The diagnosis is sigmoid volvulus.
The loop of sigmoid colon has a classical bean shape, with the apex over the S2/3 junction in the left iliac fossa with the loop of sigmoid colon distending covering the liver and descending colon.
The most important feature of a sigmoid volvulus rather than a large redundant distended loop of sigmoid colon is the absence of haustra.
What is your diagnosis?
This is caecal volvulus.
Supine radiograph shows a distended upturned cecum with the configuration of a reversed letter C. there is gas-filled small bowel, paucity of gas in the ascending colon, and gas in the rectum.
This is caecal volvulus.
Supine radiograph shows a distended upturned cecum with the configuration of a reversed letter C. there is gas-filled small bowel, paucity of gas in the ascending colon, and gas in the rectum.
What is your diagnosis?
Toxic megacolon is defined as acute dilation of the transverse colon to 5.5 cm or more / caecum more than 9 cm and loss of haustrations during a severe attack of colitis, which can be of varied etiologies.
Approximately half of UC patients who develop toxic megacolon do so within the first three months of diagnosis, although overall this condition occurs in only 5% of patients with UC.
It most often occurs in patients with extensive or pancolitis but can occur with disease limited to the left colon.
Predisposing factors include electrolyte imbalance, use of drugs that slow motility such as anticholinergics and narcotics, and procedures such as colonoscopy and barium enema performed during an acute colitis attack.
Clinically, patients may develop fever, tachycardia, hypotension, diffuse abdominal distention and tenderness, and hypoactive bowel sounds. Leukocytosis and metabolic alkalosis may be seen on laboratory tests.
Although certainly a surgical consultation should be initiated when toxic megacolon develops, medical therapy remains the first-line therapy for this condition, unless perforation is suspected or imminent (increasing abdominal distention with peritoneal signs and/or hemodynamic instability).
Medical therapy includes treatment of the underlying inflammation, bowel rest, volume/electrolyte repletion, cessation of any antimotility agents, and colonic decompression. Antibiotics are generally given empirically because the mortality risk greatly increases if sepsis develops. If patients do not improve in 48 to 72 hours, then colectomy should be performed.
Approximately 50% of patients will generally require surgery.
Causes of toxic megacolon include inflammatory bowel disease, amoebic dysentery, Shigella, Salmonella and Campylobacter enteritis.
ReplyDeleteThe classic radiologic feature of a sigmoid volvulus is a distended ahaustral sigmoid loop (bent inner tube) appearance, the apex of which often is directed toward the patient’s right shoulder. The classic features of cecal volvulus include a massively dilated cecum located in the epigastrium or left upper quadrant, a coffee bean appearance of the distended cecum, distended loops of small bowel suggesting SBO, and a single long air–fluid level present on upright or decubitus films. A colon cutoff sign is seen in pancreatitis.
ReplyDeleteCecal volvulus: the dilated loop of colon directed toward left upper abdomen, often with only one air-fluid level.The dilated cecum may have a “reverse C” configuration
ReplyDeleteSigmoid volvulus is the third leading cause of large bowel obstruction after diverticulitis and carcinoma in Western countries. In Western countries sigmoid volvulus is usually acquired from long-standing constipation, Parkinson disease, Alzheimer disease, or chronic debilitation. In other countries, Chagas disease and extreme high-fiber diet are causes. Radiographic findings include a “coffee bean” or “kidney bean” sign referring to a closed loop of sigmoid distended with gas, with apposed medial walls of dilated bowel forming an oblique line that resembles the cleft of a coffee bean. The dilated sigmoid classically points to right upper quadrant, but may be midline or leftward. On contrast enema, the twist in the bowel has a bird’s beak appearance. The CT “whirl” sign, which is a visible twisting of both bowel and mesenteric vessels by over 180 degrees, is a known sign of volvulus but is nonspecific. Moderate or severe dilatation of the sigmoid with a sigmoid transition point is a more specific finding.
ReplyDeleteCecal volvulus is less common and occurs in slightly younger patients than sigmoid volvulus; it accounts for 25 to 40 percent of cases of volvulus of the colon and about 1 percent of intestinal obstruction. Inadequate fixation and persistence of an ascending colon mesentery, or incomplete embryologic rotation of the bowel, results in a freely mobile cecum and an increased risk for cecal volvulus formation. Typically, patients develop sudden onset of abdominal pain and distention. Less commonly, patients may present with more chronic abdominal symptoms. Early diagnosis is of utmost importance because a delay in diagnosis increases the risk of vascular compromise and subsequent bowel necrosis.
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