Is it a Volvulus?’ A Case of Idiopathic Megacolon · Ang KY, Ooi CK (2018) Is it a Volvulus?’ A...
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Central Bringing Excellence in Open Access Archives of Emergency Medicine and Critical Care Cite this article: Ang KY, Ooi CK (2018) Is it a Volvulus?’ A Case of Idiopathic Megacolon. Arch Emerg Med Crit Care 3(2): 1040. *Corresponding author Ooi Chee Kheong, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Tel: +65 6357 8777; Fax: +65 62543772; Email: Submitted: 30 April 2018 Accepted: 16 June 2018 Published: 18 June 2018 ISSN: 2476-2016 Copyright © 2018 Kheong et al. OPEN ACCESS Keywords • Intestinal volvulus • Megacolon • Colectomy • Abdominal pain Case Report Is it a Volvulus?’ A Case of Idiopathic Megacolon Ang Kai Yun, and Ooi Chee Kheong* Department of Emergency, Tan Tock Seng Hospital, Singapore Abstract Idiopathic megacolon refers to the permanent dilatation of the colon without an identifiable cause. Patients usually present with chronic constipation. Volvulus is a known complication of this condition. We present a case of a 31-year-old woman who presents with abdominal pain and distension. She was initially diagnosed with sigmoid volvulus based on clinical and abdominal radiograph findings. Computed tomography of the abdomen and pelvis showed abnormal dilatation of the colon with no signs of volvulus. A colonoscopy revealed no obvious obstructive causes. Her symptoms resolved with medical treatment. A follow up colonography two months later showed persistent colonic dilatation, hence idiopathic megacolon was diagnosed. The radiographic findings of idiopathic megacolon may be dramatic and mimic the appearance of large bowel volvulus. It is a reasonable diagnosis to consider since both diagnoses may present with abdominal symptoms. It is prudent for the emergency physician to consider the more serious diagnosis of volvulus by further imaging and surgical consult. ABBREVIATIONS ED: Emergency Department; CTAP: Computed Tomography of Abdomen and Pelvis INTRODUCTION Idiopathic megacolon refers to the permanent dilatation of the colon without an identifiable cause [1]. The prevalence of this condition is unknown. Patients usually present with chronic constipation not relieved with medical treatment. We present a case of a 31-year-old woman who presented with abdominal pain and distension. She was later diagnosed with idiopathic megacolon. CASE PRESENTATION A 31-year-old woman presented to the emergency department (ED) with abdominal pain of two days duration. She described it as an intermittent sharp cramp localized in the left iliac fossa, non-radiating in nature and not related to food intake. This was associated with occasional abdominal distension since her caesarean delivery a year ago. There was no history of previous abdominal surgery. She denied any recent change in bowel habits or history of chronic constipation or laxative use. She denied having any chronic medical or psychiatric history. On physical examination, the abdomen was distended with no localized tenderness or guarding. Bowel sounds were active. Her laboratory results, including full blood count, electrolytes and liver function tests were normal. Abdominal X-rays revealed gross dilatation of a large bowel loop extending from the lower abdomen up to the diaphragm, suggestive of the northern exposure sign (Figure 1) [2]. The clinical impression was abdominal distension due to sigmoid volvulus. The surgical team was consulted in the ED. Proctoscopy did not reveal any abnormalities, nor did it resolve the abdominal distension with no obstructive mass or predisposing causes visualized (Figure 2). There was also no evidence of pneumoperitoneum or intestinal obstruction. There was an incidental finding of absent right kidney. The patient Figure 1 Abnormal X-ray showing colonic dilatation.
Transcript of Is it a Volvulus?’ A Case of Idiopathic Megacolon · Ang KY, Ooi CK (2018) Is it a Volvulus?’ A...
CentralBringing Excellence in Open Access
Archives of Emergency Medicine and Critical Care
Cite this article: Ang KY, Ooi CK (2018) Is it a Volvulus?’ A Case of Idiopathic Megacolon. Arch Emerg Med Crit Care 3(2): 1040.
*Corresponding authorOoi Chee Kheong, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Tel: +65 6357 8777; Fax: +65 62543772; Email:
Submitted: 30 April 2018
Accepted: 16 June 2018
Published: 18 June 2018
ISSN: 2476-2016
Copyright© 2018 Kheong et al.
OPEN ACCESS
Keywords•Intestinal volvulus•Megacolon•Colectomy•Abdominal pain
Case Report
Is it a Volvulus?’ A Case of Idiopathic MegacolonAng Kai Yun, and Ooi Chee Kheong*Department of Emergency, Tan Tock Seng Hospital, Singapore
Abstract
Idiopathic megacolon refers to the permanent dilatation of the colon without an identifiable cause. Patients usually present with chronic constipation. Volvulus is a known complication of this condition. We present a case of a 31-year-old woman who presents with abdominal pain and distension. She was initially diagnosed with sigmoid volvulus based on clinical and abdominal radiograph findings. Computed tomography of the abdomen and pelvis showed abnormal dilatation of the colon with no signs of volvulus. A colonoscopy revealed no obvious obstructive causes. Her symptoms resolved with medical treatment. A follow up colonography two months later showed persistent colonic dilatation, hence idiopathic megacolon was diagnosed. The radiographic findings of idiopathic megacolon may be dramatic and mimic the appearance of large bowel volvulus. It is a reasonable diagnosis to consider since both diagnoses may present with abdominal symptoms. It is prudent for the emergency physician to consider the more serious diagnosis of volvulus by further imaging and surgical consult.
ABBREVIATIONSED: Emergency Department; CTAP: Computed Tomography
of Abdomen and Pelvis
INTRODUCTIONIdiopathic megacolon refers to the permanent dilatation of
the colon without an identifiable cause [1]. The prevalence of this condition is unknown. Patients usually present with chronic constipation not relieved with medical treatment. We present a case of a 31-year-old woman who presented with abdominal pain and distension. She was later diagnosed with idiopathic megacolon.
CASE PRESENTATIONA 31-year-old woman presented to the emergency department
(ED) with abdominal pain of two days duration. She described it as an intermittent sharp cramp localized in the left iliac fossa, non-radiating in nature and not related to food intake. This was associated with occasional abdominal distension since her caesarean delivery a year ago. There was no history of previous abdominal surgery. She denied any recent change in bowel habits or history of chronic constipation or laxative use. She denied having any chronic medical or psychiatric history. On physical examination, the abdomen was distended with no localized tenderness or guarding. Bowel sounds were active. Her laboratory results, including full blood count, electrolytes and liver function tests were normal. Abdominal X-rays revealed gross dilatation of a large bowel loop extending from the lower abdomen up to the diaphragm, suggestive of the northern exposure sign (Figure
1) [2]. The clinical impression was abdominal distension due to sigmoid volvulus. The surgical team was consulted in the ED. Proctoscopy did not reveal any abnormalities, nor did it resolve the abdominal distension with no obstructive mass or predisposing causes visualized (Figure 2). There was also no evidence of pneumoperitoneum or intestinal obstruction. There was an incidental finding of absent right kidney. The patient
Figure 1 Abnormal X-ray showing colonic dilatation.
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Ang KY, Ooi CK (2018) Is it a Volvulus?’ A Case of Idiopathic Megacolon. Arch Emerg Med Crit Care 3(2): 1040.
Cite this article
subsequently underwent flexible sigmoidoscopy and colonoscopy whilst admitted. Both revealed an extremely capacious sigmoid colon with no twisting or volvulus. She was discharged well two days later. A follow up colonography scan performed two months Flatus tube was inserted without much success in relieving the symptoms. A computed tomography of the abdomen and pelvis (CTAP) showed extensive large bowel dilatation measuring up to 8.2 cm later showed persistent dilatation of the colon.
DISCUSSIONThe initial concern for our patient was sigmoid volvulus based
on clinical and radiological findings. However, the diagnosis of volvulus was excluded based on CT and endoscopic findings. Her symptoms which started in adulthood without gastrointestinal symptoms during childhood made Hirschsprung’s disease unlikely. There was also no other symptoms and signs of infection, endocrinopathies or connective tissue diseases. The fact that the colonic distension persisted two months after discharge points towards the diagnosis of idiopathic megacolon.
Idiopathic megacolon describes the abnormal dilatation of the colon (usually more than 8 cm) with no identifiable causes such
as mechanical obstruction or volvulus [3]. It affects both sexes equally [4]. The pathophysiology of this condition is not well studied. Histological studies show that patients with idiopathic megacolon have a defect in the smooth muscle synthesis within the gut wall [5]. Chronic constipation and abdominal distension are common symptoms [6]. The diagnosis is made clinically and radiologically. If Hirschsprung’s disease is suspected, contrast enema, anorectal manometry or full thickness rectal biopsy should be performed. Medical treatment of idiopathic megacolon include long term laxatives. If the symptoms become intractable or complications such as volvulus develop, surgical treatment includes colectomy with ileorectal anastomosis [7].
The radiographic findings of idiopathic megacolon maybe dramatic and mimic the appearance of large bowel volvulus due to the abnormal dilatation of the colon. Typical radiographic findings of sigmoid volvulus include coffee bean sign or northern exposure sign. It is a reasonable diagnosis to consider since both diagnoses may present with abdominal symptoms. Moreover, volvulus is a known complication of idiopathic megacolon. It is prudent for the emergency physician to consider the more serious diagnosis of volvulus by further imaging and surgical consult.
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4. Gattuso JM, Kamm MA. Clinical features of idiopathic megarectum and idiopathic megacolon. Gut. 1997; 41: 93-99.
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Figure 2 Contrasted CT showing colonic dilatation.
