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Case of the Month 04/09

Q: This 70 year old male with extensive past medical history including left hemiparesis and myotonic dystrophy was brought in to the ED after the family noticed increasing abdominal distention and no bowel movement for 2 days.

What's wrong with these pictures?

View answer

There is a massively dilated (13.3 cm) loop of large bowel (see image below) suggestive of a volvulus. A large bowel diameter over 5-6 cm is considered abnormal and a diameter above 9 cm is concerning for pending perforation. It may be difficult to differentiate a cecal from a sigmoid volvulus on plain film. Both have dilated loops of bowel positioned in a U shape (some call this the "coffee bean sign"). Classically, a sigmoid volvulus will have no haustra visible and a cecal volvulus will have at least 1-2. These plain films were read by radiology as "massively dilated right colon raising concern for cecal volvulus."

Q: What are some possible next diagnostic and/or therapeutic options?

View answer

Because volvulus of the sigmoid colon and cecum can have similar appearances to each other as well as to that of pseudo-obstruction or Ogilvie’s syndrome (dilation of the large bowel with no actual mechanical blockage), any case which is not clear from plain films require further testing. Options include contrast barium enema, CT or colonoscopy. This patient underwent a CT which revealed a sigmoid volvulus. The image below shows the classic "birds beak" appearance at the point of the volvulus.

He underwent successful decompression of the volvulus with a rigid proctoscope followed by rectal tube placement.