Andrew Dauber, HMS III

Gillian Lieberman, MD

Cecal Volvulus and Malrotation

Andrew Dauber, Harvard Medical School Year IIIGillian Lieberman, MD

May 2003

Andrew Dauber, HMS III

Gillian Lieberman, MD

2

Patient AF – Clinical History

AF is a 37 year old female who presents to the ED with a 24 hour history of intermittent right midepigastric pain with nausea. She denies any vomiting, hematemesis, diarrhea, melena, or rectal bleeding.

PMH – Three c-sections. No history of GI problems.

PE – Abdomen tympanitic, soft, bowel sound present. Diffusely tender to palpation, worst over right midepigastrium. No guarding. Guaiac negative. No cervical motion tenderness on pelvic exam.

Andrew Dauber, HMS III

Gillian Lieberman, MD

3

Differential Diagnosis• Hepatitis• Cholecystitis• Cholangitis• Gastritis• Pancreatitis• Peptic ulcer disease• Bowel obstruction• IBD• Salpingitis• Appendicitis

Andrew Dauber, HMS III

Gillian Lieberman, MD

4

AF Lab Values

CBC 10.6/33.7/319 93.9% PMN

Electrolytes 137/4.4/98/23/12/0.7/107

ALT 29, AST 48, Alk Phos 66, Amylase 49, Lipase 28, T. Bili 0.3

Urinalysis normal

GC and Chlamydia gene probe negative

Andrew Dauber, HMS III

Gillian Lieberman, MD

5

AF Ultrasound

• Gallbladder normal, no wall thickening or stones

• Common bile duct not dilated

• Pancreas could not be evaluated due to overlying bowel gas

• Liver only remarkable for 2 small hemangiomas

Courtesy of Michael Schuster, MD BIDMC

Andrew Dauber, HMS III

Gillian Lieberman, MD

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Revised Differential Diagnosis• Hepatitis• Cholecystitis• Cholangitis• Gastritis• Pancreatitis• Peptic ulcer disease• Bowel obstruction• IBD• Salpingitis• Appendicitis

Diagnoses still under consideration

Andrew Dauber, HMS III

Gillian Lieberman, MD

7

AF CT Scan – Scout Images

Courtesy of Michael Schuster, MD BIDMC

Dilated large bowel ascending from the pelvis to the LUQ

Andrew Dauber, HMS III

Gillian Lieberman, MD

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Differential Diagnosis of Intestinal Obstruction in an Adult – Common Causes

• Adhesions• Crohn’s Disease• Fecal Impaction• Hernia• Neoplasm – Malignant or Benign• Volvulus

Andrew Dauber, HMS III

Gillian Lieberman, MD

9

AF CT Scan – Image 1

• Normal Stomach• Dilated Cecum

Courtesy of Michael Schuster, MD BIDMC

Andrew Dauber, HMS III

Gillian Lieberman, MD

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AF CT Scan – Image 2

• Dilated Cecum• Contrast in the

descending colon indicating that there is only a partial obstruction

Courtesy of Michael Schuster, MD BIDMC

Andrew Dauber, HMS III

Gillian Lieberman, MD

11

AF CT Scan – Image 3

• Dilated Cecum• Site of torsion – CT

whirl sign of volvulus• Normal small bowel –

not dilated or thickened

Courtesy of Michael Schuster, MD BIDMC

Andrew Dauber, HMS III

Gillian Lieberman, MD

12

AF CT Scan – Images 4 + 5

• Duodenum only seen on right side of abdomen• Difficult to visualize duodenojejunal junction and

ligament of Treitz• Findings raise question of malrotation

Courtesy of Michael Schuster, MD BIDMC

Andrew Dauber, HMS III

Gillian Lieberman, MD

13

Cecal Volvulus• Approximately 40–50% of colonic volvulus• Average age of presentation in the 50s• Majority of patients with cecal volvulus have full

axial rotation which twists the mesentery and blood supply

• ~10% have cecal bascule = cecum folds in an anterior cephalad direction

• Cecal bascule does not lead to torsion of the mesentery but can cause bowel wall distension and ischemia

Andrew Dauber, HMS III

Gillian Lieberman, MD

14

Cecal Volvulus - continued

• Usually occurs in patients with increased cecal mobility due to abnormal fixation of the right colon

• Patients present with abdominal pain, nausea, vomiting, and obstipation

• Diagnosis established with CT or barium enema• Plain film may be suggestive• Treatment consists of cecal resection or reduction

of volvulus and cecopexy

Andrew Dauber, HMS III

Gillian Lieberman, MD

15

Cecal Volvulus – Plain film and Barium Enema

UpToDate – Cecal Volvulus

Dilated cecal basculeSite of torsion in mid-ascending colon seen on barium enema

Andrew Dauber, HMS III

Gillian Lieberman, MD

16

Malrotation• Definition = any variation in the position of the

intestines• Always accompanied by malfixation of the

intestines• Peritoneal (Ladd) bands can stretch from

abnormally placed cecum to porta hepatis and abdominal wall

• Ladd bands can cause duodenal obstruction• Malfixation leads to abnormally short mesenteric

base which predisposes to midgut vovulus

Andrew Dauber, HMS III

Gillian Lieberman, MD

17

Malrotation - continued• May be associated with duodenal stenosis and

atresia, abdominal wall defects, heterotaxy syndromes, and Hirschsprung’s

• Typically presents in first month of life with bilious emesis

• Older children and adults may present with non- specific symptoms such as intermittent abdominal pain, non-bilious emesis, diarrhea, failure to thrive, or volvulus

• If detected, must be surgically corrected to prevent volvulus

Andrew Dauber, HMS III

Gillian Lieberman, MD

18

Normal Gut Development• Gut begins as a straight midline tube which as it grows

herniates into the base of the umbilical cord• During weeks 6-10 of fetal life, midgut loop rotates 90

degrees counterclockwise around SMA• Week 10 – gut returns to abdominal cavity and gut rotates

another 180 degrees counterclockwise• Duodenal-jejunal loop ends up in LUQ posterior to SMA

fixed at ligament of Treitz• Ileocecal junction is fixed in RLQ• Mesentery runs from ligament of Treitz to ileocecal

junction

Andrew Dauber, HMS III

Gillian Lieberman, MD

19

Malrotation – Radiologic Diagnosis

• No specific findings on plain film – may result in findings of duodenal obstruction if volvulus present

• Upper GI contrast study is diagnostic• UGI can locate the position of the duodeno-jejunal

junction which is normally to the left of the left sided pedicles at the duodenal bulb

• In malrotation, duodeno-jejunal junction is displaced inferiorly and to the right side

Andrew Dauber, HMS III

Gillian Lieberman, MD

20

Malrotation – Radiologic Diagnosis continued

• Barium enema may show malposition of the cecum

• On ultrasound, SMV located to the left of the SMA is suggestive of malrotation

Andrew Dauber, HMS III

Gillian Lieberman, MD

21

Malrotation Plain Film

• No specific plain film findings in malrotation

• Classic picture of partial duodenal obstruction with dilation of proximal duodenum but presence of distal bowel gas

Grainger & Allison’s Diagnostic Radiology: A Textbook of Medical Imaging, 4th Ed.

Andrew Dauber, HMS III

Gillian Lieberman, MD

22

Malrotation Variants on UGI #1

• Duodenal nonrotation in a 2 year old

• Duodenum and Jejunum are found completely to the right of the spine

Long F et al. Radiographic Patterns of Intestinal Malrotation in Children. Radiographics, May 1996.

Andrew Dauber, HMS III

Gillian Lieberman, MD

23

Malrotation Variants on UGI #2

• Duodenal partial rotation in a 3 year old girl with non-bilious vomiting

• Duodenaljejunal junction (arrow) was midline

• At surgery, the ligament of Treitz was absent

Long F et al. Radiographic Patterns of Intestinal Malrotation in Children. Radiographics, May 1996.

Andrew Dauber, HMS III

Gillian Lieberman, MD

24

Malrotation Variants on UGI #3

• Corkscrew configuration of the duodenum and jejunum

• Pathognomonic for midgut volvulus

Long F et al. Radiographic Patterns of Intestinal Malrotation in Children. Radiographics, May 1996.

Andrew Dauber, HMS III

Gillian Lieberman, MD

25

Malrotation Variants on UGI #4

• Z-shaped configuration of duodenum and jejunum

• Associated with duodenal obstruction due to Ladd bands

• May be seen in volvulus as well

Long F et al. Radiographic Patterns of Intestinal Malrotation in Children. Radiographics, May 1996.

Andrew Dauber, HMS III

Gillian Lieberman, MD

26

Malrotation Variants on Barium Enema #1

• Nonrotation of the colon in a 9 year old with abdominal pain

• Entire colon can be seen on the left side with the cecum (C) in the LLQ

Long F et al. Radiographic Patterns of Intestinal Malrotation in Children. Radiographics, May 1996.

Andrew Dauber, HMS III

Gillian Lieberman, MD

27

Malrotation Variants on Barium Enema #2

• Partial rotation of the colon in a 10 month old boy with vomiting

• Cecum (C) is seen in the RUQ

Long F et al. Radiographic Patterns of Intestinal Malrotation in Children. Radiographics, May 1996.

Andrew Dauber, HMS III

Gillian Lieberman, MD

28

Malrotation on Ultrasound• 10 day old boy with

emesis• SMV (V) is seen at

left ventral aspect of SMA (arrowhead)

Weinberger E et al. Sonographic Diagnosis of Intestinal Malrotation in Infants. AJR, October 1992.

• Normal SMV is to the right of the SMA

•Novelline R, Squire L. Living Anatomy, Hanley & Belfus, Inc., 1987.

Andrew Dauber, HMS III

Gillian Lieberman, MD

29

AF – Clinical CourseAF was taken to surgery where she was found to have a very dilated cecum with elongated right colon. There was very poor fixation of the colon to the retroperitoneum but a long mesenteric attachment was found.

AF did not have a malrotation. Her ligament of Treitz and hepatic flexure were in the proper positions.

Her cecum had rotated 270 degrees and folded on itself ending up in the LUQ.

Andrew Dauber, HMS III

Gillian Lieberman, MD

30

AF – Clinical Course continued

At surgery, AF’s volvulus was reduced and a right colectomy was performed to prevent recurrence.

The pathologic specimen showed a dilated cecum with submucosal edema and muscularis propria ischemia.

AF recovered well and was discharged home.

Andrew Dauber, HMS III

Gillian Lieberman, MD

31

References• Bonis P, Hodin R. Cecal Volvulus. UpToDate Online 11.1 2003.• Frank A, Goffner L, Fruauff A, Losada R. Cecal Volvulus: The CT Whirl

Sign. Abdominal Imaging 1993; 18:288-289.• Long F, Kramer S, Markowitz R, Taylor G. Radiographic Patterns of Intestinal

Malrotation in Children. Radiographics 1996;16:547-556.• Malrotation. Behrman: Nelson Textbook of Pediatrics, 16th Ed., W.B.

Saunders Company, 2000.• Malrotation and Volvulus. Grainger & Allison’s Diagnostic Radiology: A

Textbook of Medical Imaging, 4th Ed., Churchill Livingstone, Inc., 2001.• Novelline R, Squire L. Living Anatomy, Hanley & Belfus, Inc., 1987.• Reeder M, Felson B. Differential Diagnosis of Intestinal Obstruction in an

Adult. Gamuts in Radiology, Audiovisual Radiology of Cincinatti, Inc, 1975.• Weinberger E, Winters W, Liddell R, Rosenbaum D, Krauter D. Sonographic

Diagnosis of Intestinal Malrotation in Infants: Importance of the Relative Positions of the Superior Mesenteric Vein and Artery. AJR 1992; 159:825-828.

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Gillian Lieberman, MD

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Acknowledgements

• Michael Schuster, MD• Gillian Lieberman, MD• Pamela Lepkowski• Larry Barbaras and Cara Lyn D’amour