Roentgenographic appraisal of large bowel obstruction in adults

Roentgenographic Appraisal of Large Obstruction in Adults THERESA L. SIEBERT, M.D. AND NATHANIEL FINBY, From tbe Department of Radiology, New York, New York.

St. Luke’s Hospital,

American

and

Journal

oj Surgery,

Volume ICU. September

1963

New York, New York

the reverse direction), the distention invoIves onIy the large bowe1. If the ileoceca1 vaIve is or becomes incompetent, distention of the smaI1 bowel ensues and coIonic distention is Iess pronounced.

intehigent roentgenographic is undoubtedly the singIe most vaIuabIe diagnostic too1 in the management of patients with obstruction of the coIon. An earIy and accurate diagnosis is essentia1 for effective management. The mortaIity of patients with Iarge bowe1 obstruction has decreased steadiIy in the past few years, as earIier and more accurate diagnoses and advances in surgica1 treatment of these patients have been made. Current reports in the Iiterature indicate that mortaIity stiI1 varies between 5 and 24 per cent [r,2]. The purpose of this paper is to discuss the roentgenographic evaIuation of patients suspected of having large bowe1 obstruction, and to highIight pathognomonic radiographic patterns. OccasionaIIy, roentgenographic studies present d&cult problems in interpretation, IocaIization and diagnosis. Obstruction of the colon is seen roentgenographicaIIy Iess frequentIy than obstruction of the smaI1 bowe1. The incidence of obstruction of the coIon as opposed to smaI1 bowe1 obstruction has been reported as occurring in a ratio of I : 5 [I] or I : 6 [2]. Even when disease of the colon exists, obstruction is infrequently the presenting symptom. When it is, the most common etioIogic factors are, in decreasing order of frequency, malignant neopIasm, diverticulitis, voIvulus, adhesions and intussusception. Obstruction of the Iarge bowe1 in this report is defined as compIete or almost complete mechanica obstruction of the Iumen of the coIon. When this occurs, the bowe1 proxima1 to the compromised segment becomes abnormaIIy distended. If the ileoceca1 vaIve is competent (shows the passage of air and ffuid from the smaI1 bowe1 into the coIon, but not in ROMPT

P evaIuation

M.D.,

Bowel

SCOUT FILMS OF THE ABDOMEN The First step in the roentgenographic evaIuation of such patients is to obtain scout IiIms of the abdomen. This examination should consist of two roentgenograms: the first obtained with the patient in a supine position and the second with the patient either in an upright or IateraI decubitus position. The upright or IateraI decubitus film is frequently the most informative, since a loop of fluid-fiIIed bowe1 can, on examination of the supine fiIm, either be missed or misinterpreted as a mass. On study of the upright or IateraI decubitus IiIm, however, the smaI1 amount of gas aIso present in the Ioop creates an air-Auid IeveI, which, added to the composite picture, can be vital to a correct interpretation. (Fig. 8.) On the basis of this examination, the first question to be answered is, does obstruction exist? In the norma aduIt the small bowe1 is usuaIIy not identiIiabIe since it does not contain gas. The Iarge bowe1 usuaIIy contains smaI1 amounts of gas and feces and can be seen segmentaIIy outIined from cecum to rectum. In the presence of Iarge bowel obstruction, distention of the coIon occurs; if the iIeoceca1 vaIve is and remains competent, this distention can become enormous. The distended coIon mainIy contains gas, but feca1 and ffuid retention of varying degree is aIso present. With incompetency of the iIeoceca1 vaIve, distention of the smaI1 bowe1 with gas and ffuid compIicates the picture. The usua1 criteria for differentiating between smaI1 and Iarge bowe1 are: (I) the presence of 490

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a marginal haustral pattern in the coIon as opposed to the smooth paraIle1 outhne of smal1 bowe1, and (2) the mucosal markings (pIicae circulares) of the small bowe1 which extend across the entire width of the Iumen of the howe forming a sharp margin with the outer wall and which are cIoser to each other than the plicne semiIunares of the colon. These do not extend across the entire Iumen of the howe and are more wideIy spaced. These criteria are heIpfu1 in IocaIizing the site of obstruction except when distention of either small or Iarge bowe1 is very great. In such cases al1 identifying characteristics are effaced, and accurate differentiation is impossible without contrast material. This contrast material shouId always be introduced via the rectum since barium by mouth is contraindicated in patients with suspected obstruction of the large bowei. \lany nonobstructive conditions can cause distended loops of Iarge howe such as postoperative paralytic iIeus, paralytic ileus secondary to spine fracture or other trauma, sentinel Ioops of distended bowe1 associated with pancreatitis, bowel distention secondary to thrombosis of the mesenteric artery or vein, and segmenta Iarge bowel distention of fuIminating ulcerative colitis. CoIonic distention in these conditions is usuaIIv not as pronounced as in mechanical obstruction, and the total clinica history often heIps to cIarify doubtful cases. If there is stiI1 uncertainty as to whether or not one is dealing with a mechanica Iarge bowe1 obstruction, a barium enema shouId be performed without delay as the second step in roentgenographic evaIuation. CIeansing enemas are not necessary prior to this type of emergency barium enema. Often, in this situation, part of the enema fIuid is not expehed. This fluid dilutes the barium and makes fhioroscopy diIficuIt . BARIUM

ENEMA

in AduIts

barium proxima1 to the obstructive site if this can be accomplished without the use of excessive pressure or manipuIation. UsuaIIv, amounts of barium as smaII as 5 to 15 cc. proxima1 to the obstruction are suffcient to determine the nature of the obstruction. The possibility of obtaining this additional diagnostic information, however, does not justify attempts which might risk howe perforation. Determined efforts to pass contrast material proximal to an obstruction by using a tightfitting rectal baboon, by raising the height of the barium container, or by increasing the pressure of the flow are not warranted. The IIuoroscopist shouId aIso keep in mincl the fact that the obstruction may be complete in respect to the norma Bow of intestinal gas and feca1 content, yet barium enema fIuid may pass easiIy in a retrograde direction through the obstructed area. In such cases, even though the retrograde passage of barium easily proceeds proxima1 to a clinically complete or partia1 obstruction, the entire coIon should not be fiIled with barium. Passage of large amounts of barium into the proxima1 colon also m:i>transform an incomprete obstruction into a compIete obstruction. A proxima1 colon MIetl with barium presents a serious preoperative probIem. Such a condition may necessitate coIostomy, resection of the coIon, and hnnll~ cIosure of the colostomy, instead of a possible single operation, primary resection. Therefore, no specia1 attempt should be made to demonstrate additional Iesions proximal to an obstruction. The patient with a compIete or nearly complete clinica obstruction wiI1 require operation. The surgeon at operation ordinarily will be able to discover any additional areas of disease. ROENTGENOGRAPHIC OBSTRUCTIVE

CHARACTERISTICS

OF

LESIONS

A4alignant Neoplasms. In adults, 6; to 85 per cent of all obstructions of the colon are caused by carcinoma [I-J]. Malignant neopIasms arising from any site within the colon are capable of causing obstruction; however, the sigmoid and rectosigmoid are the areas of the colon most frequentIy invoIved by carcinoma. Sigmoid neoplasms are more likely to be scirrous and encircle the lumen (“napkin ring”) than Iesions of the ascending and transverse colon. The lumen of the sigmoid is narrower and, therefore, more easily com-

EXAMINATION

AIthough barium by mouth is contraindicated in suspected obstruction of the Iarge howeI, a barium enema is not at all hazardous if the fhioroscopist observes a few common safeguards. He shouId reaIize that the main goal is mereIy to establish whether or not mechanica obstruction exists and at what Ievel. When an obstruction to the retrograde Aow of barium is encountered, the ffuoroscopist should attempt to pass a smaI1 amount of 491

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FIG. I. AbdominaI fiIms of this eighty-one year oId man showed marked distention of both smaI1 and Iarge boweI. The large bowel distention terminated rather abruptly just proxima1 to the spIenic flexure. Thrombosis of the superior mesenteric artery was considered in the differentia1 diagnosis, but an emergency barium enema demonstrated aImost compIete obstruction within the proximal descending coIon with the typica roentgenographic appearance of a “napkin-ring” neoptasm. At surgery, this proved to be an adenocarcinoma of the descending coIon with obstruction. A considerabIe amount of Auid is present in the bowe1 proximal to the obstruction which explains why the boweI was fiIIed with gas only to the dista1 transverse coIon.

FIG. 2. Roentgenogram of the abdomen of a seventynine year oId woman with abdomina1 pain and distention of six days’ duration shows marked distention of the entire Iarge bowe1 extending to the mid-sigmoid. OnIy a few air-containing Ioops of iIeum are observed in the right Iower quadrant. The ileocecal vaIve is probably becoming incompetent. A compIeteIy obstructing adenocarcinoma of the sigmoid was found.

promised. The fecal stream at this level is semi-soIid, and not Iiquid as in the ascending why sigmoid coIon. AI1 these facts expIain neoplaJms are the most common cause of colonic obstruction. Cancer of the colon occurs most frequentIy in persons between the ages of forty and eighty, with a slight maIe predominance. However, it should be kept in mind that 5 per cent of the patients are under thirty years of age [4]. UnfortunateIy, there is no symptom cornpIes characteristic of carcinoma of the coIon. Similar cIinica1 pictures are observed in both carcinoma of the Ieft coIon and in diverticuIitis, aIthough recta1 bIeeding and constipation are more fre[5]. Roentquently associated with carcinoma genographicahy, maIignant Iesions are characterized by sharply demarcated defects, usuaIIy of short segments, which show Iipping of the edges and destruction of mucosa. The fact that diverticuIa are present does not mitigate against the diagnosis of malignancy since, in series of proved cases of maIignant neopIasms, concomitant diverticulosis has been reported in 18 to 2 I per cent [5,6].

CASE I. Figure I demonstrates a compIeteIy diagnostic barium enema examination. The patient, an eighty year old man, presented with abdominal pain and obstructive symptoms of two days’ duration. The abdomina1 roentgenogram showed distention of the smaI1 and Iarge bowe1 extending approximateIy to the Ievel of the dista1 transverse coIon. Thrombosis of the superior mesenteric artery was considered in the differentia1 diagnosis, but the barium enema examination (Fig. I) showed the cIassic appearance of a napkin-ring neopIasm of the proxima1 descending coIon. C,ASE II. In a seventy-nine year oId woman with abdomina1 pain, progressive distention and miId diarrhea of six days’ duration, the abdomina1 roentgenogram established the diagnosis of mechanica1 obstruction of the Iarge bowe1 at the sigmoid to the retroIeveI. (Fig. 2.) CompIete obstruction

grade ffow of barium was encountered in the midsigmoid, and since no barium passed proxima1 to the site of obstruction, the presence and site of the mechanical obstruction were confirmed without more definitive roentgenographic diagnosis. At

492

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an adenocarcinoma

of the

BoweI sigmoid

Obstruction

in A&Its

peopIe of eastern European countries than in those of western Europe and the United States. The sigmoid mesentery of eastern Europeans is usuahy longer and this is believed to predispose to the higher incidence of volvulus of the colon. Some believe that the more bulky type of food ingested by eastern Europeans also plays a roIe. The exact cause of volvulus of the sigmoid is not known, but it is usually observed in a long and freely movable sigmoid loop with adjacent afferent and efferent limbs [9]. In cases of sigmoid voIvulus, the roentgenogram of the abdomen shows markedly overdistended loops of sigmoid, usuaIIy situated in the center of the abdomen but which, with increasing distention, tend to rise obliquely to the right, even as high as the diaphragm Ire]. In sigmoid volvuIus, the distended loop is a closed loop and the walls of the involved segments point toward the left iliac fossa, where the root of the mesentery forms a small mass resembling a tumor [II].

was

Diverticulitis. Diverticula are said to occur in 5 per cent of persons over forty years of age, and diverticula will develop in 20 per cent of persons with diverticulitis [4]. A check of 2,000 consecutive barium enema studies made during a three year period [7] showed that the incidence of diverticulosis increased steadiIy with age unti1 it could be demonstrated in approximately two thirds of those who were eightyfive years old. Clinical symptoms of patients with diverticulitis, which goes on to obstruc tion, can be remarkably similar to those of patients with neoplasm. NevertheIess, intermittent attacks of pain in the Ieft lower quadrant, fev-er, abdominal tenderness and fistula formation occur more frequently with diverticuIitis. CASE III. A sixty-seven year old man (Fig. 3) demonstrated obstruction of the mid-sigmoid coIon on a barium enema study, but the differentia1 between neoplasm and diverticulitis was most difficuIt. (Fig. 3A.) However, a study performed four months previously (Fig. 3B), when the patient had been admitted for simiIar but Iess severe compIaints, lent support to the roentgenographic impression of diverticulitis. Surgery proved that such was the case, and a smaI1 IocaIized perforation was aIso present at this site in the sigmoid. Pathologic report showed only inflammatory disease without evidence of any maIignancy. This differentia1 between diverticuIitis and neopIasm in the obstructecl colon, usually at the sigmoid Ievel, constantly pIagues both the attending physician and the radiologist.

CASE Iv. The patient was a fifty-six year old with increasing abdominal distention. woman, Abdominal roentgenogram shows enormous distention of a sigmoid loop, secondary to a volvuIus. (Fig. 4A.) This Iesion is we11 demonstrated on barium enema study. (Fig. 4B.) Another surgicaIIy proved case volvulus was observed in Case v.

of sigmoid

CASE v. The patient was a seventy-three year oId man in whom distention not only of the sigmoid Ioops but also of the large and small bowe1 was present to a much greater degree than is usual. (Figs. 5A and B.) The distention of the small bowel reflects an incompetent ileocecal valve.

A volvuIus is a torsion of the v01vu1us. bower on its mesentery with resuhant symptomatology caused by narrowing of the bowel lumen, stranguIation of its bIood vesseIs or a combination of both [4]. In the Iarge bowel, the sigmoid is the most common site. VoIvulus accounts for about 5 per cent of a11 mechanica obstruction of the large bowel, and sigmoid volvuIus accounts for about 75 per cent of all cases of voIvuIus [a]. Sigmoid voIvuIus occurs more frequently in men than in women in a ratio of 2 : I, and the narrower peIvis of the man is believed to account for this sex predominance. The ages of most frequent occurrence are between twenty and fifty years. VolvuIus of the sigmoid appears to be about three times more common in

CASE VI. This case proved most interesting. A sixty-three year oId woman presented with episodes of intermittent pain in the left lower quadrant of four weeks’ duration and a three day history of increasing abdominal distention. On barium enema examination (Fig. 6), an opacitied segment of mid-sigmoid was observed somewhat similar to that in the twisted segment of a sigmoid voIvulus. (Compare this with Figures 4B and 5B.) Because the sigmoid colon proximally was not dilated, sigmoid volvulus was not considered and was not present at subsequent surgery. This rather unusua1 case proved to be a carcinoma arising in a coIonic diverticulum, forming a mass extrinsic to the main coIonic lumen about which thr sigmoid coIon was coiIed.

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FIG. 3. A, prehminary scout film had shown a distended large bowel to the sigmoid. Barium enema showed almost compIete obstruction at the sigmoid. Differentiation between neopIasm and diverticulitis was impossible on the basis of this study alone. B, a barium enema study of this patient performed four months previousIy, showed typica findings of diverticutitis, thereby facilitating diagnosis of the acute situation. Surgery discIosed a perforation in the mid-sigmoid secondary to diverticuIitis. Histologic examination showed no evidence of maIignancy.

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Bowel Obstruction

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B

FIG. 4. A, the abdominal roentgenogram of this lifty.-six year old woman shows enormous distention of a segment of Iarge bowel, presumed to be slgmoid, with proximal large boweI obstruction. The irregular ca1cification in the right peIvis is within a uterine fibroid. B, the barium enema beautifully demonstrates the twisting of the rnuc~~~:~lfo1ds at the distal limb of the sigmoid voIvuIus.

FIG. 5. A, the abdominal roentgenogram shows enormous distention of the Iarge boweI. The Iarge overlapping gas shadows in the mid-abdomen represent the superimposed Ioops of distended sigmoid secondary to sigmoid voIvuIus. B, barium enema demonstrates the twisting of the distal loop in sigmoid voIvuIus. The narrowed segment can simulate cancer unless mucosaI detail is observed.

Siebert

and Finby the right or left of the midline, or in either flank. A reversa1 of the normal IateraI convex cecal border to the mesia1 side of the distended displaced cecum is aIso a most usefu1 diagnostic [12]. Case VII (Fig. 7A) graphically observation demonstrates many of these points. AIthough Iaddered loops of moderately dilated termina1 iIeum are seen in the right Iower quadrant, no air- or fecal-containing cecum is seen. Instead, a dilated air-containing viscus (which couId be taken for the stomach) is present in the Ieft upper abdomen. Contrast study (Fig. 7B) clearly demonstrates that this is a distended cecum. In this case the entire ascending coIon participates in the voIvuIus, and the point of torsion is in the proxima1 transverse coIon. CASE VIII. AbdominaI roentgenograms of an older woman with abdomina1 pain and distention showed muItipIe distended Ioops of smaI1 bowel in the mid-abdomen with a generaIized haze in the lower part of the abdomen suggesting either a vague mass or free fluid. However, upright fiIm of this patient (Fig. 8) showed a Iong air-fluid leve1 in the Ieft lower quadrant having the appearance of a greatly distended viscus, presumably the dispIaced cecum. At surgery, a cecal voIvuIus was found with the air- and fluid-distended cecum in the Ieft lower quadrant. This case cIearIy iIIustrates that the condition most Figiel’s [12] observation diflieult to differentiate from ceca1 voIvuIus, presenting in this manner, is a Iarge gas-containing abscess.

FIG. 6. The mid-sigmoid, outlined with barium, shows a similarity to the twisted segments of sigmoid noted in the previous cases of sigmoid voIvuIus. The sigmoid is not dilated nor is the remaining coIon. Obstruction of the coIon in this,patient was caused by a carcinoma arising in a diverticuIum of the sigmoid with a mass extrinsic to the true bowe1 Iumen. The sigmoid coiIed itseIf about the mass but no true voIvuIus was present.

The second most common site of voIvuIus of the large bowe1 is the cecum and ascending coIon which accounts for IO to 20 per cent of a11 cases of volvuIus [I I]. VoIvuIus of the cecum is dependent for its occurrence on the failure of the primary mesentery to become adherent to the posterior abdomina1 wal1. Some degree of abnorma1 fixation of the iIeum or ascending coIon must aIso be present to serve as the point of fulcrum about which the mobiIe cecum may rotate. Patients with this condition are usuaIIy between twenty and forty years of age, younger than those with voIvuIus of the sigmoid. The roentgenographic diagnostic feature is a markedly distended cecum, which may remain in norma position but is more frequently displaced. In fact, the absence of cecal shadow in its norma position in the right lower quadrant is often of great diagnostic importance when deaIing with a case of suspected ceca1 voIvulus. A large air-containing viscus, presumabIy cecum, is observed either in the Ieft upper quadrant, in the mid-abdomen to

Before Ieaving the subject of cecal voIvuIus, reference shouId be made to a very exceIIent article by Ritvo, FarreII and Schaeffer [13]. In this article, they state that a review of proved cases of ceca1 voIvuIus at Boston City HospitaI demonstrated that 50 per cent of these patients had another organic disease of the Iarge bowe1 distal to the site of voIvuIus. For this reason, they believe that any patient who has been operated upon for cecal voIvuIus should not

be discharged from the hospita1 unti1 a carefu1 barium enema examination has been performed. The purpose of this procedure is to ruIe out any coexisting disease of the colon, which may have predisposed to the voIvuIus. Intussusception. Of a11 cases of intussusception, onIy 5 per cent occur in adults [r4]. When present, a precipitating organic Iesion shouId be strongIy suspected. IntestinaI tumor, hypertrophied Iymph tissue or a Meckel’s diverticuIum is usuaIIy responsibIe. Less frequentIy,

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A

B

small bowel distention is more frequentIy present than in sigmoid voIvuIus. Note that multiple distended loops of small bowel .lre present in the mid- and Iower abdomen without a cecal shadow in the right Iower quadrant. tnstcad, a large air-containing viscus is present in the left upper quadrant. This is the distended, displaced cecum. B, the barium enema study clearly shows the twisted mucosa1 pattern in the proximal transverse colon. In this case, the cntirc. cecum and nsccnding colon participated in the volvuIus. FIG. 7. Cecal

vo[vuIus

was proved in this case. A, in ceca1 voIvulus,

FIG. 8. Roentgenogram of the abdomen with the patient in the erect position demonstrates diIated loops of both smaIIland_Iarge bowel with a Iong air-ffuid IeveI in the Iower ‘part of the abdomen. The Auid IeveI was in a markedIy diIated cecum which had undergone a 540 degree voIvuIus. The dilatation of Iarge bowe1 distal to the voIvuIus is not commonIy seen, but has been described in other cases of cecai voIvulus.

FIG. 9. A submucous Iipoma of the mid-transverse coIon Ied this coIocoIic intussusception. In this roentgenogram of the barium enema, the Iipoma itself is seen in its intussuscepted position at the spIenic Aexure Ievel. The “coi1 spring” appearance proximal to the Iipoma is pathognomonic of intussusception.

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B

FIG. IO A, abdominal film showed multipIe Ioops of moderateIy distended smaI1 bowe1, an absence of ceca1 shadow in the right Iower quadrant and a diIated hoIIow viscus in the Ieft upper abdomen. The roentgenographic appearance suggested a cecal voIvuIus. B, barium enema, however, discIosed a coIocoIic intussuceeption at the splenic ffexure IeveI. The entire cecum, ascending colon and transverse coIon have intussuscepted into the colon distal to the spIenic Aexure. Within the cecum and Ieading the intussusception was a submucous Iipoma measuring IO cm.

parasitic or inflammatory conditions, appendiceal Iesions, foreign bodies or aberrant isIands of tissue are discovered. Spontaneous invagination in the aduIt is unusual.

coIon, rectum and descending coIon in that order of frequency. They are seen most frequently in the fifth and sixth decades of life, although they have been reported in persons sixteen to eighty-seven years of age. CoIonic Iipomas cause intussusception in one-third of the patients, and bleeding in one-fourth, and are not prone to become malignant.

CASE IX. Figure g beautifulIy ilIustrates the roentgenographic “coil spring” appearance seen in intussusception. This patient, a thirty-nine year oId man, had a coIocoIic intussusception Ied by a submucous Iipoma within the mid-transverse colon.

SUMMARY

CASE x. In this patient with coIocoIic intussusception, fiIms of the abdomen (Fig. I oA) showed muItipIe Ioops of distended smaI1 bowe1 throughout the abdomen. A cecal shadow couId not be identified in the right lower quadrant. CecaI voIvuIus was suspected. The barium enema examination (Fig. IOB) discIosed an obstruction to the ffow of barium at the spIenic fIexure IeveI where a coIocoIic intussusception was present. At surgery, a submucous Iipoma of the cecum measuring IO cm. in diameter was found. Led by the lipoma, the entire cecum, ascending and transverse coIon had intussuscepted to the splenic ffexure IeveI.

An earlier and more accurate roentgenographic diagnosis has undoubtedIy been one of the major factors in the reduced mortaIity in obstruction of the coIon. In suspected cases of mechanica obstruction of the Iarge bowe1, scout roentgenograms of the abdomen are indicated and usuahy quite informative. If these do not prove to be absoIuteIy diagnostic and bowe1 distention is present, a barium enema study shouId be performed at once. No preparation is necessary for this emergency procedure. If there is an obvious obstruction to retrograde flow of barium during ffuoroscopy, a Iimited amount of barium should be ahowed to pass proximal to the obstruction. With proper roentgenographic study, one can estabIish the presence and site of a mechanical

[4] states that lipomas occur Shackelford more commonIy in the Iarge than in the smaI1 intestine. In the coIon, they are found in the cecum, ascending coIon, sigmoid, transverse

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Large large bowel obstruction, and, of the obstructing lesion will The most important points among colonic obstructions noma, diverticulitis, sigmoid volvulus and intussusception demonstrated.

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Obstruction

existing carcinoma and diverticuht of the colon; a review of three hundred and fifty-five cases of carcinoma of the colon. Arch. Surp., 79: 373,

often, the nature be demonstrated. in differentiating caused by carcivolvuIus, cecal are discussed and

‘959. 7. WELCH, (3. E., ALLEN, A. W. and D~NALDSOS, G. A. An aooraisal of resection of the coIon for diverticulitis of the sigmoid. Ann. Surr., 138: 332. 195’3. 8. MESCHAN, I. Roentgen Signs in Clinical Diagnosis. Philadelphia, 1956. W. B. Saunders Co. 9. FRIMANN-DAHL, J. Roentgen Examinations in Acute AbdominaI Diseases. Springheld, III., 195 I. CharIes C Thomas. IO. BELLINI, M. A. Sigmoid voIvulus. KadioloR,y, 55: 26% 1949. I I. FRIMANN-DAHL, J. VoIvuIus of the right colon. Acta radial., 41: 141, 1954. 12. FI~IEL. L. S. and FIGIEL. S. J. VoIvulus of the cecum and ascending colon. Radio&v, 61: 496, 1

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1

13. RITVO, .M., FARRELL, G. and SCHAEFFEK, I. Association of voIvulus of the cecum and ascending colon with other obstructive colonic lesions. Am. J. Roentgenol., 78: 587, 1957. IL. RICHARDSON.H. 1-I. A case of ileo ilea intussusceotion of un&uaI etiology. Am. J. Roentgenol., 6;: 610, 1954.

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