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Adult Female with Abdominal Pain
The Journal of Emergency Medicine, Vol. 54, No. 3, pp. e59–e60, 2018 Ó 2018 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
https://doi.org/10.1016/j.jemermed.2017.09.002
Visual Diagnosis in Emergency Medicine
ADULT FEMALE WITH ABDOMINAL PAIN Juwarat A. Kadiri, MD, Sarah E. Frasure, MD, and Heidi H. Kimberly, MD Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: Sarah E. Frasure, MD, Department of Emergency Medicine, Brigham and Women’s Hospital, Neville House – 236A, 75 Francis St., Boston, MA 02115
INTRODUCTION We present a case of a young woman with diffuse abdominal pain, normal vital signs, and normal bloodwork, who was ultimately diagnosed with a cecal volvulus, after the emergency physician performed a screening point-ofcare abdominal ultrasound, which demonstrated significant air reverberation artifact, prompting further imaging. Case Presentation A 26-year-old woman with a history of irritable bowel syndrome (IBS) presented to the Emergency Department with 1 day of diffuse abdominal pain and distention. She also complained of nausea and nonbloody, nonbilious vomiting. She denied constipation or diarrhea. Her abdominal pain was described as worse than prior IBS flares. Her vital signs were unremarkable. Her physical examination was notable for a mildly distended abdomen with mild diffuse tenderness to palpation. The emergency physician administered antiemetic and analgesic medications as well as intravenous fluids. Blood and urine laboratory testing were unremarkable. A point-of-care ultrasound of the abdomen was performed (Figure 1). A computed tomography (CT) scan of the abdomen and pelvis was subsequently ordered, and the results prompted a surgical consult (Figure 2).
Figure 1. Sagittal image of the left upper quadrant with a curvilinear transducer, which demonstrates air reverberation artifact (multiple horizontal A-lines). The arrow is pointing towards the A-line artifact.
DISCUSSION Cecal volvulus occurs when the ascending colon twists on itself, causing obstruction of the gastrointestinal tract and impedance of mesenteric blood flow. Cecal volvulus accounts for 1–3% of adult intestinal obstructions and is more common in younger patients (30–60 years of age) (1). Approximately 20% of the population is at risk for cecal volvulus due to a congenitally hypermobile cecum as a result of abnormal fusion of the mesentery to the
RECEIVED: 7 April 2017; FINAL SUBMISSION RECEIVED: 4 August 2017; ACCEPTED: 14 September 2017 e59
e60
Figure 2. Coronal computed tomography image with dilatated loops of large bowel (arrow).
parietal peritoneum (1–3). Point-of-care ultrasound of the abdomen using a curvilinear probe and a ‘‘mowing the lawn’’ pattern can be used for the detection of small bowel obstruction (4). In this case, however, the bedside ultrasound identified a significant air reverberation artifact (horizontal A lines), which could represent distended air-filled colon or intraperitoneal free air, thus prompting further imaging. A typical scanning protocol to screen for pneumoperitoneum with bedside ultrasound involves placement of the patient in a semi-lateral left decubitus position and evaluating the right hypogastric and epigastric area using the liver as an acoustic window (5). In this patient, the air reverberation artifact occurred diffusely throughout the abdomen, making pneumoperitoneum
J. A. Kadiri et al.
less likely. CT imaging demonstrated extremely dilatated, air-filled cecum with haustral creases, a typical CT finding of cecal volvulus (6). A ‘‘whirl’’ sign is a highly specific finding in volvulus, and is seen in both cecal and sigmoid volvulus. The source of the twist, identified as the eye of the whirl on CT imaging, can differentiate between cecal and sigmoid volvulus; the former originates at the cecum, and the latter originates in the sigmoid. Although conservative management, with colonoscopy or barium enemas, has been studied, there is an increased risk of perforation and recurrence (7). Thus, cecal volvulus is primarily managed surgically. Our patient was taken to the operating room for an exploratory laparotomy and right colectomy. She had an uncomplicated postsurgical course and was discharged from the hospital 1 week later. REFERENCES 1. Ballantyne GH, Brandner MD, Beart RW Jr, Ilstrup DM. Volvulus of the colon. Incidence and mortality. Ann Surg 1985;202:83–92. 2. Haskin PH, Teplick SK, Teplick JG, Haskin ME. Volvulus of the cecum and right colon. JAMA 1981;245:2433–5. 3. Madiba TE, Thomson SR. The management of cecal volvulus. Dis Colon Rectum 2002;45:264–7. 4. Jang TB, Schindler D, Kaji AH. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J 2011;28:676–8. 5. Hoffman B, Nurnberg D, Westergaard MC. Focus on abdominal air: diagnostic ultrasonography for the acute abdomen. Eur J Emerg Med 2012;19:284–91. 6. Moore CJ, Corl FM, Fishman EK. CT of cecal volvulus: unraveling the image. AJR Am J Roentgenol 2001;177:95–8. 7. Consorti ET, Liu TH. Diagnosis and treatment of caecal volvulus. Postgrad Med J 2005;81:772–6.
https://doi.org/10.1016/j.jemermed.2017.09.002
Visual Diagnosis in Emergency Medicine
ADULT FEMALE WITH ABDOMINAL PAIN Juwarat A. Kadiri, MD, Sarah E. Frasure, MD, and Heidi H. Kimberly, MD Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: Sarah E. Frasure, MD, Department of Emergency Medicine, Brigham and Women’s Hospital, Neville House – 236A, 75 Francis St., Boston, MA 02115
INTRODUCTION We present a case of a young woman with diffuse abdominal pain, normal vital signs, and normal bloodwork, who was ultimately diagnosed with a cecal volvulus, after the emergency physician performed a screening point-ofcare abdominal ultrasound, which demonstrated significant air reverberation artifact, prompting further imaging. Case Presentation A 26-year-old woman with a history of irritable bowel syndrome (IBS) presented to the Emergency Department with 1 day of diffuse abdominal pain and distention. She also complained of nausea and nonbloody, nonbilious vomiting. She denied constipation or diarrhea. Her abdominal pain was described as worse than prior IBS flares. Her vital signs were unremarkable. Her physical examination was notable for a mildly distended abdomen with mild diffuse tenderness to palpation. The emergency physician administered antiemetic and analgesic medications as well as intravenous fluids. Blood and urine laboratory testing were unremarkable. A point-of-care ultrasound of the abdomen was performed (Figure 1). A computed tomography (CT) scan of the abdomen and pelvis was subsequently ordered, and the results prompted a surgical consult (Figure 2).
Figure 1. Sagittal image of the left upper quadrant with a curvilinear transducer, which demonstrates air reverberation artifact (multiple horizontal A-lines). The arrow is pointing towards the A-line artifact.
DISCUSSION Cecal volvulus occurs when the ascending colon twists on itself, causing obstruction of the gastrointestinal tract and impedance of mesenteric blood flow. Cecal volvulus accounts for 1–3% of adult intestinal obstructions and is more common in younger patients (30–60 years of age) (1). Approximately 20% of the population is at risk for cecal volvulus due to a congenitally hypermobile cecum as a result of abnormal fusion of the mesentery to the
RECEIVED: 7 April 2017; FINAL SUBMISSION RECEIVED: 4 August 2017; ACCEPTED: 14 September 2017 e59
e60
Figure 2. Coronal computed tomography image with dilatated loops of large bowel (arrow).
parietal peritoneum (1–3). Point-of-care ultrasound of the abdomen using a curvilinear probe and a ‘‘mowing the lawn’’ pattern can be used for the detection of small bowel obstruction (4). In this case, however, the bedside ultrasound identified a significant air reverberation artifact (horizontal A lines), which could represent distended air-filled colon or intraperitoneal free air, thus prompting further imaging. A typical scanning protocol to screen for pneumoperitoneum with bedside ultrasound involves placement of the patient in a semi-lateral left decubitus position and evaluating the right hypogastric and epigastric area using the liver as an acoustic window (5). In this patient, the air reverberation artifact occurred diffusely throughout the abdomen, making pneumoperitoneum
J. A. Kadiri et al.
less likely. CT imaging demonstrated extremely dilatated, air-filled cecum with haustral creases, a typical CT finding of cecal volvulus (6). A ‘‘whirl’’ sign is a highly specific finding in volvulus, and is seen in both cecal and sigmoid volvulus. The source of the twist, identified as the eye of the whirl on CT imaging, can differentiate between cecal and sigmoid volvulus; the former originates at the cecum, and the latter originates in the sigmoid. Although conservative management, with colonoscopy or barium enemas, has been studied, there is an increased risk of perforation and recurrence (7). Thus, cecal volvulus is primarily managed surgically. Our patient was taken to the operating room for an exploratory laparotomy and right colectomy. She had an uncomplicated postsurgical course and was discharged from the hospital 1 week later. REFERENCES 1. Ballantyne GH, Brandner MD, Beart RW Jr, Ilstrup DM. Volvulus of the colon. Incidence and mortality. Ann Surg 1985;202:83–92. 2. Haskin PH, Teplick SK, Teplick JG, Haskin ME. Volvulus of the cecum and right colon. JAMA 1981;245:2433–5. 3. Madiba TE, Thomson SR. The management of cecal volvulus. Dis Colon Rectum 2002;45:264–7. 4. Jang TB, Schindler D, Kaji AH. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J 2011;28:676–8. 5. Hoffman B, Nurnberg D, Westergaard MC. Focus on abdominal air: diagnostic ultrasonography for the acute abdomen. Eur J Emerg Med 2012;19:284–91. 6. Moore CJ, Corl FM, Fishman EK. CT of cecal volvulus: unraveling the image. AJR Am J Roentgenol 2001;177:95–8. 7. Consorti ET, Liu TH. Diagnosis and treatment of caecal volvulus. Postgrad Med J 2005;81:772–6.