Ileocolic vascular curvature: a new CT finding of cecal volvulus
Authors: Margaret Wong, R. Brooke Jeffrey, Adam N. Rucker, Eric W. Olcott
Journal Abdominal Radiology 2020 Oct; 45(10):3057-3064.
doi: https://doi.org/10.1007/s00261-020-02491-w
Dr. Smarda Magdalini, Radiology Consultant at Computed Tomography Department of Konstantopouleio General Hospital of Athens, Greece
Cecal volvulus constitutes a relatively rare and potentially fatal emergency condition, in need for immediate open surgery. Less invasive methods of treatment (for example operative detorsion, cecopexy and cecostomy) have been proven to be associated with more complications and higher rates of mortality, so they are not usually preferred [1, 2].
The symptoms of cecal volvulus are not specific and therefore, the clinical image can be misleading. Patients often present to the hospital with acute abdominal pain, abdominal distention, nausea, vomiting and reduction – inhibition of stool output, that is, with symptoms of bowel dilatation of any reason [3].
Apart from the aforementioned nonspecific clinical findings, laboratory findings are also not typical for the disease. So, abdominal imaging and specifically imaging evaluation with computed tomography (CT), plays an important role in the early diagnosis of this potentially fatal nosological entity. Several imaging CT features have been proposed so far as indicative of this condition, including the ‘whirl’ sign, the ‘coffee bean’ sign, decompression of the colon distally to the cecum, small bowel dilation, transition point existence, abnormal appendix position (near the midline, with small bowel being lateral to the cecum) and finally, the ectopic position of cecum [4 – 7].
This article focuses on a new CT observation concerning a mesenteric vasculature differentiation in patients with cecal volvulus that has not been described so far in the literature. More specifically, the authors of this article reported a hook-like curvature of distal ileocolic vessels (‘ileocolic vascular curvature’) in the vast majority of patients who had undergone an urgent abdominal CT examination at their Department because of having the aforementioned symptoms, and afterwards, they proved to suffer from this emergency condition. This finding contradicts the normal linear course of ileocolic vasculature encountered in patients without proven cecal volvulus. A patient search was conducted using the Department’s Picture Archiving and Communication System (PACS) throughout 12.5 years and with the selection of keywords relative to the disease in the Department’s existing CT reports, using the institution’s search engine.
A total number of 14 patients with cecal volvulus from the original CT reports were compared with 40 control patients with cecum dilation without volvulus on original CT reports concerning the existence of the above-mentioned CT features, including ileocolic vascular curvature. Among all 8 CT features examined in this quantitative study, only ileocolic vascular curvature and ectopic cecum were independently and significantly associated with cecal volvulus in multivariable regression (odds ratio 178, p = 0.014, and 63, p = 0.013, respectively). In addition, their sensitivity (12/14 [85.7%, 95% CI 57.2–98.2%] and 13/14 [92.9%, 95% CI 66.1–99.8%], respectively) and specificity (40/40 [100.0%, 95% CI 91.2–100.0%] and 38/40 [95.0%, 95% CI 83.1–99.4%], respectively) were high, differing remarkably from the respective percentages of the rest CT features, which approximated 50%.
The most important limitation of this study is the small sample size, also encountered in previously published studies of the same topic, having to do with the infrequent occurrence of this emergency condition. The small number of patients is considered to be the reason for the deviations of findings between this study and the few previously published quantitative studies concerning the same pathology [8, 9]. It should be pointed out as well, that differences in the results among relevant studies may reflect differences in study design (for example, different criteria for the selection of patients taking part in the study). In addition, this study’s low sensitivity and/or specificity of most CT features apart from ileocolic vascular curvature and ectopic cecum may not correspond to reality, since these values could change dramatically with substantially larger sample size.
To conclude, the new CT observation of ileocolic vascular curvature in patients with cecal volvulus may prove to be a valuable tool for the diagnosis of this relatively rare but of high mortality condition if diagnostically missed. Further studies with larger sample sizes could provide more safe results concerning the contribution of this new CT finding in the diagnosis and treatment of cecal volvulus.
References:
[1] Halabi WJ, Jafari MD, Kang CY, Nguyen VQ, Carmichael JC, Mills S, igazzi A, Stamos MJ (2014) Colonic volvulus in the United States: trends, outcomes, and predictors of mortality. Ann Surg 259 (2): 293–301
[2] Madiba TE, Thomson SR (2002) The management of cecal volvulus. Dis Colon Rectum 45 (2): 264–267
[3] Gingold D, Murrell Z (2012) Management of colonic volvulus. Clin Colon Rectal Surg 25 (4): 236–244
[4] Fisher JK (1981) Computed tomographic diagnosis of volvulus in intestinal malrotation. Radiology 140 (1): 145–146.
[5] Frank AJ, Goffner LB, Fruauff AA, Losada RA (1993) Cecal volvulus: the CT whirl sign. Abdom Imaging 18 (3): 288–289
[6] Moore CJ, Corl FM, Fishman EK (2001) CT of cecal volvulus: unraveling the image. AJR Am J Roentgenol 177 (1): 95–98
[7] Figiel LS, Figiel SJ (1953) Volvulus of the cecum and ascending colon. Radiology 61 (4): 496–515
[8] Dane B, Hindman N, Johnson E, Rosenkrantz AB (2017) Utility of CT Findings in the Diagnosis of Cecal Volvulus. AJR Am J Roentgenol 209 (4): 762–766
[9] Rosenblat JM, Rozenblit AM, Wolf EL, DuBrow RA, Den EI, Levsky JM (2010) Findings of cecal volvulus at CT. Radiology 256 (1): 169–175
Dr. and PhD. Smarda Magdalini is a Radiology Consultant at Computed Tomography Department of Konstantopouleio General Hospital of Athens, Greece. She has completed postgraduate studies in Interventional Radiology and Vascular Imaging as well. Her main interests in Diagnostic Radiology are Abdominal and Vascular Imaging and recently, Neuroimaging.
Comments may be sent to magda.3110@hotmail.com