The Journal of Emergency Medicine, Vol. 47, No. 3, pp. e77–e78, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2013.11.128
Visual Diagnosis in Emergency Medicine
FEMALE PATIENT WITH ABDOMINAL PAIN Steven Foy, MD Division of Emergency Medicine, Stanford University, Stanford, California Reprint Address: Steven Foy, MD, Division of Emergency Medicine, Stanford University, 300 Pasteur Drive, Alway Building, Room M121, Stanford, CA 94305
in the right lower quadrant. Her laboratory studies, including a complete blood count, comprehensive metabolic panel, urinalysis, urine pregnancy, and lactic acid, were unremarkable. Computed tomography (CT) scan of the abdomen with I.V. and oral contrast was performed.
CASE REPORT A 51-year-old postmenopausal woman with no significant medical or surgical history presented to the emergency department 6 hours after she developed severe right lower quadrant abdominal pain, nausea, and vomiting. She was afebrile and hemodynamically stable. The abdomen was diffusely tender, with maximal tenderness
DISCUSSION The CT scout film (Figure 1) demonstrated a prominent distended cecum in the midline of the abdomen. This is better appreciated in the axial image (Figure 2) and the
Figure 1. Computed tomography scout film of the abdomen and pelvis demonstrating the prominent distended cecum (arrow) in the midline of the abdomen.
Figure 2. Computed tomography axial slice of the abdomen and pelvis demonstrating anterior midline displacement of the cecum (arrow) with a large amount of fecal material.
RECEIVED: 30 August 2013; ACCEPTED: 17 November 2013 e77
e78
S. Foy
which can lead to massive distention, strangulation, and perforation. The clinical presentations of all types of cecal volvulus are similar. The peak age of onset is 30 60 years, where as sigmoid volvulus generally affects elderly individuals (2). Patients complain of abdominal pain, distention, nausea, and vomiting. Notably absent are the classic bird’s beak, coffee bean, and whirl signs; making this diagnosis easy to miss (2,3). CT scan may show a massively distended cecum in the anterior abdomen or anterior to the ascending colon with decompressed colon distally, wall thickening, fat stranding, pneumatosis intestinales, and intraperitoneal free air (2–4). Urgent surgical consultation is required and treatment is cecectomy or decompression and cecopexy. In this case, in the operating room, the cecum was found to have folded across a single constricting band, as is the usual case, and a cecectomy with primary re-anastamosis was performed (4,5). The patient recovered well postoperatively.
REFERENCES Figure 3. Coronal reconstruction, again demonstrating displacement of the cecum (arrow) with a large amount of fecal material, but no oral contrast material distal to the cecum.
coronal reconstruction (Figure 3), which demonstrate a large distended cecum that is displaced in the anterior abdomen. Findings are consistent with cecal bascule. Cecal bascule is a subtype of cecal volvulus in which the cecum folds anteriorly rather than rotating around the mesentery (1). Folding of the cecum causes obstruction,
1. Bobroff LM, Messinger NH, Subbarao K, Beneventano TC. The cecal bascule. Am J Roentgenol Radium Ther Nucl Med 1972;115: 249–52. 2. Moore CJ, Corl FM, Fishman EK. CT of cecal volvulus: unraveling the image. AJR Am J Roentgenol 2001;177:95–8. 3. Delabrousse E, Sarlie`ve P, Sailley N, Aubry S, Kastler BA. Cecal volvulus: CT findings and correlation with pathophysiology. Emerg Radiol 2007;14:411–5. 4. Lazar DA, Cohen SA, Evora DK, Losasso BE, Bickler SW. Cecal bascule in a child: an unusual cause of postoperative bowel obstruction. J Pediatr Surg 2012;47:609–11. 5. Rozycki GS. Special feature: image of the month. Cecal bascule. Arch Surg 2001;136:835–6.
http://dx.doi.org/10.1016/j.jemermed.2013.11.128
Visual Diagnosis in Emergency Medicine
FEMALE PATIENT WITH ABDOMINAL PAIN Steven Foy, MD Division of Emergency Medicine, Stanford University, Stanford, California Reprint Address: Steven Foy, MD, Division of Emergency Medicine, Stanford University, 300 Pasteur Drive, Alway Building, Room M121, Stanford, CA 94305
in the right lower quadrant. Her laboratory studies, including a complete blood count, comprehensive metabolic panel, urinalysis, urine pregnancy, and lactic acid, were unremarkable. Computed tomography (CT) scan of the abdomen with I.V. and oral contrast was performed.
CASE REPORT A 51-year-old postmenopausal woman with no significant medical or surgical history presented to the emergency department 6 hours after she developed severe right lower quadrant abdominal pain, nausea, and vomiting. She was afebrile and hemodynamically stable. The abdomen was diffusely tender, with maximal tenderness
DISCUSSION The CT scout film (Figure 1) demonstrated a prominent distended cecum in the midline of the abdomen. This is better appreciated in the axial image (Figure 2) and the
Figure 1. Computed tomography scout film of the abdomen and pelvis demonstrating the prominent distended cecum (arrow) in the midline of the abdomen.
Figure 2. Computed tomography axial slice of the abdomen and pelvis demonstrating anterior midline displacement of the cecum (arrow) with a large amount of fecal material.
RECEIVED: 30 August 2013; ACCEPTED: 17 November 2013 e77
e78
S. Foy
which can lead to massive distention, strangulation, and perforation. The clinical presentations of all types of cecal volvulus are similar. The peak age of onset is 30 60 years, where as sigmoid volvulus generally affects elderly individuals (2). Patients complain of abdominal pain, distention, nausea, and vomiting. Notably absent are the classic bird’s beak, coffee bean, and whirl signs; making this diagnosis easy to miss (2,3). CT scan may show a massively distended cecum in the anterior abdomen or anterior to the ascending colon with decompressed colon distally, wall thickening, fat stranding, pneumatosis intestinales, and intraperitoneal free air (2–4). Urgent surgical consultation is required and treatment is cecectomy or decompression and cecopexy. In this case, in the operating room, the cecum was found to have folded across a single constricting band, as is the usual case, and a cecectomy with primary re-anastamosis was performed (4,5). The patient recovered well postoperatively.
REFERENCES Figure 3. Coronal reconstruction, again demonstrating displacement of the cecum (arrow) with a large amount of fecal material, but no oral contrast material distal to the cecum.
coronal reconstruction (Figure 3), which demonstrate a large distended cecum that is displaced in the anterior abdomen. Findings are consistent with cecal bascule. Cecal bascule is a subtype of cecal volvulus in which the cecum folds anteriorly rather than rotating around the mesentery (1). Folding of the cecum causes obstruction,
1. Bobroff LM, Messinger NH, Subbarao K, Beneventano TC. The cecal bascule. Am J Roentgenol Radium Ther Nucl Med 1972;115: 249–52. 2. Moore CJ, Corl FM, Fishman EK. CT of cecal volvulus: unraveling the image. AJR Am J Roentgenol 2001;177:95–8. 3. Delabrousse E, Sarlie`ve P, Sailley N, Aubry S, Kastler BA. Cecal volvulus: CT findings and correlation with pathophysiology. Emerg Radiol 2007;14:411–5. 4. Lazar DA, Cohen SA, Evora DK, Losasso BE, Bickler SW. Cecal bascule in a child: an unusual cause of postoperative bowel obstruction. J Pediatr Surg 2012;47:609–11. 5. Rozycki GS. Special feature: image of the month. Cecal bascule. Arch Surg 2001;136:835–6.
