Right Colonic Adhesions
1
Diagnostic Radiology
Jack Twersky, M.D., and Elliot Himmelfarb, M.D. 2 Adhesive bands may cause narrowing of the colon. The radiographic appearance may show evidence of a sharp, localized narrowing and smooth mucosal contour. Adhesions involving the ascending colon may also precipitate acute colonic obstruction due to formation of a cecal bascule. The nature of the adhesive bands and their relationship to prior surgery, to anomalies of mesenteric fixation, and to appendices epiploicae are discussed. INDEX TERMS: Adhesions. Colon, volvulus • Intestines, appendices epiploicae • Intestines, obstruction • Mesentery
Radiology 120:37-40, July 1976
sharp, localized circumferential narrowing of the large bowel, with slight distension of the proximal colon. Adhesions involving the right colon can alternately present
are the most common cause of small bowel obstruction and can also affect the large bowel. On barium enema, the adhesion causes a NTRA-ABDOMINA L ADHESIONS
I
Fig. 1. CASE I. Localized constriction of the ascending colon was present throughout the entire study. Fig. 2. CASE I. A and B. Spot films reveal a smooth mucosal contour and variation in caliber of the short constricted segment. The cecum is dilated. 1 From the Department of Radiology, State University of New York, Downstate Medical Center, Brooklyn, N. Y. Accepted for publication in January 1976. 2 Present address: Department of Radiology, University of Tennessee, Memphis, Tenn. shan
37
38
July 1976
JACK TWERSKY AND ELLIOT HIMMELFARB
she had experienced stabbing, intermittent right lower quadrant pain. For the past 24 hours, the pain became unremitting and increased in intensity. There was no history of previous abdominal or pelvic surgery. Physical examination revealed right lower quadrant tenderness and a suggestion of a right lower quadrant mass. Barium enema revealed a localized extrinsic constriction of the midascending colon (Fig. 1). Spot films revealed a normal mucosa and variation in caliber of the constricted area (Fig. 2). At surgery, the entire colon was found to be intraperitoneal on a mesentery. An omental band constricted the midascending colon. It was noted that with cecal distension, a valve-like mechanism was formed, completely obstructing the ascending colon at the site of the omental band. There was a normal-appearing long, retrocecal appendix. The band was lysed and an appendectomy was performed. The patient has remained asymptomatic for the past several years. CASE II. H. S., a 60-year-Old man, presented with mild abdominal pain of several months' duration. Six months previously he had a cholecystectomy with exploration of the common bile duct. A fistula secondary to a perforated common bile duct was found. An indwelling Ttube catheter was left in situ for several months. This was removed without further incident. Shortly afterward, the current symptoms of abdominal pain developed. A barium enema revealed an annular constriction of the midascending colon (Fig. 3). The constriction involved a short segment of bowel, was constant, and had normal underlying mucosa (Fig. 4). Exploratory laparotomy revealed a linear adhesive band narrowing the ascending colon. This was lysed. The patient had an uneventful recovery and he has remained asymptomatic since. CASE III. R. W., a 55-year-Old woman, presented with abdominal pain of five days' duration. The symptoms began suddenly, with waves of crampy abdominal pain which continued periodically with increasing intensity over the past five days. During this time, she noted abdominal distension. She had not had a bowel movement for the past three days. Three years previously, a total abdominal hysterectomy had been performed. Physical examination revealed a distended abdomen with hypertympany. High-pitched intestinal rushes were heard. Supine and upright views of the abdomen revealed a distended cecum in the midabdomen (Fig. 5). A barium enema demonstrated a normal caliber large bowel from the rectum to the midascending colon. At this point, a constriction was present, with a small amount of contrast material passing the constriction, entering a distended cecum (Fig. 6). There was no twisting of mucosal folds, but rather a folding of the constricted area, with the cecum anterior to the ascending colon (Fig. 7). At operation, an adhesion constricting the ascending colon was present. The cecum was folded over the adhesion, with complete obstruction of the cecum at the area of folding (Fig. 8). Upon lysis of the adhesion, the cecum immediately became deflated and assumed its normal position in the right lower quadrant. No further surgery was done. The patient has remained asymptomatic for the past several years.
DISCUSSION Fig. 3. CASE II. Circumferential constriction of the ascending colon. Surgical clips are from' previous gallbladder surgery. Fig. 4. CASE II. Spot films reveal the smooth mucosal contours of the short constricted segment.
as acute large bowel obstruction due to formation of a "cecal bascule." We present 3 cases of right colonic adhesions to demonstrate the typical radiographic features. CASE REPORTS CASE I. M. S., a 22-year-old woman, presented with right lower quadrant abdominal pain of one day's duration. For the past six months
Adhesions are the end result of an area of inflammation that has healed by fibrosis. Experimental studies in adhesion formation have shown an initial inflammatory response in an area of mechanical trauma (12). Microscopically, a structure of fibrin mesh with numerous polymorphonuclear leukocytes is first present. These are replaced by microphages and fibroblasts, and the final adhesion is formed by fibroblasts and collagen tissue. Most commonly, adhesions are due to previous surgical trauma. The majority of patients with intestinal obstruction due to adhesions have had previous abdominal or pelvic surgery. Adhesive bands are, however, seen in the ab-
Diagnostic
RIGHT COLONIC ADHESIONS
Vol. 120
Fig. 5. Fig.6. in caliber. Fig. 7. Fig. 8.
39
Radiology
CASE III. The markedly dilated cecum occupies the midabdomen. There is small bowel dilatation. CASE III. A small amount of contrast material has entered the distended cecum. The remainder of the colon is normal CASE III. CASE III.
Lateral view demonstrates the constricted area (arrow). There is no twisting of mucosal folds. Artist's sketch of surgical findings. A distended cecum is folded over an adhesion of ascending colon.
sence of surgery in patients with abnormal fixation of the colon. These congenital bands may not be inflammatory in origin, but rather represent an aberration in development
of the mesentery. Usually, such bands obstruct the duodenum. However, they have previously been reported obstructing the ascending colon, as in our CASE I (11).
40
JACK TWERSKY AND ELLIOT HIMMELFARB
In the absence of either surgery or abnormalities of peritoneal development, adhesions may be secondary to disease of the appendices epiploicae. The latter are fatty-tissue, serosa-covered appendages found along the entire large bowel excluding the rectum. They are subject to torsion, inflammation, and infarction (9). When this occurs, the abnormal appendix may become adherent to the abdominal wall or to another intra-abdominal structure. The end result is an adhesion which may cause small or large bowel obstruction. Seven such cases of large bowel obstruction have been reported (1,6,9, 13). Adhesions involving the ascending colon can present clinically as acute intestinal obstruction. The adhesion causes only partial obstruction, which results in cecal distension. If there is also an anomaly of mesenteric fixation and therefore a mobile cecum, the distended cecum may become "folded" anteriorly on the ascending colon, over the adhesive band, resulting in an acute obstruction. There is no torsion or closed loop obstruction. Radiographically, the findings are anterior positioning of the cecum relative to the ascending colon, and a folding rather than twisting of the mucosa at the site of obstruction (3). This type of cecal obstruction is called a "cecal bascule" (16). This is not a rare phenomenon. Of 22 cases of cecal volvulus described by Krippaehne et a/. (7), 7 were actually cecal bascules. Of these, 5 were treated by simply lysing the adhesion. There was no recurrence of intestinal obstruction in spite of the fact that all these patients continued to have a mobile cecum. This suggests that the adhesive band is necessary, if not responsible, for the formation of a cecal bascule. The area of large bowel constriction by an adhesion has a specific appearance. While Kyaw and Koehler (8) described several cases of large bowel adhesions presenting as sharp intramural mass lesions, an adhesive band usually causes a circumferential narrowing of the bowel. The radiologic findings were accurately described by Marshak (10) as a short, smooth area of constriction with fusiform narrowing and intact mucosa. Our CASES I and II exhibited these features. CASE I also showed variation in intraluminal diameter, a helpful diagnostic finding. Glucagon has been advocated for use in overcoming focal colonic spasm, permitting better evaluation of an organic constriction. A colonic adhesion produces a focal narrowing with normal mucosal contours. These diagnostic criteria can be appreciated without the use of glucagon. However, a third criterion, namely variation in caliber of the constriction, may be more apparent if glucagon is used. This is, of course, hypothetical because glucagon was not used in any of our patients. Several entities should be considered in the differential diagnosis. Occasionally, an area of circular muscle contraction may be present. Several. areas of large bowel predispose to this appearance. In the ascending colon it has been called the sphincter of Hirsch; in the transverse
July 1976
colon, it is at Cannon's point; in the left colon there are two points, at the splenic flexure and at the junction of the proximal and midsigmoid colon (5). These "contraction rings" or "colonic valves" rarely persist during an entire barium enema. A repeat barium enema is usually normal. Pericolic inflammatory disease due to diverticulitis (2), rupture of a retrocecal appendix with abscess formation, or even a perinephric abscess (14) may produce circumferential narrowing of the colon. However, the inflammatory basis is evident by spiculation of the mucosa and submucosal edema. Stricture formation secondary to a vascular accident or to a rare benign ulcer of the colon may be theoretically indistinguishable from an adhesion. An idiopathic muscular stricture of the colon, an entity described in the sigmoid and descending colon, manifests as a narrowing of the coJon with variation in caliber, smooth contours, and shelf-like margins (4, 15). However, it is longer than the constriction produced by an adhesion. This latter point also helps rule out the unusual scirrhous carcinoma of the colon.
Department of Radiology Downstate Medical Center 450 Clarkson Avenue Brooklyn, N. Y. 11203
REFERENCES 1. Astler VB, Carver GB, Carmona MG: Epiploic appendages as a cause of intestinal obstruction. AMA Arch Surg 76:555-558, Apr 1958 2. Beranbaum SL, Zausner J, lane B: Diverticular disease of the right colon. Am J RoentgenoI115:334-348, Jun 1972 3. Bobroff LM, Messinger NH, Subbarao K, et al: The cecal bascule. Am J Roentgenol 115:249-252, Jun 1972 4. Cassano C, Torsoli A: Idiopathic muscular strictures of the sigmoid colon. Gut 9:325-331, Jun 1968 5. DeLorimier AA, Moehring HG; Hannan JR: Clinical RoentgenOlogy. Vol. IV. Springfield, III., Thomas, 1956, p 260 6. Kirsch D, Drosd RE: Roentgen changes in disease of the appendices epiploicae. Am J Roentgenol 81:640-649, Apr 1959 7. Krippaehne WW, Vetto RM, Jenkins CC: Volvulus of the ascending colon. Am J Surg 114:323-332, Aug 1967 8. . Kyaw MM, Koehler PR: Pseudotumors of colon due to adhesions. Radiology 103:597-599, Jun 1972 9. Lynn TE, Dockerty MB, Waugh JM: A clinicopathologic study of the epiploic appendages. Surg Gynec Obstet 103:423-433, Oct 1956 10. Marshak RH: Extrinsic lesions affecting the rectosigmoid. Am J RoentgenoI58:439-450, Oct 1947 11. McWhorter GL: Chronic intermittent obstruction of ascending colon by parietocolic bands or membranes. Surg Clin N Am 16:101111, Feb 1936 12. Milligan DW, Raftery AT: Observations on the pathogenesis of peritoneal adhesions: a light and electron microscopical study. Br J Surg 61:274-280, Apr 1974 13. Overton RC, Bolton BF, Usher Fe: Extrinsic deformities of the colon mimicking carcinoma. Surgery 36:906-915, Nov 1954 14. Pendergrass RC: Extrinsic deformities of the colon. Radiology 51:320-324, Sep 1948 15. Seaman WB: Disease of the colon: new concepts, old problems. Radiology 100:251-269, Aug 1971 16. Weinstein M: Volvulus of the cecum and ascending colon. Ann Surg 107:248-259, Feb 1938
1
Diagnostic Radiology
Jack Twersky, M.D., and Elliot Himmelfarb, M.D. 2 Adhesive bands may cause narrowing of the colon. The radiographic appearance may show evidence of a sharp, localized narrowing and smooth mucosal contour. Adhesions involving the ascending colon may also precipitate acute colonic obstruction due to formation of a cecal bascule. The nature of the adhesive bands and their relationship to prior surgery, to anomalies of mesenteric fixation, and to appendices epiploicae are discussed. INDEX TERMS: Adhesions. Colon, volvulus • Intestines, appendices epiploicae • Intestines, obstruction • Mesentery
Radiology 120:37-40, July 1976
sharp, localized circumferential narrowing of the large bowel, with slight distension of the proximal colon. Adhesions involving the right colon can alternately present
are the most common cause of small bowel obstruction and can also affect the large bowel. On barium enema, the adhesion causes a NTRA-ABDOMINA L ADHESIONS
I
Fig. 1. CASE I. Localized constriction of the ascending colon was present throughout the entire study. Fig. 2. CASE I. A and B. Spot films reveal a smooth mucosal contour and variation in caliber of the short constricted segment. The cecum is dilated. 1 From the Department of Radiology, State University of New York, Downstate Medical Center, Brooklyn, N. Y. Accepted for publication in January 1976. 2 Present address: Department of Radiology, University of Tennessee, Memphis, Tenn. shan
37
38
July 1976
JACK TWERSKY AND ELLIOT HIMMELFARB
she had experienced stabbing, intermittent right lower quadrant pain. For the past 24 hours, the pain became unremitting and increased in intensity. There was no history of previous abdominal or pelvic surgery. Physical examination revealed right lower quadrant tenderness and a suggestion of a right lower quadrant mass. Barium enema revealed a localized extrinsic constriction of the midascending colon (Fig. 1). Spot films revealed a normal mucosa and variation in caliber of the constricted area (Fig. 2). At surgery, the entire colon was found to be intraperitoneal on a mesentery. An omental band constricted the midascending colon. It was noted that with cecal distension, a valve-like mechanism was formed, completely obstructing the ascending colon at the site of the omental band. There was a normal-appearing long, retrocecal appendix. The band was lysed and an appendectomy was performed. The patient has remained asymptomatic for the past several years. CASE II. H. S., a 60-year-Old man, presented with mild abdominal pain of several months' duration. Six months previously he had a cholecystectomy with exploration of the common bile duct. A fistula secondary to a perforated common bile duct was found. An indwelling Ttube catheter was left in situ for several months. This was removed without further incident. Shortly afterward, the current symptoms of abdominal pain developed. A barium enema revealed an annular constriction of the midascending colon (Fig. 3). The constriction involved a short segment of bowel, was constant, and had normal underlying mucosa (Fig. 4). Exploratory laparotomy revealed a linear adhesive band narrowing the ascending colon. This was lysed. The patient had an uneventful recovery and he has remained asymptomatic since. CASE III. R. W., a 55-year-Old woman, presented with abdominal pain of five days' duration. The symptoms began suddenly, with waves of crampy abdominal pain which continued periodically with increasing intensity over the past five days. During this time, she noted abdominal distension. She had not had a bowel movement for the past three days. Three years previously, a total abdominal hysterectomy had been performed. Physical examination revealed a distended abdomen with hypertympany. High-pitched intestinal rushes were heard. Supine and upright views of the abdomen revealed a distended cecum in the midabdomen (Fig. 5). A barium enema demonstrated a normal caliber large bowel from the rectum to the midascending colon. At this point, a constriction was present, with a small amount of contrast material passing the constriction, entering a distended cecum (Fig. 6). There was no twisting of mucosal folds, but rather a folding of the constricted area, with the cecum anterior to the ascending colon (Fig. 7). At operation, an adhesion constricting the ascending colon was present. The cecum was folded over the adhesion, with complete obstruction of the cecum at the area of folding (Fig. 8). Upon lysis of the adhesion, the cecum immediately became deflated and assumed its normal position in the right lower quadrant. No further surgery was done. The patient has remained asymptomatic for the past several years.
DISCUSSION Fig. 3. CASE II. Circumferential constriction of the ascending colon. Surgical clips are from' previous gallbladder surgery. Fig. 4. CASE II. Spot films reveal the smooth mucosal contours of the short constricted segment.
as acute large bowel obstruction due to formation of a "cecal bascule." We present 3 cases of right colonic adhesions to demonstrate the typical radiographic features. CASE REPORTS CASE I. M. S., a 22-year-old woman, presented with right lower quadrant abdominal pain of one day's duration. For the past six months
Adhesions are the end result of an area of inflammation that has healed by fibrosis. Experimental studies in adhesion formation have shown an initial inflammatory response in an area of mechanical trauma (12). Microscopically, a structure of fibrin mesh with numerous polymorphonuclear leukocytes is first present. These are replaced by microphages and fibroblasts, and the final adhesion is formed by fibroblasts and collagen tissue. Most commonly, adhesions are due to previous surgical trauma. The majority of patients with intestinal obstruction due to adhesions have had previous abdominal or pelvic surgery. Adhesive bands are, however, seen in the ab-
Diagnostic
RIGHT COLONIC ADHESIONS
Vol. 120
Fig. 5. Fig.6. in caliber. Fig. 7. Fig. 8.
39
Radiology
CASE III. The markedly dilated cecum occupies the midabdomen. There is small bowel dilatation. CASE III. A small amount of contrast material has entered the distended cecum. The remainder of the colon is normal CASE III. CASE III.
Lateral view demonstrates the constricted area (arrow). There is no twisting of mucosal folds. Artist's sketch of surgical findings. A distended cecum is folded over an adhesion of ascending colon.
sence of surgery in patients with abnormal fixation of the colon. These congenital bands may not be inflammatory in origin, but rather represent an aberration in development
of the mesentery. Usually, such bands obstruct the duodenum. However, they have previously been reported obstructing the ascending colon, as in our CASE I (11).
40
JACK TWERSKY AND ELLIOT HIMMELFARB
In the absence of either surgery or abnormalities of peritoneal development, adhesions may be secondary to disease of the appendices epiploicae. The latter are fatty-tissue, serosa-covered appendages found along the entire large bowel excluding the rectum. They are subject to torsion, inflammation, and infarction (9). When this occurs, the abnormal appendix may become adherent to the abdominal wall or to another intra-abdominal structure. The end result is an adhesion which may cause small or large bowel obstruction. Seven such cases of large bowel obstruction have been reported (1,6,9, 13). Adhesions involving the ascending colon can present clinically as acute intestinal obstruction. The adhesion causes only partial obstruction, which results in cecal distension. If there is also an anomaly of mesenteric fixation and therefore a mobile cecum, the distended cecum may become "folded" anteriorly on the ascending colon, over the adhesive band, resulting in an acute obstruction. There is no torsion or closed loop obstruction. Radiographically, the findings are anterior positioning of the cecum relative to the ascending colon, and a folding rather than twisting of the mucosa at the site of obstruction (3). This type of cecal obstruction is called a "cecal bascule" (16). This is not a rare phenomenon. Of 22 cases of cecal volvulus described by Krippaehne et a/. (7), 7 were actually cecal bascules. Of these, 5 were treated by simply lysing the adhesion. There was no recurrence of intestinal obstruction in spite of the fact that all these patients continued to have a mobile cecum. This suggests that the adhesive band is necessary, if not responsible, for the formation of a cecal bascule. The area of large bowel constriction by an adhesion has a specific appearance. While Kyaw and Koehler (8) described several cases of large bowel adhesions presenting as sharp intramural mass lesions, an adhesive band usually causes a circumferential narrowing of the bowel. The radiologic findings were accurately described by Marshak (10) as a short, smooth area of constriction with fusiform narrowing and intact mucosa. Our CASES I and II exhibited these features. CASE I also showed variation in intraluminal diameter, a helpful diagnostic finding. Glucagon has been advocated for use in overcoming focal colonic spasm, permitting better evaluation of an organic constriction. A colonic adhesion produces a focal narrowing with normal mucosal contours. These diagnostic criteria can be appreciated without the use of glucagon. However, a third criterion, namely variation in caliber of the constriction, may be more apparent if glucagon is used. This is, of course, hypothetical because glucagon was not used in any of our patients. Several entities should be considered in the differential diagnosis. Occasionally, an area of circular muscle contraction may be present. Several. areas of large bowel predispose to this appearance. In the ascending colon it has been called the sphincter of Hirsch; in the transverse
July 1976
colon, it is at Cannon's point; in the left colon there are two points, at the splenic flexure and at the junction of the proximal and midsigmoid colon (5). These "contraction rings" or "colonic valves" rarely persist during an entire barium enema. A repeat barium enema is usually normal. Pericolic inflammatory disease due to diverticulitis (2), rupture of a retrocecal appendix with abscess formation, or even a perinephric abscess (14) may produce circumferential narrowing of the colon. However, the inflammatory basis is evident by spiculation of the mucosa and submucosal edema. Stricture formation secondary to a vascular accident or to a rare benign ulcer of the colon may be theoretically indistinguishable from an adhesion. An idiopathic muscular stricture of the colon, an entity described in the sigmoid and descending colon, manifests as a narrowing of the coJon with variation in caliber, smooth contours, and shelf-like margins (4, 15). However, it is longer than the constriction produced by an adhesion. This latter point also helps rule out the unusual scirrhous carcinoma of the colon.
Department of Radiology Downstate Medical Center 450 Clarkson Avenue Brooklyn, N. Y. 11203
REFERENCES 1. Astler VB, Carver GB, Carmona MG: Epiploic appendages as a cause of intestinal obstruction. AMA Arch Surg 76:555-558, Apr 1958 2. Beranbaum SL, Zausner J, lane B: Diverticular disease of the right colon. Am J RoentgenoI115:334-348, Jun 1972 3. Bobroff LM, Messinger NH, Subbarao K, et al: The cecal bascule. Am J Roentgenol 115:249-252, Jun 1972 4. Cassano C, Torsoli A: Idiopathic muscular strictures of the sigmoid colon. Gut 9:325-331, Jun 1968 5. DeLorimier AA, Moehring HG; Hannan JR: Clinical RoentgenOlogy. Vol. IV. Springfield, III., Thomas, 1956, p 260 6. Kirsch D, Drosd RE: Roentgen changes in disease of the appendices epiploicae. Am J Roentgenol 81:640-649, Apr 1959 7. Krippaehne WW, Vetto RM, Jenkins CC: Volvulus of the ascending colon. Am J Surg 114:323-332, Aug 1967 8. . Kyaw MM, Koehler PR: Pseudotumors of colon due to adhesions. Radiology 103:597-599, Jun 1972 9. Lynn TE, Dockerty MB, Waugh JM: A clinicopathologic study of the epiploic appendages. Surg Gynec Obstet 103:423-433, Oct 1956 10. Marshak RH: Extrinsic lesions affecting the rectosigmoid. Am J RoentgenoI58:439-450, Oct 1947 11. McWhorter GL: Chronic intermittent obstruction of ascending colon by parietocolic bands or membranes. Surg Clin N Am 16:101111, Feb 1936 12. Milligan DW, Raftery AT: Observations on the pathogenesis of peritoneal adhesions: a light and electron microscopical study. Br J Surg 61:274-280, Apr 1974 13. Overton RC, Bolton BF, Usher Fe: Extrinsic deformities of the colon mimicking carcinoma. Surgery 36:906-915, Nov 1954 14. Pendergrass RC: Extrinsic deformities of the colon. Radiology 51:320-324, Sep 1948 15. Seaman WB: Disease of the colon: new concepts, old problems. Radiology 100:251-269, Aug 1971 16. Weinstein M: Volvulus of the cecum and ascending colon. Ann Surg 107:248-259, Feb 1938
