Cecal Volvulus

Case Summary

This is a case of a 16-y-old female patient with a history of epilepsy and a G2 dependency for feeding, who presented to the emergency department with progressive abdominal discomfort, dyspepsia, and constipation. The team considered the possibility of a colonic volvulus or an adhesive obstruction, and reviewed abdominal X-ray images and CT scan results to confirm the diagnosis. The team also discussed the potential obsolescence of certain exams because of advanced imaging techniques and shared experiences and pathology of rare cases of volvulus.

Epileptic Patient's Abdominal Pain and Tachycardia

The patient was found to be significantly tachycardic and had a significantly descended abdomen. Lab results showed a slightly elevated white blood cell count and a high C-reactive protein. The patient's abdominal exam was tense, particularly in the left quadrant, and she had not vomited. The team considered the possibility of a colonic volvulus or an adhesive obstruction, with the latter being less likely due to the patient's history. The patient's global developmental delay was also noted as a potential indicator of a colonic volvulus.

Chronic Constipation and Colon Valvulus Discussion

Next, the team discussed the association between chronic constipation and valvulus of the colon, particularly in neurologically impaired patients. A presenter shared experience of never encountering such cases in neurologically normal patients. The team then reviewed abdominal X-ray images of a patient, which showed multiple distended bubble loops and a significantly dilated bowel loop, consistent with a volvulus at the level of the ascending colon. The team agreed that the findings were consistent with an obstruction at the level of the ascending colon, likely due to the cecum flipping on itself.

Discussion of CT Scan in Colonic Volvulus Diagnosis

A CT scan was performed on a patient suspected to have a colonic volvulus. The patient was severely distended and needed resuscitation, and the plain films suggested a classic case of colonic volvulus. However, the team wanted to confirm the diagnosis before proceeding to surgery. The CT scan was initially ordered by the ER, and it was not a delay in the operation as the patient was being resuscitated. The decision to perform the CT scan was a judgment call, and opinions varied among the team. A moderator suggested that the CT scan was useful for building confidence in clinical diagnosis, especially in rare cases like colonic volvulus. The team agreed that the decision to perform the CT scan was reasonable, given the patient's condition and the need for a confirmed diagnosis.

Discussion of Exam Obsolescence and Volvulus Cases

The potential obsolescence of a certain exam due to the availability of more advanced imaging techniques was discussed. The team highlighted the usefulness of a CT scan, which can reveal up to 150 chest X-rays' worth of information. The focus shifted to a case of a sequel volvulus, explaining the signs of high-grade obstruction and the involvement of the ileocecal valve. Also mentioned was a whirlpool sign indicating a mesentery caught upon itself, which confirmed the diagnosis of a volvulus.

Sigmoid Colon Volvulus and Transverse Colon Volvulus Case

The presenter discussed a rare case of sigmoid, transverse colon velvius, which he encountered during a 10-y practice. He described the procedure, which involved an exporter laparotomy with an ileocectectomy, and the challenges faced because of the severely distended cecum. He also mentioned the discovery of a large fecaloma and the need to ensure no distal obstruction from the anastomosis. He explained the use of a midline laparotomy incision and the successful resection of the bowel. The patient recovered well post-surgery, but faced a setback because of undiagnosed aspiration pneumonia.

Volvulus Pathology and Surgical Considerations

The team presented the pathology of a case involving a massively dilated cecum with hemorrhagic areas, a thin wall, and flattened mucosal folds. The histological examination showed dilated submucosal vessels and areas of necrosis consistent with a history of volvulus. The team discussed the decision to perform a stoma and the importance of considering the patient's distended abdomen and redundant abdominal wall. They also shared two interesting cases of volvulus, one involving the transverse colon and the other a sigmoid volvulus in a patient with severe cerebral palsy. The team also discussed the practice preference for using CT scans, with most agreeing to rely on abdominal films for diagnosis. They mentioned the increased risk of leukemia associated with a single CT scan of the abdomen, as per the American Pediatric Surgical Association.