Acute fulminant cecal volvulus ischemic bowel with pseudomembranous colitis (Online Only)

Diagnosis

Acute fulminant cecal volvulus ischemic bowel with pseudomembranous colitis </<span class="end-tag" />P
><p><B>PATHOLOGY </<span class="end-tag" />B></<span class="end-tag" />p><P

>An exploratory laparotomy con&#64257;rmed a cecal volvulus, and a right hemicolectomy (with an ileocolonic anastomosis) was performed. Gross examination revealed a segment of small bowel measuring 109 &times; 2.5 cm. The serosal surface showed a focal area of thin intestinal wall measuring 2 &times; 1.5 &times; 0.2 cm. Loss of the mucosal folds was noted. The musocal wall was yellow and necrotic. The large bowel measured 35 cm from the ileocecal valve. The serosal surface was thin, and the mucosal surface showed multiple grayish-yellow plaques (Figure 5). The histologic diagnosis of pseudomembranous colitis with extensive mucosal necrosis extending to the surgical margins of the small bowel was made. </<span class="end-tag" />P

Findings

The radiographic abdominal obstruction series showed &#64257;ndings of distal bowel obstruction. Unenhanced CT imaging of the abdomen and pelvis con&#64257;rmed the plain radiographic &#64257;ndings of multiple dilated loops of small bowel and proximal large bowel with air-&#64258;uid levels (Figure 1). The descending and rectosigmoid colons were collapsed (Figure 2). Particular note was made of the distal ileum with feces within it&ndash;&ndash;the small bowel feces sign (SBFS) (Figure 3), which is commonly associated with distal obstruction. Axial CT images depicted a dilated cecum in an anterior and superior location in the abdomen (Figure 1). Coronal CT images reveal a beaked appearance of the cecum consistent with volvulus (Figure 4). There was associated mesenteric in&#64258;ammatory change within the right lower quadrant. </<span class="end-tag" />P
><P

>The classic plain radiographic presentation of cecal volvulus is that of a massively dilated bowel loop projecting into the left middle or upper abdomen. Occasionally, the &ldquo;coffee bean&rdquo; sign may be seen. The small bowel is typically dilated due to an obstruction with collapse of the distal colon. Contrast enema or multiplanar CT can reveal a beak-like con&#64257;guration de&#64257;ning the point of obstruction. Axial CT images may reveal the whirl sign.<Sup>1 </<span class="end-tag" />Sup></<span class="end-tag" />P

Discussion

Cecal volvulus is a relatively uncommon cause of abdominal obstruction that accounts for 1% to 1.5% of adult intestinal obstruction. Predisposition to torsion results from de&#64257;cient cecal peritoneal &#64257;xation secondary to incomplete intestinal rotation<Sup>1 </<span class="end-tag" />Sup>associated with an aggravating factor. This rare, potentially life-threatening condition often presents with variable clinical and radiographic appearances. Mortality rates up to 40% have been reported in cases of delayed diagnosis.<Sup>1 </<span class="end-tag" />Sup>We describe the &#64257;rst known reported case in the English literature of a cecal volvulus associated with an SBFS. </<span class="end-tag" />P
><P

>Computed tomography has emerged as a vital diagnostic tool in assessing the cause, location, and complications of abdominal obstruction. It also provides critical information for surgical or medical management of disease pathologies. The SBFS is described as particulate fecal-like material within a &gt;2.5 cm dilated loop of small bowel.<Sup>2 </<span class="end-tag" />Sup>Pathologically, this occurs from delayed intestinal motility, absorption, and increased secretions resulting from bowel occlusion.<Sup>3 </<span class="end-tag" />Sup>Traditionally seen on CT in a small bowel obstruction, its prevalence has remained low, approximately 7%.<Sup>3 </<span class="end-tag" />Sup>However, the speci&#64257;city of SBFS is high, and this radiographic sign should alert radiologists to the presence of intestinal obstruction. Since its location is usually proximal to the level of obstruction, the SBFS is also valuable in identifying the transition zone.<Sup>4 </<span class="end-tag" />Sup></<span class="end-tag" />P
><P

>The SBFS is commonly associated with causes of small bowel obstruction. Adhesions account for the majority of etiologies; however, external hernia, tumors, and Crohn&rsquo;s disease have also been reported.<Sup>5 </<span class="end-tag" />Sup>Fecal-like material may be seen in a normal nondilated lumen of the small bowel. This is thought to result from re&#64258;ux of an incompetent ileocecal valve.<Sup>5 </<span class="end-tag" />Sup>Due to its pathogenesis, the SBFS is usually present in a subacute intestinal obstruction. Its presence is an acute event and is one of unique consequence. </<span class="end-tag" />P
><p><B>CONCLUSION </<span class="end-tag" />B></<span class="end-tag" />p><P

>The small bowel feces sign has traditionally been seen in small bowel obstruction. With a high speci&#64257;city for small bowel obstruction, the </<span class="end-tag" />P
><P

>radiographic recognition of SBFS should not exclude cecal pathologies. </<span class="end-tag" />P
<OL
type="1"
><LI

>Consorti ET, Liu TH. Diagnosis and treatment of caecal volvulus.Postgrad Med.2005;81:772-776. </<span class="end-tag" />LI
><LI

>Mayo-Smith WW, Wittenberg J, Bennett GL, et al. The CT small bowel faeces sign: Description and clinical signi&#64257;cance. Clin Radiol.1995;50:765-767. </<span class="end-tag" />LI
><LI

>Catalano O. The faeces sign: A CT &#64257;nding in small-bowel obstruction.Radiologe.1997;37:417-419. </<span class="end-tag" />LI
><LI

>Fuchsj&auml;ger MH. The small-bowel feces sign. Radiology.2002;225: 378-379. </<span class="end-tag" />LI
><LI

>Lazarus DE, Slywotsky C, Bennett GL, et al. Frequency and relevance of the &ldquo;small-bowel feces&rdquo; sign on CT in patients with small-bowel obstruction. AJR Am J Roentgenol. 2004;183:1361-1366.