By Bilal Mujtaba, MD, Brian Bianco, DO, and Najda A. Mujtaba, MD
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.
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