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CME IN IMAGES
Year : 2018  |  Volume : 16  |  Issue : 1  |  Page : 22-23

Gas in the Abdomen


Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication27-Apr-2018

Correspondence Address:
Dr. Mamta Madhiyazhagan
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_10_18

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How to cite this article:
Madhiyazhagan M, Abhilash KP, Chandy G, Mathew D. Gas in the Abdomen. Curr Med Issues 2018;16:22-3

How to cite this URL:
Madhiyazhagan M, Abhilash KP, Chandy G, Mathew D. Gas in the Abdomen. Curr Med Issues [serial online] 2018 [cited 2020 Jan 25];16:22-3. Available from: http://www.cmijournal.org/text.asp?2018/16/1/22/231364


  Case Scenario Top


A 44-year-old man with no comorbid illnesses presented with abdominal pain for 2 months and vomiting for 2 months with significant loss of weight and appetite and obstipation for 1 week. The pain was intermittent, mostly postprandial, located in the epigastric region with no radiation. He had vomiting after food intake, which was not bloodstained, nonbilious, and nonprojectile. He had worsening of the above symptoms for the past 1 week, associated with obstipation for 1 week. He also had decreased urine output for the past 2 days. He gives history of appendicectomy 5 years back. He was a smoker for the past 5 years and chewed tobacco for the past 3 years. Clinical examination showed a distended abdomen with visible intestinal peristalsis.

Chest and abdomen X-rays are shown below as show in [Figure 1] and [Figure 2].
Figure 1: Chest X-ray.

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Figure 2: Abdomen X-ray.

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  Questions Top


  1. What is the abnormality seen on X-ray that correlates with symptoms?
  2. What is the probable diagnosis and treatment?
  3. What differential diagnoses can be considered?



  Answers Top


1. Dilated bowel loops

The plain abdomen erect X-ray shows the right-sided distended loops with haustrations. Obstruction less likely as air is seen in distal and proximal bowel loops.

2. Large bowel obstruction-Cecal bascule

Cecal bascule is a cause of large bowel obstruction where there is folding of the cecum anteriorly over the ascending colon.[1] It is one of the two types of cecal volvulus (the other being axial ileocolic). Cecal volvulus accounts for 1% of all adult intestinal obstructions and nearly 25%–30% of all cases of colonic volvulus.[2] Cecal volvulus incidence peaks in ages 20–40 years with a slight male predominance.

Pathophysiology

It is caused by rotational torsion of the cecum or ascending colon along its own axis. The base of the cecum folds anteriorly over the ascending colon, creating a flap valve obstructing emptying of the cecum.[1]

Investigation

The plain X-ray film findings of cecal volvulus demonstrate a distended cecum.

Computed tomography (CT) abdomen demonstrates the signs of cecal obstruction and distention. The “Whirl sign” may be seen– this is a nonspecific sign on CT [3] where the twisting of the bowel around its mesentery gives the appearance of a “whirl.”

Treatment

In hemodynamically stable patients, detorsion is typically followed by an ileocecal resection or a right colectomy. In unstable patients, a cecopexy (suturing the cecum to the abdominal side wall) with or without a cecostomy tube placement can be performed in lieu of a resectional procedure.[4]

3. Differential diagnosis

[Table 1] [5-9] gives the differential diagnoses for this condition.
Table 1: Differential Diagnosis

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bobroff LM, Messinger NH, Subbarao K, Beneventano TC. The cecal bascule. Am J Roentgenol Radium Ther Nucl Med 1972; 115:249-52.  Back to cited text no. 1
    
2.
Habre J, Sautot-Vial N, Marcotte C, Benchimol D. Caecal volvulus. Am J Surg 2008;196:e48-9.  Back to cited text no. 2
    
3.
Consorti ET, Liu TH. Diagnosis and treatment of caecal volvulus. Postgrad Med J 2005;81:772-6.  Back to cited text no. 3
    
4.
Gollub MJ, Yoon S, Smith LM, Moskowitz CS. Does the CT whirl sign really predict small bowel volvulus? Experience in an oncologic population. J Comput Assist Tomogr 2006;30:25-32.  Back to cited text no. 4
    
5.
Markogiannakis H, Messaris E, Dardamanis D, Pararas N, Tzertzemelis D, Giannopoulos P, et al. Acute mechanical bowel obstruction: Clinical presentation, etiology, management and outcome. World J Gastroenterol 2007;13:432-7.  Back to cited text no. 5
    
6.
Ramanathan S, Ojili V, Vassa R, Nagar A. Large bowel obstruction in the emergency department: Imaging spectrum of common and uncommon causes. J Clin Imaging Sci 2017;7:15.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Vanek VW, Al-Salti M. Acute pseudo-obstruction of the colon (Ogilvie's syndrome). An analysis of 400 cases. Dis Colon Rectum 1986;29:203-10.  Back to cited text no. 7
    
8.
Hayakawa K, Tanikake M, Yoshida S, Urata Y, Inada Y, Narumi Y, et al. Radiological diagnosis of large-bowel obstruction: Nonneoplastic etiology. Jpn J Radiol 2012;30:541-52.  Back to cited text no. 8
    
9.
Read NW, Abouzekry L, Read MG, Howell P, Ottewell D, Donnelly TC, et al. Anorectal function in elderly patients with fecal impaction. Gastroenterology 1985;89:959-66.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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