Downloaded from www.ajronline.org by 202.62.17.156 on 01/26/16 from IP address 202.62.17.156. Copyright ARRS.

For personal use only; all rights reserved

419

Cecal

Volvulus
R. Kirks,1

Donald
David

Leonard

F. Merten,1

Cecal

and

volvulus,

children.

this

patient.

The

appearance
agnosis.
the night

E. Swischuk,2

Howard

a common

Although

suggestive,

in Children

condition

abdominal

entity

may

in adults,

are

not be considered

positive

contrast

enema

volvulus

and

two

is rare

nadiognaphs

in cecal
We describe
colon.

Filston3

C.

has

patients

with

the

were

lytes,

di-

volvulus

and

An

of

there

1 1 -year-old

girl

nal distension,
Duke University
severe

and

complete

of vomiting,

she

abdomi-

was

abdominal

temperature,
count,

serum

moderate

masses,

blood

spastic

and

pressure,

electrolyes,

and

after

An abdominal
enema
1

(figs.

radiograph

showed

midabdomen

(figs.

1 A and

confirmed

a volvulus

of

C and

Through

decreased

was

transverse

the

present

with

right

the

removed

rate,

were

except

bowel

of bowel

and

norin the

contrast

ascending

after

colon

laparotomy,

there

was

the
by sump

easy

detorsion

(incomplete

junction

in the

4%

surgery.

An

upper

2 months

position

surgery

of the duodenojejunal

years
stated

was

Ladd

bands

series
was

normal

1 2-year-old

Received

was

examined

Medical

Branch

April

Department
2Department
3Department
AJR

boy

of Texas

136:419-422,

9, 1 980;
of Radiology,
of Radiology,
of Surgery,
February

at

the

after

Child

3 days

0361 -803x/81

/1

Health

Center,

of vomiting

362-041

of

barium

ascending

colon

of the

performed.

The

and

terminal

ileum

The
was

right
with

a fibrous

cecum

detorsion
course

1 week

after

had
of

diverticulum,

postoperative

was

however,

mobile

easy

Meckel

discharged

colon

ischemia;

the

and
was

a
un-

surgery.

and

$00.00

colon

was

bowel

first

obstructions

age

that
the

noted

[3].

in male

volvulus

of the
up

volvulus

to

can

by

Rokitansky

cecum
80-90

may be found
years.
McGraw
at any

for

than sigmoid
volpatients
40-60

sigmoid
volvulus
is
65-90
[3]. Fnimann-Dahl

occur

in

in adults,
accounting
1 8% of colon obstructions

less frequently
affects
female

Conversely,
patients
aged

newborn

cecal

described

problem
and

age

more
[4]

in all ages
et al. [5]

and

stated

that

the youngest
case reported
was in an infant
of i 0 months.
Sigmoid
volvulus
in children
has
been
well
described
[6-9],
but we are unaware
of a detailed
discussion
of cecal
volvulus
in children.
The common
term cecal volvulus
is a misnomer
since the
ileum
torsion

the

colon

volvulus

fixed

point

Since

failure

ascending

accepted
after revision
October
1 , 1980.
Duke
University
Medical
Center,
Box 3834,
Durham,
NC
Child
Health
Center,
University
of Texas
Medical
Branch,
Duke
University
Medical
Center,
Durham,
NC 27710.

1981

resection
was

the

bowel

umbilicus.
There

It is a common

].

of

terminal

junction.

University

of the

the

Cecal
volvulus
occurs
vulus
and predominantly

in
Case

of the

[i
of all

from

of the

gastrointestinal
after

of

or

adhesion.

patient

loop

Subsequent

of the cecum

[2].

cecal

rotation)

midline.

not

the

Volvulus
1 837

drain-

present.
A cecostomy
tube was placed
to the ventral
peritoneum;
the tube was

follow-through

for the abnormal

at

decompression

Malrotation

duodenojejunal

3 weeks

small

After
needle,

colon.

or midgut
volulus
were not
and the cecum
was sutured
with

incision

palpable.

a 1 6 gauge

of

cecum

and

common

easily

through

volvulus

the

loop

was

distended

2A).

Discussion

bowel

respiratory

A water-soluble

after

electro-

of

D).

a right

volvulus
age

a dilated
1 B).

this

physical

re-

mal.
upper

it and

volvulus

eventful

quadripa-

urinalysis

diverticulum

the
serum

and

distension

pulse,

a Meckel

of

sounds.

2B).

malrotation

between

cecostomy

examination

to pain,

was

week

no

(fig.

obstruction
(fig.

the volvulus
was

rest
count,

a large,

quadrant

cecum

disten-

bowel

normal.

showed

dilated

the
blood

showed

upper

beneath

cecal

also

abdominal

increased

and

complete

radiograph
left

and

masses
The

were

There

twisted

to

distended

Physical

only
There

One

became

feedings.

contractures.

blood

dysfunction.

responsive

no palpable

The

system

gastric

child

flexion

the abdomen,
sounds.

because

gastrostomy,

to tolerate

a comatose

resis,

evaluated

nervous

of a feeding

was unable
vealed

was

and hypoactive
bowel sounds. She was admitted
Medical Center initially with anoxic encephalopathy

central

placement

normal.

At laparotomy,

adhesion

and

abdominal

examination
to the

apparent.

An

no

the

revealed

tympany,

was
urinalysis

in

examination

quadrant

abdominal

bowel
enema

Reports

Case

Physical

upper

examination

distal

Case

pain.

left

There

a characteristic
confirms

abdominal
sion,

in the pediatric

readily

pediatric

in

highly

American

and ascending
colon
[4]. The anatomic
are

about

occurs

27710.
Address
reprint
Galveston,
TX 77550.

Roentgen

also involved
factors
for

a mobile
segment
of large
bowel
and a
which
this loop of bowel
may twist
[2].

of retnopenitoneal
colon

are usually
predisposing

Ray Society

fixation

in 1 0%-i

requests

5%

of the
of the

to D. R. Kirks.

cecum

population

and
[5],

Downloaded from www.ajronline.org by 202.62.17.156 on 01/26/16 from IP address 202.62.17.156. Copyright ARRS. For personal use only; all rights reserved

I-

Fig.

cecum
confirms

1 -Case

1.

A, Anteropostenior

in left midabdomen
that

distended

(arrows).
bowel

loop

supine
abdominal
film. Distended
Contrast
medium via gastrostomy
tube
is not

view. Single, sharp air-fluid

level in dilated
obstructed
small bowel lateral and caudad

stomach.

B, Left

lateral

decubitis

cecum. Multiple
air-fluid
levels
to the cecum. C, Anteroposterior

in

supine
struction

cecum.
entered
level.

film, water-soluble
of ascending

D, Left
partially

contrast

enema

study.

Tapered,

bird-beak

ob-

(arrow)
points
toward
dilated
and malpositioned
lateral decubitis
view, after enema.
Contrast
material
has
obstructed
cecum.
Sharp air-fluid
(water-soluble
contrast)
colon

Downloaded from www.ajronline.org by 202.62.17.156 on 01/26/16 from IP address 202.62.17.156. Copyright ARRS. For personal use only; all rights reserved

AJR:136,

February

1981

CASE

REPORTS

421

,d
Fig.

dilated

2.-Case

2.

cecum

in left

it is surprising
cant

A,

that

factors

Anteroposterior

upper

cecal

contributing

distension
(chronic
illness),
adhesions,

supine

quadrant

volvulus
to

is rare

colon

constipation,
malnotation,

abnormality

(case

associated
with a Meckel
The classic
symptoms
distension

(81

or

distension

with

usually
pears

associated
as a large

small
air-filled

ileus, mental
weight
loss, and

obstipation

disease).
factors:
nervous
adhesions

focal

and

findings
on physical
a palpable
mass,
two

distension

of the

bowel
obstruction.
structure
in the

signs

of cecal

plays a critical
show
generalized

role

cecum

in
ab-

and

The cecum
apleft midabdomen

(case
1 ) on left upper
quadrant
appearance
of the malpositioned

(case
2). A kidney-shaped
cecum
with air in the ileum

suggesting

is said

the

hilus

of a kidney

to be characteristic

film,

after

points

barium

toward

enema.

dilated

Tapered

cecum.

firms

the

diagnosis

the ascending
(cases
1 and
the

obstruction

Sharp

of right colon
volvulus
[2].
fluid level in the distended
and

of ascending

air-fluid

level

shows

bird-beak

colon
which
points
toward
2). Occasionally,
contrast

lytic

gastric
small

ileus,

diagnosis

and

of cecal

[1 2]. Correct

preoperative

of the

malpositioned

bascule

on demonstration

cecum.
enema

This may
secondary

and

if there

is gangrene

there
is no vascular
detonsion
and fixation

midgut
para-

Although
abdominal
films are suggesis necessary
to confirm
the diagnosis.

is resected

an

condition,
complicating

has a morbowel
is-

or arterial
The necrotic

exteniorization
or perforation

is encountered

by

a cecostomy,
so

rarely

compart

procedure

is

at surgery.

compromise,
as in our cases,
of the cecum
are performed.

fixation,
usually
accomplished
vides bowel
decompression.
volvulus

in-

the

cecal

volvulus,
obstruction,

occur
if there
is venous
to torsion
of the colon.

Cecal

volvulus

sigmoid
colon

chemia.
promise
bowel

of

1).

a serious
surgical
which
is due to

performed

obstruction

the dilated
cecum
material
may enter

Cecal
volvulus,
tality
of 1 0% [2]

of

cecum.

distension
[1 1 ],
bowel
obstruction,

depends

and distended
tive, a contrast

(arrow)

colon

in malpositioned

There
is often a single,
sharp
aircecum.
A contrast
enema
con-

partially
obstructed
cecum
(case
The radiologic
differential
diagnosis

cludes
volvulus,

(89%),

(60%),

[1 0]. The latter

of the bowel.
physical
findings

radiography
Plain
films

dominal

bowel

diverticulum
(case 2).
of colon
volvulus
are pain

shock,
and temperature
elevation
are late findings
implying
gangrene
Since
the early symptoms
and
nonspecific,
diagnosis.

Signifi-

include

intrapenitoneal

vomiting
(28%)
[1 0]. The most common
examination
are abdominal
distension,

volvulus
are
preoperative

in children.

Hirschsprung
contributing
due to central

1 ) and

Markedly
upright

postoperative
pregnancy,

constipation

%),

film.

Anteroposterior

volvulus

distal colon obstruction

(carcinoma,
Both
of our patients
had significant
malnotation
and bowel
distension
system

abdominal

B,

(arrows).

If

simple
Bowel
also

in infants

proand

422

REPORTS

children
that its true incidence
is unknown.
It is presumably
due to acquired
colon
distension
superimposed
on a con-

3.

genitally

4.

of

Downloaded from www.ajronline.org by 202.62.17.156 on 01/26/16 from IP address 202.62.17.156. Copyright ARRS. For personal use only; all rights reserved

CASE

mobile

cecal

adult.
therapy
entity

cecum.

volvulus

clinical

in children

However,
correct
may be delayed
in the

The

pediatric

are

diagnosis
because

and

radiologic

identical

to

features
those

and definitive
of unfamiliarity

patient.

Jacqueline

D. Wright

for preparing

and

typing

the

REFERENCES
1 . Rokitansky
C. Intestinal strangulation.
Arch Gen Med 1 837;i 4:
202-204
2. Kerry RI, Lee F, Ransom
HK. Roentgenologic
examination
in
the diagnosis
and treatment
of colon
and volvulus.
AJR
1971;i 13:343-348

1954;4i

February

volvulus.
colon.

McGraw
JP, Kremen AJ, Rigler LG. The roentgen
volvulus of the cecum. Surgery
1948;24:793-804
6. Allen RP, Nordstrom
JE. Volvulus
of the sigmoid
1964;9i

1981

Arch

Acta

Surg

Radiol

:141-155

5,

AJR

ACKNOWLEDGMENT
We thank
manuscript.

Meyers JR, Heifetz CJ, Baue AE. Cecal

1972;1 04:594-599
Frimann-DahI
J. Volvulus
of the right
(Stockh)

in the
surgical
with this

AJR:136,

diagnosis

of

in children.

:690-693

7. Hunter
JG, Keats TE. Sigmoid
volvulus
in children.
AJR
1970;1 08:621-623
8. Wilk PJ, Ross M, Leonidas
J. Sigmoid
volvulus in an 1 1-yearold girl. Am J Dis Child 1 974; 1 27 :400-402
9. Campbell
JR, Blank E. Sigmoid volvulus in children.
Pediatrics
I 974;53 : 702-705
10.

Kerry

11.

1969;99:21 5-222
Caruso
RD, Berk RN.
1 971 98 : 369-372

1 2.

RL,

Ransom

Bobroff

LM,

cecal

bascule.

Messinger
AJR

HK.

Volvulus

The
NH,

fuzzy

of

the

fluid

Subbarao

1 972; 1 1 5 :249-252

colon.

level

sign.

K, Beneventano

Arch

Surg

Radiology

TC. The