Acute fulminant cecal volvulus ischemic bowel with pseudomembranous colitis (Online Only)
Published Date: November 12, 2007
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 confirmed a cecal volvulus, and a right hemicolectomy (with an ileocolonic anastomosis) was performed. Gross examination revealed a segment of small bowel measuring 109 × 2.5 cm. The serosal surface showed a focal area of thin intestinal wall measuring 2 × 1.5 × 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 findings of distal bowel obstruction. Unenhanced CT imaging of the abdomen and pelvis confirmed the plain radiographic findings of multiple dilated loops of small bowel and proximal large bowel with air-fluid levels (Figure 1). The descending and rectosigmoid colons were collapsed (Figure 2). Particular note was made of the distal ileum with feces within it––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 inflammatory 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 “coffee bean” 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 configuration defining 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 deficient cecal peritoneal fixation 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 first 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 >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 specificity 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’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 reflux 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 specificity 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"
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