Endgames Spot Diagnosis

A woman with abdominal distension and pain

BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i1382 (Published 22 March 2016) Cite this as: BMJ 2016;352:i1382
  1. Joseph Dalby Sinnott, core surgical trainee1,
  2. David C Howlett, consultant radiologist2
  1. 1 Eastbourne, ESHT, Eastbourne, UK2 Department of Radiology, East Sussex Hospitals NHS Trust, Eastbourne, UK
  1. Correspondence to: J D Sinnott j.d.sinnott{at}gmail.com

A 40 year old woman presented to the surgical assessment unit with a 12 hour history of abdominal distension and tenderness. She had not opened her bowels or passed wind since her symptoms started. An abdominal radiograph was requested—what does it show (fig 1)?


The abdominal radiograph shows a caecal volvulus.


Caecal volvulus is much less common than sigmoid volvulus because the caecum is usually less mobile. It can be difficult to distinguish between the two on abdominal radiography, although several different features can be useful. In caecal volvulus there is likely to be small bowel dilation, which is usually seen in the right iliac fossa. The caecum itself usually rotates away from the right lower quadrant up into the central abdomen (fig 2; arrows). The famous “coffee bean” sign is rarely seen in caecal volvulus. Also, as shown here, in caecal volvulus the distal bowel collapses, whereas it is dilated in sigmoid volvulus. Nevertheless, plain radiography alone is often not enough to make the diagnosis, and computed tomography should be performed if caecal volvulus is suspected. This technique can also locate the exact position of the twist, look for signs of ischaemia, and rule out other differential diagnoses such as large bowel obstruction secondary to cancer. Furthermore, computed tomography helps in operative planning because caecal volvulus is usually managed with a right hemicolectomy.


Fig 2 Abdominal radiograph showing a caecal volvulus (arrows). The caecum has rotated into the central abdomen and dilated small bowel loops are present within the right lower quadrant


  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: none.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Patient consent obtained.

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