Presentation
Abdominal distension and vomiting.
Patient Data
Markedly dilated loops of small bowel, and a dilated transverse colon is seen on the chest x-ray. The chest x-ray is taken standing up (erect) and shows air-fluid levels in both the small and large bowel. On the abdominal x-ray, there is no gas seen in the large bowel beyond the splenic flexure. The upper abdominal x-ray shows an abrupt transition from distended to collapsed colon just beyond the splenic flexure (colonic cut-off sign). The findings indicate small and large bowel obstruction.
A CT of the chest, abdomen and pelvis should be the next step as the findings are suspicious for a colonic malignancy.
The CT confirms a tight stricture involving the proximal descending colon with marked proximal colonic distension.
Case Discussion
The colon cut-off sign has been described most commonly with acute pancreatitis, secondary to the inflammation extending to the splenic flexure via the phrenicocolic ligament. However, the degree of distension is not as much as in a true colonic stricture, with much of the small bowel distension in pancreatitis being due to ileus. If you see this pattern of x-ray findings in somebody with abdominal distension without features of acute pancreatitis, a malignant stricture should be suspected and CT of the chest, abdomen and pelvis arranged.
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