Evaluation of 18 CT signs in diagnosing cecal volvulus: a multi-reader retrospective study.

PURPOSE: To assess the diagnostic performance and reliability of 18 CT signs to diagnose cecal volvulus, a surgical emergency, versus a group of non-volvulus mimickers. MATERIALS AND METHODS: Four radiologists retrospectively and independently assessed 18 CT signs in 191 patients with cecal volvulus (n = 63) or a non-volvulus control group ((n = 128), including cecal bascule (n = 19), mobile cecum (n = 95), and colonic pseudo-obstruction (n = 14)) at a single institution from 2013 to 2021. Fleiss' kappa coefficient was used to assess inter-reader agreement. For diagnostic performance metrics, we assessed sensitivity, specificity, and positive and negative predictive values. For predictive performance, all 18 signs were included in bivariate and stepwise lasso multivariate logistic regression models to diagnose cecal volvulus. Performance was assessed by ROC curves. RESULTS: 191 patients (mean age: 63 years +/- 15.5 [SD]; 135 women) were included in the study. Nine of the 18 CT signs of cecal volvulus demonstrated good or better (> 0.6) inter-reader agreement. Individual CT signs with sensitivity, specificity, positive and negative predictive values all above 70% for diagnosing cecal volvulus were transition point, bird beak, and X-marks-the-spot. A lasso regression model determined four CT features: transition point, bird beak, coffee bean, and whirl had excellent prediction (AUC = .979) for cecal volvulus if all present. CONCLUSION: CT signs for cecal volvulus that have high sensitivity and specificity include: transition point, bird beak, and X-marks-the-spot and were reliable in distinguishing non-volvulus mimickers. If the following four features were present: transition point, bird beak, coffee bean, and whirl, there was excellent prediction (AUC = .979) for cecal volvulus.

'It's just a mucocele': a case report of a massive appendiceal mucocele presenting as a left upper quadrant mass.

Tumours of the appendix are very rare tumours that can and often present with a mucocele. This is a case report highlighting the associated pathology of appendix tumours and the management of a large mucocele. Specifically, how a right hemicolectomy is very rarely needed in these cases regardless of size and local anatomical relationships and some important considerations for the practicing surgeon in the non-tertiary centre that encounters a case like this.

Internal hernia through the foramen of Winslow: a rare cause of intestinal obstruction with imminent ischaemia of the caecum.

An internal hernia through the foramen of Winslow represents a rare surgical pathology. This report describes a case with incipient caecal ischaemia and discusses current diagnostic and therapeutic approaches. A patient in his early 60s presented at the emergency department with abdominal pain and last bowel movement three days prior. A CT scan of the abdomen suggested an internal hernia into the lesser sac. Intraoperatively, the suspected diagnosis could be confirmed laparoscopically with a twisted mobile caecum herniating through the foramen of Winslow. Due to a suspected ischaemia and laparoscopic frustrated reduction, a right open hemicolectomy was performed. The hernia gap was closed. The postoperative course was uneventful. Despite the rarity of internal hernias in patients without prior abdominal surgery, surgeons should be aware of this entity. The diagnosis can be difficult and sometimes only established intraoperatively. Open surgery is usually required. If the gap is clearly identified, the recommendations tend towards its closure.

Acute purulent diverticulitis in the cecum: case report.

A 40-year-old female with a 24-hour course of abdominal pain suggestive of acute appendicitis. An emergency laparotomy was performed, finding plastron in the cecum and ascending colon, color changes, with purulent liquid and 5 cm in diameter, fixed to Toldt's. It was decided to perform a right hemicolectomy with an ileotransverse end-to-side anastomosis with adequate postsurgical evolution. The histopathological report showed acute purulent diverticulitis of the cecum, which is very low incidence in the Mexican population, that's why this case report is carried out.

Mujer de 40 de años con cuadro de dolor abdominal de 24 h de evolución clínicamente sugestiva de apendicitis aguda. Se realiza laparotomía de urgencia, encontrando plastrón en ciego y colon ascendente, irregular, pétreo, con cambios de coloración, de 5 cm de diámetro, fijo a la fascia de Toldt, con líquido purulento. Se decide realizar hemicolectomía derecha con ileotransverso anastomosis terminolateral, con adecuada evolución posquirúrgica. El reporte histopatológico mostró diverticulitis aguda purulenta de ciego, lo cual es de baja incidencia en la población mexicana, motivo por el que se realiza este reporte de caso.

[Caecum hernia of foramen of Winslow]. / Hernie caecale du foramen de Winslow.

Winslow's foramen hernia, or Blandin's hernia, is a rare internal hernia with a non-specific clinical presentation and its diagnosis may be difficult. The hernia occurs across the omental hiatus, bounded by the inferior vena cava posteriorly and the portal triad anteriorly. CT imaging provides several diagnostic clues in this condition. Prompt surgical management allows reduction before complications arise. We present a case of caecal internal herniation through Winslow's foramen in a patient who underwent gastrojejunal bypass about ten years ago. Laparoscopy with reduction of the caecal bascule and closure of the foramen is performed successfully.

La hernie du foramen de Winslow, ou hernie de Blandin, est une hernie interne rare, avec une présentation clinique non spécifique et son diagnostic peut être difficile. La hernie se produit au travers de l'hiatus omental, limité par la veine cave inférieure en arrière et la triade portale en avant. L'imagerie médicale par tomodensitométrie nous fournit plusieurs indices diagnostiques dans cette pathologie. La prise en charge chirurgicale rapide permet une réduction avant la survenue de complications. Nous présentons un cas de hernie interne caecale par le foramen de Winslow chez un patient ayant bénéficié d'un bypass gastro-jéjunal une dizaine d'années auparavant. Une laparoscopie avec réduction de la bascule caecale et fermeture du foramen est réalisée avec succès.

Cecal-Colon Intussusception due to Appendiceal Mucinous Adenocarcinoma.

Intussusception is a rare presentation in adults and describes when one portion of the intestine telescopes into another portion. Intussusception is associated with malignancies serving as the lead point in adults. Appendiceal mucinous neoplasms are uncommon tumors often incidentally discovered during appendectomy procedures to manage acute appendicitis. Here we present a case report of an instance of mucinous adenocarcinoma of the appendix that manifested as a large bowel obstruction with intussusception limited to the colon, underscoring the possibility of concurrent intussusception and mucinous neoplasms. The case highlights the importance of meticulous diagnostic evaluation and management, particularly without well-defined treatment protocols. Appropriate diagnostic workup and management, including surgical intervention, are critical for patient outcomes and overall prognosis. The study recommends that patients diagnosed with confirmed or suspected appendiceal neoplasms undergo upfront oncologic resection where aggressive malignancy is a concern. Colonoscopy should be performed postoperatively for all patients to identify synchronous lesions.

Caecal volvulus in a 35-year-old man: a case report.

Caecal volvulus is a rare cause of mechanical bowel obstruction (1-1.5%) that carries a high mortality rate if diagnosis or surgical intervention is delayed. We report a 35-year-old man who presented with acute colicky abdominal pain, vomiting, and constipation for the past 18 hours. A plain abdominal X-ray showed distended large bowel loops with two large well-defined air-fluid levels superimposed on each other, suggestive of caecal volvulus. The patient underwent emergency laparotomy, and the intraoperative finding confirmed the diagnosis of gangrenous extended caecal volvulus, which involves the terminal ileum, cecum, and the whole of the ascending colon. A right hemicolectomy was performed, and bowel continuity was restored by primary ileotransverse anastomosis. The patient recovered without complications and was discharged on postoperative day 6. In conclusion, caecal volvulus is a rare cause of adult intestinal obstruction. Early diagnosis and surgical intervention can prevent perforation and reduce morbidity related to volvulus perforation.

Advanced Appendiceal Cancer with Systematic Metastasis without Gastrointestinal Symptoms Found by Subcutaneous Tumor.

An 86-year-old woman with a subcutaneous nodule in her left axilla visited our hospital. She had no gastrointestinal symptoms, but contrast-enhanced computed tomography revealed a cecal mass and systemic metastasis, including cutaneous, bone, peritoneal dissemination and ascites. Colonoscopy revealed a circumferential, elevated cecal lesion. She underwent right hemicolectomy to prevent colon obstruction. The pathological diagnosis was poorly differentiated adenocarcinoma (por1>tub2>muc) arising from the appendix with a BRAFV600E mutation and microsatellite instability-high. Chemotherapy was administered, and she is currently still alive and undergoing chemotherapy. We describe a rare case of advanced appendiceal cancer without gastrointestinal symptoms diagnosed due to cutaneous metastasis.

An Unusual Combination of Arthrogryposis, Gastroschisis, Cecal Volvulus, and Malignant Hyperthermia in a Young Woman: A Case Report.

BACKGROUND The purpose of this study is to discuss a patient with a history of conditions, including arthrogryposis, gastroschisis, and malignant hyperthermia, who presented with cecal volvulus requiring urgent surgical intervention. CASE REPORT A 29-year-old woman with a history of arthrogryposis, gastroschisis, malignant hyperthermia, and multiple childhood abdominal surgeries presents to the Emergency Department (ED) with 2 days of abdominal pain and bloody diarrhea. A CT abdomen/pelvis revealed findings concerning for a cecal volvulus. The patient was premedicated and monitored closely by the anesthesia team due to her history of malignant hyperthermia. She underwent an exploratory laparotomy, where a dilated cecum and proximal ascending colon were found to be completely volvulized around the mesentery. Manual bowel detorsion was performed, which resulted in reperfusion of the ischemic-appearing bowel, which then appeared viable. She recovered well after the procedure and was discharged on postoperative day 5. CONCLUSIONS This case highlights a patient who presented with a combination of 4 findings: arthrogryposis, gastroschisis, malignant hyperthermia, and cecal volvulus. With arthrogryposis reported to be associated with gastroschisis and malignant hyperthermia, this report not only corroborates this association, but also aims to draw attention to the fact that these conditions have potential to occur jointly with cecal volvulus. Given the patient's history of gastroschisis requiring extensive abdominal surgeries that contribute as risk factors for cecal volvulus, it is possible there may be other arthrogryposis patients who present with cecal volvulus similar to that seen in this patient.

Colonic sand impaction with cecal rupture and peritonitis in an adult African savanna elephant, and review of noninfectious causes of gastrointestinal disease in elephants.

Gastrointestinal disorders are among the most common disease processes in captive elephants. Colic is a frequent clinical presentation and may have several infectious and noninfectious causes. Ingestion of sand has been reported in elephants living in enclosures with loose sandy soils. Similar to the situation in horses, sand ingestion can cause intestinal impaction and colic in elephants. Here we describe a case of colonic sand impaction with cecal rupture and peritonitis in an African savanna elephant from a zoologic collection that died after several days of colic. On autopsy, abundant, gritty, sandy material was found within a segment of colon immediately aboral to the cecum. There was a full-thickness tear in the cecal wall, free intestinal contents within the abdominal cavity, and peritonitis. To our knowledge, the postmortem examination of an elephant with sand impaction and cecal rupture has not been reported previously; this condition should be included among the differential diagnoses in elephants with colic. We review the reports of noninfectious causes of gastrointestinal disease in elephants, which include cases of small intestinal and colonic torsion and of intestinal obstruction by fecal boluses.

The Cecum Revisited: A Multimodality Imaging Case-based Review of Common and Uncommon Cecal Diseases.

A wide range of conditions involving the cecum may be found in patients undergoing imaging work-up for conditions as various as right lower pain, diarrhea, fever, and weight loss. The cecum may be the only area of involvement by a particular disease. However, it may also be affected by a more diffuse process of the gastrointestinal tract or even as part of systemic diseases. Imaging provides an excellent evaluation of the cecal region and its surrounding planes, with an impactful clinical application in multiple scenarios. While typical features in many situations allow establishing a confident diagnosis, there are also challenging entities with overlapping features, making it critical for the radiologist awareness of the whole gamut of these conditions, as well as the ability to correlate imaging findings with other clinical data. Additional challenges to the imaging evaluation include anatomical variations of the cecal position and the absence of proper colonic distention in some cases. This article aims to revisit the spectrum of cross-sectional imaging features of common and uncommon pathologies involving the cecum, ranging from inflammatory and infectious to vascular and neoplastic ones.

Case Report: Caecal volvulus management from diagnosis to treatment in a young patient.

Caecal volvulus (CV) is a rare cause of intestinal obstruction, defined by an axial torsion of the caecum, ascending colon, and terminal ileum around the mesenteric vascular pedicles, leading to ischemia and bowel necrosis. A 20-year-old woman, with no significant medical history, was admitted for generalized abdominal pain evolving for three days, along with constipation and abdominal distension, but with no vomiting. Physical examination showed a generalized abdominal tenderness with no rigidity or rebound tenderness, associated with abdominal distension and tympanic upon percussion. Laboratory findings were within normal limits. An abdominal computed tomography scan revealed distension of a loop of the large bowel with its long axis extending from the right lower quadrant to the epigastrium or left upper quadrant. Colonic haustral pattern was absent. An abdominal computed tomography scan showed a rounded focal collection of air-distended bowel with haustral creases in the upper left quadrant. In addition, spiraled loops of the collapsed cecum (giving a whirl sign) were noted, along with low-attenuating fatty mesentery from the twisted bowel. The patient underwent an emergency laparotomy and caecectomy using GEA 80 charges. The patient had no complaints post-operation. CV is a rare cause of bowel obstruction, mainly caused by an exceedingly mobile caecum. Despite its rareness, CV represents the second most common cause of large bowel volvulus, behind sigmoid volvulus. For acute obstruction by CV, it is hard to differentiate it clinically from obstruction of the small bowel; therefore, radiological exams are needed. Surgery is the gold standard treatment for CV. We report a rare case of CV to highlight the rarity of this pathology, specify its diagnostic and therapeutic means, and its clinical and biological evolution.

Rare Pediatric Cecal Anomalies: A Lesson in Pediatric Surgery.

BACKGROUND: Rare incidence cases are part of the routine work of pediatric surgeons. Cecal anomalies in children are an example of such cases. Objectives: To describe the presentation, workup, management and outcome of rare cecal anomalies in children and to analyze the skills needed for their successful treatment. METHODS: A retrospective chart review was conducted of all cases of cecal anomalies managed by the pediatric surgical service at a tertiary hospital from June 2017 to January 2020. Data regarding demographics, clinical presentation, radiological studies, surgical treatment, pathology, complications, and outcome were collected. RESULTS: Five cases of cecal anomalies were encountered over a period of 32 months, including a cecal volvulus, cecal duplication, cecal intussusception, and two cecal masses (one ulcerated lipoma and one polyp). All patients, except the patient with cecal duplication, presented acutely and were managed surgically. Long-term follow-up of 17-24 months was unremarkable in all cases. CONCLUSIONS: A wide knowledge base, careful judgment, and creativity enable pediatric surgeons to successfully treat rare conditions such as rare cecal anomalies. These skills should be part of the education of pediatric surgery trainees.

[Cecal volvulus: one case and literature review]. / Vólvulo cecal: un caso y revisión de la literatura.

Background: Cecal volvulus is a rare disease that causes intestinal obstruction. It has various congenital and acquired risk factors. It is frequently associated with abnormal cecal fixation, and it is caused by torsion of the cecum in one of its three axes. It is not different from other causes of intestinal obstruction, but a delay in its diagnosis can lead to ischemia, necrosis and colon perforation. Its management depends on the viability of the tissues, ranging from untwisting and cecopexy to hemicolectomy with or without anastomosis. We present a case of caecal volvulus (caecal bascule) and review the literature as well. Clinical case: 43-year-old female, who was admitted to an emergency department with data of intestinal obstruction. A simple tomography of the abdomen was performed, where a dilated colon and an image that resembles an inverted coffee bean were identified. An exploratory laparotomy was performed, identifying a bascule-type cecal volvulus, without vascular compromise. Devolvulation, decompression through appendectomy, and caecopexy were performed. After the surgical event, the patient recovered without incident and was discharged with adequate controls by external consultation. Conclusions: Cecal volvulus is a cause of intestinal obstruction with a low incidence, which is why early recognition and treatment are key to avoiding the complications that its evolution entails. This type of disease should be among our differential diagnoses, since treatment is surgical and delay leads to a high mortality rate.

Introducción: el vólvulo cecal es una enfermedad poco común que causa obstrucción intestinal. Tiene diversos factores de riesgo congénitos y adquiridos. Se suele asociar a una fijación cecal anormal y se produce por la torsión del ciego en alguno de sus tres ejes. No se diferencia de otras causas de obstrucción intestinal, pero un retraso en su diagnóstico puede derivar en isquemia, necrosis y perforación del colon. El manejo depende de la viabilidad de los tejidos y va desde la destorsión y cecopexia hasta la hemicolectomía con o sin anastomosis. Se presenta un caso de vólvulo cecal (báscula cecal) y se hace una revisión del tema. Caso clínico: mujer de 43 años que ingresó a un servicio de urgencias con datos de obstrucción intestinal. Se realizó tomografía simple de abdomen donde se identificó dilatación del colon e imagen que semejaba un grano de café invertido. Se hizo laparotomía exploradora y se identificó vólvulo cecal del tipo báscula, sin compromiso vascular. Se realizó desvolvulación, descompresión a través de apendicectomía, y cecopexia. Posterior a evento quirúrgico, la paciente se recuperó sin incidentes y fue dada de alta con controles adecuados por consulta externa. Conclusiones: el vólvulo cecal es una causa de obstrucción intestinal con baja incidencia, por lo que el reconocimiento y tratamiento precoz son claves para evitar las complicaciones que conlleva su libre evolución. Este tipo de enfermedad debe de estar entre nuestros diagnósticos diferenciales, ya que el tratamiento es quirúrgico y el retraso conlleva a una alta tasa de mortalidad.

Cecal Diverticulitis: A Diagnosis to Keep in Mind When Evaluating Acute Appendicitis.

Cecal diverticulitis is a rare cause of right lower-quadrant abdominal pain. As its symptoms mimic those of acute appendicitis, the final diagnosis in the patients is generally confirmed after surgery. Herein, we report a 45-year man who was admitted to the department of emergency with lower right abdominal pain. Cecal diverticulitis was diagnosed on computed tomography (CT) images, and a conservative treatment approach was recommended. He was hospitalised, and intravenous antibiotics and hydration were administered immediately. Oral feeding was interrupted. After five days of intensive medical care, the patient was discharged without any further complications. Based on my experience, I advise that CT can be used to differentiate cecal diverticulitis from the acute appendicitis. In uncomplicated cases, conservative approaches are advised. Key Words: Cecal diverticulitis, Computed tomography, Acute appendicitis, Conservative treatment.