Abdominal radiographs of cecal volvulus discussed. Dr Mintz
Abdominal x-ray in patient with severe of abdominal pain. There is marked distention of the colon. The sigmoid colon is twisted with a “coffee bean” appearance. This is a characteristic x-ray finding of sigmoid volvulus. 2016PF49G
Episode 6 in this series is presented by Dr Vikas Shah. VIEW CASE: https://radiopaedia.org/courses/cases-in-radiology-abdominal-emergency You can rent Radiopaedia's Abdominal Emergency Radiology Course here: https://radiopaedia.org/courses/abdominal-emergency-radiology-course-online
Very rare finding of MesenteroAxial Gastric volvulus on CT, with detailed discussion by a radiologist.
Dr. Carlo Oller, emergency physician, talks about Volvulus
For Educational Use Only - Fair Use - Why does a barium enema cause the intestines to glow rn
Gut Malrotation, Nonrotation, and Volvulus is arrest of the normal gut as it rotates around the super mesenteric artery. Embryology, Signs and Symptoms, Diagnosis and Treatment for students taking USMLE Step 2. EMBRYOLOGY Normal at 6 weeks the gut goes through the yolk sac and as time goes on it continues to enlarge and goes into the yolk sac even further. At 9 weeks there is rotation of the gut and the distal part of the gut rotates until it is anterior to the proximal part of the gut. Afterwards the gut returns to the fetus abdomin and there is another 180 degree rotation continues. Therefore there is a total of 270 degree of rotation around the Superior mesenteric artery. There are two types of malrotation. The first type of gut malrotation is gut nonrotation and gut malrotation. In gut nonrotation the the colon is on the left side of the small bowel. In gut malrotation, rotation does occur for a little bit but becomes arrested when on the way and therefore there is no downward movement. Gut malrotation is associated with more clinical findings due to the mesentary. The mesenteric base is really small and normally it goes from the duodenojejunal flexure down to the cecum. However, in gut malrotation it is much easier for it to spin on itself and this is known as volvulus. There is also formation of Ladd Bands which goes over the dudoenum and causes obstruction of dodenum. Sign and symptoms of gut malrotation is related to the narrow mesentery allowing volvulus to occur which can lead to ischemia and necrosis. Ladd bands will cause duodenal obstruction. Presentation of gut malrotation starts in infancy with biluous vomiting. There is also abdominal pain and distention. If volvulus occurs there may be some associated bloody stool which is a poor sign because it suggests ischemia and necrosis of the gut. This may lead to sepsis and fluid third spacing and therefore you must maintain fluid levels. Volvulos ocurs in about 22% in children and 12% in adults. There are a few differential diagnosis. Age is the biggest factor. In the pre-term group there is necrotizing enterocolitis and this can differentiated by x-ray. In older infants there may be intussesception which is telescoping of the small intestine, which can be done through ultrasound bulls eye sign. On X-ray there will be gas and double bubble sign due to dudodenal obstruction from Ladd bands blocking dudodenum. Barium swallow or Gi series which is highlight the walls of the very nicely. In Volvulus there will be a classical corkscrew appearance. Often times there will be a misplaced dudonum which can be highlighted as well. Another imaging modality you can use Barium Enema, which will highlight the colon. The cecum is present on the right side of the abdomen. In a patient with gut nonrotation the cecm is on the left side of the large bowel. An ultrasound can also be performed and will show abnormal placement of the duodenum, Superior mesenteric Artery and Superior Mesenteric Vein. In volvulus there will be a classic whirpool sign.A CT scan is not perferred in children and adolescent, but in adults it can show perforation. Same findings on CT scan that are normally seen on Ultrasound. If findings are still equivocal than a laparatomy may be performed. TREATMENT is primarily a surgical procedure known as the Ladd Procedure. The bowel is not returned to the normal position. The mesenteric base is widened, the Ladd Bands are removed and appendix is removed Adverse effects of Ladd Procedure may be short bowel syndrome can no longer absorb enough nutrients required. It may also leads to adhesions which may lead to intestinal obstruction. Prognosis is good because 89% will resolve. Mortality rate is zero with normal infants, but a slightly higher risk of mortality if there are other features.
Lahham S, et al. Volvulus. JETem 2017. 2(3):V8-10. https://doi.org/10.21980/J8JH0Q History of present illness: A 26-year-old previously healthy female presented to the emergency department (ED) with diffuse abdominal pain, distention, and constipation for two days. Her physical exam was normal except for a soft, distended abdomen with mild diffuse tenderness to palpation. Vital signs, labs and right upper quadrant ultrasound performed in the ED were all within normal limits. Acute abdominal series (AAS) x-ray was significant for a sigmoid volvulus. Follow up CT confirmed the findings and the patient was subsequently admitted for emergent flexible sigmoidoscopy. Significant findings: Upright and supine frontal radiographs of the abdomen demonstrate gas dilation of the large bowel from the level of the cecum to the sigmoid colon with air fluid levels (yellow arrows). There is a swirled configuration of the distal descending to sigmoid colon indicating the level of the volvulus (dashed yellow line) and giving rise to the classic “coffee bean” sign (dotted white tracing). Note the elevated left hemidiaphragm on the upright view reflecting abdominal distention with increased intra-abdominal pressure (red arrow). Discussion: Volvulus is an emergent condition that occurs when the colon twists on its mesenteric axis greater than 180 degrees, producing obstruction of intestinal lumen and mesenteric vessels(1). The incidence of volvulus is rare in the United States, with the most common locations of volvulus being the sigmoid colon and cecum with 60%-70% and 20%-30% of cases reported, respectively(2). The small remaining fraction of cases occur in the splenic flexure and transverse colon(2). Sigmoid volvulus occurs more often in elderly patients with multiple comorbidities or those with neurological and psychiatric diseases and has a more subtle and insidious clinical presentation(3). In contrast, cecal volvulus is characterized by acute onset and is most frequently seen in younger (25-35), healthier individuals, particularly in long distance runners or patients who have had previous abdominal surgeries(4). Abdominal radiographs may assist with diagnosis; however CT, magnetic resonance imaging, and flexible imaging are more accurate(5). Flexible sigmoidoscopy is the standard procedure for patients with viable bowel, and sudden decompression at rigid sigmoidoscopy is successful in 70-90% of cases(2). However, for patients who fail decompression or present with diffuse peritonitis, intestinal perforation, or ischemic necrosis, emergency surgery is the appropriate treatment(2). Timely identification and management are crucial in treating sigmoid volvulus before the appearance of these aforementioned life-threatening complications(6). Topics: volvulus, sigmoidoscopy, gastroenterology, constipation. References: 1. Gerwig WH. Volvulus of the colon: symposium on function and disease of anorectum and colon. Surg Clin North Am. 1950; 60(4):721-742. doi: 1001/archsurg.1950.01250010742008 2. Lou Z, Yu ED, Zhang W, Meng RG, Hao LQ, Fu GC. Appropriate treatment of acute sigmoid volvulus in the emergency setting. World J Gastroenterol. 2013; 19(30):4979–4983. doi: 10.3748/wjg.v19.i30.4979 3. Madiba TE, Thomson SR. The management of sigmoid volvulus. J R Coll Surg Edinb. 2000; 45:74–80. 4. Mulas C, Bruna M, García-Armengol J, Roig JV. Management of colonic volvulus. Experience in 75 patients. Rev Esp Enferm Dig. 2010; 102:239–248. doi: 10.4321/S1130-01082010000400004 5. Young WS, Engelbrecht HE, Stocker A. Plain film analysis in sigmoid volvulus. Clin Radiol. 1978; 29:553–560. doi: 10.1016/S0009-9260(78)80049-X 6. Katsikogiannis N, Machairiotis N, Zarogoulidis P, Sarika E, Stylianaki A, Zisoglou M, Zervas V, Bareka M, Christofis C, Iordanidis A. Management of sigmoid volvulus avoiding sigmoid resection. Case Rep Gastroenterol. 2012; 6:293–299. doi: 10.1159/000339216 Go to http://jetem.org/volvulus/ to download this video for lectures or teaching.
Capsule 30 : Examples of How to Describe a Fracture Dr. Ahmed Refaey