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Journal of Postgraduate Medicine, Vol. 49, No. 1, Jan-March, 2003, pp. 74, 77 Spot the Diagnosis Saklani AP, Satheshkumar T, Nagabhushan J, Delicata RJ Department of Surgery, Nevill Hall Hospital, Abergavenny, NP7 7EG, UK. E-mail: asaklani@hotmail.com Code Number: jp03028 A 73-year-old lady was admitted with abdominal pain, vomiting and significant weight loss. Her initial biochemical profiles were normal. Plain radiographs of the chest and abdomen were normal. An abdominal ultrasound scan revealed stones in the gallbladder as well as in the common bile duct. She underwent endoscopic retrograde cholangiopancreaticography (ERCP) with removal of duct stones. Three days later, she developed severe abdominal pain associated with abdominal distension and obstipation. The plain radiograph done at this stage is depicted as Figure 1. What is the Diagnosis? Answer An emergency laparotomy was performed. It revealed a sigmoid volvulus with pre-gangrenous changes. Incidentally, she also had metastatic peritoneal nodules; the source of primary could not be identified. She underwent right hemicolectomy and both ends of the bowel were exteriorized. Histopathological examination revealed metastatic adenocarcinoma. However, no primary neoplasm was identified in the resected colon. Caecal volvulus represents 20-40% of all cases of colonic volvulus. About 90% of these patients have an axial twist of a segment of proximal colon as in our case, while in the remainder there is a cephalad portion of the caecum across ascending colon (caecal basecule). Caecal volvulus is associated with a mobile caecum, which usually follows malrotation of the colon, setting the stage for torsion around the pedicle of ileocolic artery. Besides caecal mobility, adhesions due to previous surgery and colonic distension due to distal obstruction have been implicated in the progression to caecal volvulus. Plain radiographs are diagnostic in sixty percent of cases, however they may be mistaken for obstruction secondary to neoplasm. The dilated caecum assumes a "comma shape", retains haustral patterns and frequently occupies the central or the left upper quadrant with its convexity towards left side. There will also be evidence of small bowel obstruction. Copyright 2003 - Journal of Postgraduate Medicine. Online full-text also available at http://www.jpgmonline.com/ The following images related to this document are available:Photo images[jp03028f1.jpg] |
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