Presentation
Eight hours of high-intensity epigastric pain associated with nausea and emesis. History of gastric bypass and hysterectomy. The blood count reports 10920 leukocytes and 59% neutrophils. Amylase 88 mg/dl, alkaline phosphatase 84 mg/dl.
Patient Data
PA erect abdominal radiograph displayed dilated viscus in the upper mid abdomen with one air-fluid level. No air is seen in the rectal ampulla and no loops of the large intestine are seen in the right lower quadrant.
AP supine abdominal radiograph shows haustral folds into this dilated loop indicating that it belongs to the large intestine.
Axial and coronal reformatted CT images show a dilated cecum, with a visible air-fluid level, located in the left upper quadrant.
In the mid-abdomen, there is a mesentery twist ("whirl" sign) around the ileocolic artery.
There are no colonic loops on the right side of the abdomen, and there is decompressed descending colon in the left upper quadrant.
The small intestinal loops are located in the right hemiabdomen.
The afferent and efferent loops of the volvulus make up the X-marks-the-spot sign.
Post-surgical changes due to partial gastrectomy are identified.
Ascitic fluid is identified in the peri-splenic space and in the pelvic cavity, which has a density of 3 HU. Nodules are also identified in the mesentery of the right sub-diaphragmatic region that reaches up to 8 mm in diameter.
The uterus is absent.
Case Discussion
The findings are consistent with a cecal volvulus; a type of intestinal volvulus in which the cecum rotates around its mesentery producing a closed-loop intestinal obstruction 1. Sigmoid volvulus is its main differential diagnosis 1,2.
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