdomen and pelvis was performed.

Image 1: Supine film showing a markedly dilated air filled loop of bowel in the midabdomen.

Image 2-5: Axial and coronal CT images of the abdomen showing dilated loop of bowel filled with air and fecal material in the upper abdomen. Cecum is not seen in the expected RLQ. Characteristic ‘whirl sign of twisted mesenteric vessels’ (arrow on the coronal image).

Img2

A colonic volvulus occurs when a part of the colon twists on its mesentery, resulting in acute, subacute, or chronic colonic obstruction

Imaging findings:
Radiography: Dilated air-filled cecum in LUQ

1. Single, long air-fluid level
2. Medially placed ileocecal valve → soft tissue indentation → kidney or coffee bean-shaped gas-filled cecum
3. Markedly distended gas or fluid-filled small bowel (SB); little gas in distal colon

Fluoroscopic Findings

1. Point of torsion at mid-ascending colon ("beaking")

CECT

1. "Beaking": Progressive tapering of afferent & efferent limbs leading into twist
2. “Whirl” sign: Tightly twisted mesenteric vessels

1. Best imaging tool: Contrast enema or CT

Epidemiology: 1/3rd of colonic volvulus cases, 2-3% of colonic obstructions

1. Associated abnormalities: Malrotation, long mesentery
2. Gross Pathologic & Surgical Features
3. Twisted, markedly dilated segment
4. Microscopic Features
5. Localized mucosal ischemic & necrotic changes
6. Etiology
1. Congenital defect in right colon attachment
2. Postpartum ligamentous laxity, mobile cecum
3. Colon distension (pseudo-obstruction, distal tumor, endoscopy, enema, post-operative ileus)
4. Chronic constipation, laxative use

D/D:

Sigmoid Volvulus
Acute Ileus
Distal Colon Obstruction
Toxic Megacolon
Ogilvie Syndrome
Cecal Bascule

Natural History & Prognosis

1. Complications: Ischemia, necrosis, perforation
2. Prognosis: Good if uncomplicated, poor if complicated
3. Treatment
4. Colonoscopy to reduce volvulus
5. Complicated cases: Surgery (cecopexy, cecostomy, resection)

Cecal Bascule:

• Variant of cecal volvulus termed a "cecal bascule," which occurs when the cecum folds anteriorly without any torsion. Cecal bascule is often seen as a dilated loop in the mid abdomen
• No beaking seen on the enema

1. Stat Dx
2. Cecal volvulus: eMedicine Radiology Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR, Consultant Radiologist and Honorary Professor, North Manchester General Hospital Pennine Acute NHS Trust, UKCoauthor(s): Sumaira MacDonald, MBChB, PhD, MRCP, FRCR