Endgames Picture Quiz

A woman with a distended abdomen

BMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c5878 (Published 01 December 2010) Cite this as: BMJ 2010;341:c5878
  1. A Shaw, specialist registrar in radiology1,
  2. B Smith, specialist registrar in radiology1,
  3. D Howlett, consultant radiologist1
  1. 1Eastbourne District General Hospital, East Sussex Hospitals Trust, Eastbourne BN21 2UD, UK
  1. Correspondence to: A Shaw aidanshaw1{at}gmail.com

A 78 year old woman presented with sudden onset colicky abdominal pain and vomiting. She had not opened her bowels or passed flatus for 24 hours but reported no change in her bowel habit. She described a history of intermittent right lower quadrant pain that resolved with flatus. She had no other medical history of note.

On examination she had a distended abdomen with generalised abdominal tenderness and guarding in the right iliac fossa. Auscultation showed tinkling bowel sounds. She underwent plain radiography of the abdomen (fig 1).

Fig 1 Plain radiograph of the abdomen

Questions

  • 1 What are the radiological findings?

  • 2 What is the likely diagnosis?

  • 3 What further tests could you perform to confirm the diagnosis?

  • 4 How would you manage this condition?

Answers

1 What are the radiological findings?

Short answer

The plain radiograph shows a markedly dilated loop of large bowel with its axis running from the right lower quadrant and visible haustra (fig 2).

Fig 2 Plain radiograph of the abdomen showing a markedly dilated loop of large bowel with its axis running from the right lower quadrant and visible haustra (arrows)

Long answer

The findings on plain radiography of the abdomen are consistent with the diagnosis of a caecal volvulus. The most prevalent radiographic findings, in descending order of frequency, include caecal dilatation, a single air fluid level, small bowel dilatation, and absence of gas in the distal colon.1 2 There is usually a large distended loop of large bowel with the axis in the right lower quadrant, but because the caecum of patients presenting with a caecal volvulus is very mobile, it may be anywhere within the abdomen. The classic “comma” sign, …

View Full Text

Sign in

Log in through your institution

Free trial

Register for a free trial to thebmj.com to receive unlimited access to all content on thebmj.com for 14 days.
Sign up for a free trial

Subscribe