What does this xray show?
What is the diagnosis?
What is the best form of treatment?
This plain xray of the abdomen shows a dilated
loop of large bowel on the left of the midline. Note the inverted J or comma
shape of the bowel loop and the absence of any large bowel on the right
side of the abdomen.
This is typical of a caecal volvulus. The patient, who had just started
a course of steroids, presented with very sudden onset of upper abdominal
pain suggestive of a perforated ulcer but was found to have a volvulus with
gangrene developing in the caecal wall.
A right hemicolectomy was performed
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The classical xray appearance is of a hugely dilated, "comma-shaped"
caecum is seen in the epigastrium and left upper quadrant. The differential
diagnosis includes other, non-specific colonic or small-bowel obstruction.
.
The mainstay of treatment is surgical. If the bowel is viable one option is
to untwist the bowel and perform a caecoplexy (suture fixation of the caecum
to the abdominal wall, combined with stripping of the peritoneum to create
raw surfaces that will aid sticking) plus or minus caecostomy. However, recurrence
is common and right hemicolectomy may be the best option.
The management is more clearly defined in patients with caecal perforation
or infarction, when a right hemicolectomy is required.
Sigmoid volvulus may be treated by endoscopic deflation, this has little role
in the treatment of caecal volvulus
There is a twisting of the caecum around its mesenteric axis. The usual fixation of the caecum in the right iliac fossa fails to occur during development, and the caecum retains a mesentery, which is continuous with the mesentery of the ileum. Rotation of the caecum around this mesentery may then occur in a clockwise or anticlockwise direction so to that the caecum comes out of the right iliac fossa and sits in the middle or left side of the upper abdomen.
It is a relatively rare condition presenting in 3 to 6 per million per year in a Scandinavian trial and representing only 1% of all intestinal obstructions but 40% of all colonic volvulus. It is more common in females and outside the western world. The peak age of presentation is 30-40 years. Caecal Volvulus is often associated with a triggering event e.g. recent laparotomy or gynaecological procedures.
Clinical features
Abdominal pain is invariably present with a third experiencing
nausea, vomiting, constipation and abdominal distension.
Tympanitic mass in LUQ. Tender mass if impending infarction.
The presentation of these features may take several forms:
· A fulminant condition with mesenteric torsion leading to intestinal
strangulation.
· Sub-acute intestinal obstruction: the diagnosis may only be made
at diagnostic laparotomy in a patient with continuing sub-acute obstruction.
· Rarely a chronic intermittent condition.
Plain abdominal radiograph holds the key to diagnosis
Overall mortality is 20%, but as high as 40% in patients with a gangrenous
bowel..
Marc Dweck