Cecal volvulus on top of Ladd’s band: a case report and review of literature

Cecal volvulus on top of Ladd’s band: a case report and review of literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Cecal volvulus on top of Ladd’s band: a case report and review of literature Mohamed Salah Ayyad, Abdallah Alqasaby, Mohamed Rezk, Ahmed Abonosier, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5348911/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 May, 2025 Read the published version in Bulletin of the National Research Centre → Version 1 posted 11 You are reading this latest preprint version Abstract Background: Cecal volvulus is a rare cause of bowel obstruction that represents a challenge in both diagnosis and management. This unique form of closed-loop obstruction occurs due to a twist in the mesentery with subsequent dilatation of the cecum. As a result of the massive distension of the large bowel, many radiologists find it difficult to recognise the signs suggestive of cecal volvulus. In this article, we highlight the role of imaging in the management of this form of bowel obstruction. Case presentation: A thirty-six-year-old female patient presented to our emergency department with symptoms of acute abdomen. Imaging revealed a massively dilated large bowel loop in an abnormal distribution in the centre of the abdomen with a whirlpool in the mesentery. Cecal volvulus was suspected. Surgical exploration confirmed the diagnosis and an abnormal band connected to the cecum (Ladd’s band) was also identified. The patient underwent division of the band with ileo-transverse colostomy. Unfortunately, the patient passed away due to cardiorespiratory failure two days after the operation. Conclusions: The radiologist should always consider cecal volvulus in the differential diagnosis of closed-loop obstruction particularly at a young age. A hypermobile cecum on imaging may suggest Ladd's band, even without signs of malrotation. All relevant items should be addressed when reporting bowel obstruction cases. Cecal Diseases General Surgery Imaging Intestinal Obstruction Volvulus Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Background Intestinal obstruction is one of the common scenarios encountered in the emergency clinical setting ( 1 ) . Volvulus is among the important causes of bowel obstruction. Although sigmoid volvulus (SV) is the most common type of colonic volvulus ( 2 ) , cecal volvulus (CV), on the other hand, is much less common ( 3 , 4 ) . CV has a relatively poor prognosis, particularly when treatment is delayed as the bowel ischemia develops rapidly and subsequently may lead to bowel necrosis and perforation ( 5 ) . Among the predisposing factors for colonic volvulus are intestinal malrotation, Ladd’s band, mobile cecum, elongated mesentery, chronic constipation, abdominal masses and high-fibre diet ( 2 ) . Intestinal malrotation occurs due to failure of the complete (270-degree) bowel rotation as it retracts from the umbilical cord. This may result in increased cecal mobility or abnormal sub-hepatic position of the cecum that predisposes to volvulus ( 6 ) . Imaging plays an important role in the diagnosis and management of CV. Being readily available, a plain radiograph represents the primary diagnostic modality ( 1 ) . Unlike small bowel obstruction, large bowel obstruction usually displays no air-fluid levels. Contrast-enhanced computerised tomography (CECT) is the mainstay investigation in the management of CV ( 2 , 4 , 6 ) . In CT images, the signs suggestive of CV are: markedly dilated cecum (> 9 cm), bird beak sign with tapering proximal and distal ends of the affected loop (denoting closed loop obstruction) and whirlpool sign (due to the twisting of the two ends of the closed loop around a fulcrum in the bowel mesentery) ( 5 , 7 , 8 ) . Cecal volvulus and SV both represent closed-loop obstruction and manifest as dilated loops. That is why the radiologist needs to differentiate between both entities. In SV, the distended loop is U-shaped with both ends in the pelvis pointing to the left lower quadrant while in CV, the loop is kidney-shaped with a notch at its middle representing the ileocecal valve ( 9 ) . The main differentiating points between both types of volvuli are mentioned in table (1). Table 1: Differentiating points between cecal and sigmoid volvulus We present a rare scenario of a CV on top of Ladd’s band and intend to share our experience in diagnosing and managing this rare closed-loop bowel obstruction. We also aim to alert the radiologist to the possible signs suggestive of the diagnosis and the important items to be fulfilled during reporting. Case presentation History and presentation: A thirty-six-year-old female patient with no past medical or surgical history presented to our emergency department complaining of acute abdominal pain, bile-stained vomiting abdominal distension and absolute constipation for the previous 3 days. Clinical findings At the time of presentation, the patient looked ill, dehydrated, and in pain. She was febrile with an oral temperature of 38.6 °C, tachycardiac with a pulse of 110/minute; a BP of 100/60 mm Hg and a respiratory rate of 25 breaths per minute. On examination, there was abdominal distention, mainly at the upper right abdominal quadrant, with generalised and rebound tenderness. Laboratory Investigations: The patient’s leukocytic count was 17.24 10 3 /ml, the haemoglobin was 11.1 g/dL and the platelet count was 240 x 10 3 /mcL. Liver functions, renal function and coagulation profile were all normal. Radiology: The patient underwent a plain x-ray which revealed a markedly dilated large bowel loop with preserved haustrations extending from the right lower quadrant (RLQ) of the abdomen to the left upper quadrant (LUQ) (Fig. 1). The dilated loop appeared kidney-shaped and the rest of the bowel appeared gasless (Fig. 1). No pneumoperitoneum was identified. A provisional diagnosis of colonic volvulus was made and the patient underwent a CECT (with oral and intravenous contrast), which revealed markedly dilated large bowel loops extending from the cecum to the mid-transverse colon with free fluid and mesenteric oedema (Fig. 2). The rest of the large bowel was collapsed. The root of the involved mesentery was twisted and edematous (Fig. 3) with normal contrast-filling of the mesenteric vessels. The anatomical relation between the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) was preserved (Fig. 4). No pneumoperitoneum was detected by radiology. The patient was diagnosed with CV based on the mentioned radiology. Management : Following prompt resuscitation with 2 litres of normal saline and the administration of intravenous antibiotics (cefotaxime and metronidazole), as well as the insertion of a nasogastric tube and urinary catheter, the patient underwent an urgent laparotomy performed through a midline incision. Intraoperatively, the cecum was found distended, in an abnormal anatomical position, lying in the right upper abdominal quadrant, twisted over a fibrous band (Ladd's band) which is connected to the retro-peritoneum (Fig. 5), confirming the diagnosis of cecal volvulus with Ladd’s band as the underlying cause. A perforation in the wall of the caecum with blackish discolouration denoting gangrene of the affected part with spillage of bowel contents was also identified presumably as a result of intense dilatation due to Caecal volvulus (Fig. 6). The decision was taken for Ladd’s band release and right hemicolectomy with ileo-transverse colostomy because of copious feculent peritonitis. The excised specimen was sent for histopathology. Microscopic examination of the prepared slides revealed focal ischemic changes in the colonic wall, ulcerated mucosa and congested vessels. The ileal safety margin showed an intact wall and mucosa with inflammatory changes. Fate: Two days post-surgery, the patient's condition took a turn for the worse, ultimately succumbing to cardiorespiratory failure. Discussion The adequate reporting of intestinal obstruction cases is one of the most important skills a radiologist should master ( 1 ) . Although SV may be encountered as a frequent cause of large bowel obstruction ( 2 ) , CV is uncommon and hardly reported. Unaware of the peculiar radiological features of such a cause of intestinal obstruction, a radiologist may find it difficult to diagnose this rare entity. ( 3 , 4 ) . Cecal volvulus usually affects the younger population between thirty and sixty years of age ( 10 ) . Our patient (aged thirty-six years) falls in this category, agreeing with the case report mentioned by Sikakulya FK and Abdulmuttaleb AT and their colleagues who mentioned similar age ( 11 , 12 ) . Al Khalifa A. and Sedik A. mentioned different age of presentation (seventy-five years) ( 5 ) . We concluded that the young age of presentation is a useful reminder to suspect cecal volvulus when encountering closed-loop obstruction in the young. A CV usually appears in plain radiographs as a dilated gas-filled loop extending from the RLQ of the abdomen to the LUQ ( 13 ) . This characteristic appearance is called “embryo sign” and is one of the radiographic signs suggestive of CV ( 14 ) . The bowel loop orientation in our patient showed a similar orientation (Fig. 1 ) matching the case presented by Moore CJ and his colleagues ( 8 ) . In the case report mentioned by Al Khalifa A. and Sedik A., there was a localized dilated loop to the right side of the midline ( 5 ) . There was haustral preservation of the affected loop in the previously mentioned articles ( 5 , 8 ) matching the appearance of the loop in our case (Fig. 1 ). We concluded that the preserved bowel haustra is a very important sign to differentiate between SV and CV being preserved in the latter. We also concluded that the position of the dilated loop is variable in CV, with the most common being oriented from the RLQ to LUQ. By CECT, the lesion in our case appeared as a markedly dilated bowel loop with a twist in the bowel mesentery (whirlpool) (Figs. 2 & 3 ). Although this finding may be encountered in different types of closed-loop obstruction, the anterior position of the cecum (cecal bascule or hyper-mobile cecum) was suggestive of the diagnosis. This description matches that of Tonerini M. et al. ( 10 ) and Rosenblat JM et al. ( 15 ) . It also matches the case report presented by Abbassi I. et al. ( 13 ) . The signs of severity in CT include low attenuation mesentery at the eye of the twist with hyper-enhancing vessels that represent marked engorgement, extra-luminal air, free fluid and lack of wall enhancement that may indicate perforation ( 16 ) . In our case, there was mesenteric oedema and minimal free fluid (Fig. 2 ), yet the colonic wall was intact with adequate enhancement. During surgical exploration, cecal perforation was identified although there were no signs of frank perforation by radiology. We concluded that signs of severity particularly mesenteric oedema should be mentioned as a separate item in the report, being one of the earliest signs of ischemia and impending peroration. The items to be fulfilled in the reporting of bowel obstruction are summarized in (Fig. 7 ). The cause of CV in our case was Ladd’s band which was the same aetiology in the case report of Kabongo KMC et al. ( 17 ) . However, in the previously mentioned case report the duodenum didn’t cross the midline and there was some degree of intestinal mal-rotation in contrast to our case in which the duodenum crossed the midline normally and there was a preserved relationship between the SMA and SMV (Fig. 4 ). The cecum in our case was hypermobile similar to the same mentioned case report ( 17 ) . We concluded that even in the absence of frank signs of intestinal mal-rotation, the presence of the cecum in the centre of the abdomen is suggestive of the presence of Ladd’s band as an underlying cause of CV particularly in the young age. In our case, the patient underwent open-surgical exploration and underwent RT colonic resection and Ladd’s band ligation, together with ileo-transverse colostomy, which was the same procedure carried out by Kabongo KMC et al. ( 17 ) . However, in the previously mentioned case report, colopexy was performed. In the case report of Al Khalifa A. and Sedik A., right hemicolectomy was also performed but instead of direct ileo-transverse colostomy, both ends were left stapled for a second look ( 5 ) . Despite surgical interference, the patient passed away shortly post-operative. We concluded that a high level of suspicion is essential for early diagnosis and prompt intervention for closed-loop obstruction. Conclusions Even though it is rare, the radiologist should suspect CV when the imaging features suggest it. Signs of severity should be reported, even if there is no obvious perforation. When reporting cases of bowel obstruction, all relevant findings should be addressed. Imaging may suggest the presence of Ladd’s band if the cecum is hypermobile, even without radiological signs of malrotation. CECT is the primary imaging modality for managing closed-loop bowel obstruction. Abbreviations Sigmoid volvulus: SV Cecal volvulus: CV Contrast-enhanced computerised tomography: CECT Right lower quadrant: RLQ Left upper quadrant: LUQ Superior mesenteric artery: SMA Superior mesenteric vein: SMV Multiplanar reformat: MPR Maximum intensity projection: MIP Declarations Ethics approval and consent to participate: Informed consent was obtained from the patient’s relatives (as the patient passed away shortly after surgery). Consent for publication: The patient’s relatives gave informed consent to use the necessary data for publication. Availability of data and materials: The data used in the article are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: The authors declare that they have no funding sources. Authors' contributions: All authors have read and approved the manuscript for publishing. MS: Analyzed the patient’s data, interpreted the radiological findings, prepared the figures and wrote the article. AA (One of the operators): revised the manuscript before submission. MR (One of the operators): revised the manuscript before submission. AAB (One of the operators): revised the manuscript before submission and collected the patient’s operative data. SK: Collected and organised the patient’s data. AAZ: Shared in writing the case presentation section, gave an opinion on other sections during writing, revised the manuscript before submission and prepared the operative room images. Acknowledgements: Not applicable. References Nelms DW, Kann BR. Imaging modalities for evaluation of intestinal obstruction. Clinics in colon and rectal surgery. 2021 Jul;34(04):205-18. Vandendries, C., C Jullès, M., Boulay-Coletta, I., Loriau, J. and Zins, M., 2010. Diagnosis of colonic volvulus: findings on multidetector CT with three-dimensional reconstructions. The British Journal of Radiology , 83 (995), pp.983-990. Atamanalp, S.S., Ozogul, B. and Kisaoglu, A., 2012. Cecal volvulus: a rare cause of intestinal obstruction/Cekal volvulus: bagirsak tikanikliginin nadir bir nedeni. Eurasian Journal of Medicine , 44 (2), p.115. Solis Rojas, C., Vidrio Duarte, R., García Vivanco, D.M. and Montalvo-Javé, E.E., 2020. Cecal volvulus: a rare cause of intestinal obstruction. Case Reports in Gastroenterology , 14 (1), pp.206-211. Al Khalifa A, Sedik A. Cecal Volvulus: A Report of a Challenging Case. Cureus . 2023 Sep;15(9). Cervantes-Gutiérrez O, Cervantes-Millán G, Sorsby-Vargas A, de la Cajiga León A, Armenta JF. Intestinal malrotation and cecum volvulus. Case presentation and bibliographic review. Cirujano General . 2023 Jan 20;43(4):259-64. Soliman M, Magnetta M, Salinas A, Feinn RS, Velichko YS, Miller FH, Kelahan LC. Evaluation of 18 CT signs in diagnosing cecal volvulus: a multi-reader retrospective study. Abdominal Radiology. 2024 Feb;49(2):357-64. Moore CJ, Corl FM, Fishman EK. CT of cecal volvulus: unravelling the image. American Journal of roentgenology. 2001 Jul;177(1):95-8. Wortman JR, Dhyani M, Ali SM, Scholz FJ. Pearls and pitfalls in multimodality imaging of colonic volvulus. Radiographics . 2020 Jul;40(4):1039-40. Tonerini M, Pancrazi F, Lorenzi S, Pacciardi F, Ruschi F, Turturici L, Bemi P. Cecal volvulus: what the radiologist needs to know. Glob Surg . 2015;1:15-8. Sikakulya FK, Kiyaka SM, Masereka R, Onyai P, Okedi XF, Anyama P. Cecal volvulus in an adult male: a rare cause of intestinal obstruction: a case report. International Journal of Surgery Case Reports. 2021 Aug 1;85:106186. Abdulmuttaleb AT, Al-Habbal Z, Ahmed F. Caecal volvulus in a 35-year-old man: a case report. Pan African Medical Journal . 2023 Dec 5;44(1). Abbassi I, Triki W, Trigui R, Salah RB, Itaimi A, Ayed K, Sebri H, Baraket O, Bouchoucha S. Case Report: Caecal volvulus management from diagnosis to treatment in a young patient . F1000Research. 2022;11. Wismayer R. Study about caecal volvulus in East Africa: a rare cause of bowel obstruction. Curr Pract Med Sci. 2022 Aug 26;10:133-41. Rosenblat JM, Rozenblit AM, Wolf EL, DuBrow RA, Den EI, Levsky JM. Findings of cecal volvulus at CT. Radiology . 2010 Jul;256(1):169-75. Pouli S, Kozana A, Papakitsou I, Daskalogiannaki M, Raissaki M. Gastrointestinal perforation: clinical and MDCT clues for identification of aetiology. Insights into imaging. 2020 Dec; 11:1-9. Kabongo KM, Mbewe C, Lupasha M. Cecal Volvulus in Malrotation at 41 years. Annals of African Surgery. 2021;18(4):252-7. Additional Declarations No competing interests reported. Supplementary Files CAREchecklist11102024.docx Cite Share Download PDF Status: Published Journal Publication published 13 May, 2025 Read the published version in Bulletin of the National Research Centre → Version 1 posted Editorial decision: Revision requested 15 Apr, 2025 Reviews received at journal 30 Jan, 2025 Reviewers agreed at journal 30 Jan, 2025 Reviewers agreed at journal 29 Jan, 2025 Reviewers agreed at journal 29 Jan, 2025 Reviews received at journal 22 Dec, 2024 Reviewers agreed at journal 16 Dec, 2024 Reviewers invited by journal 03 Nov, 2024 Editor assigned by journal 03 Nov, 2024 Submission checks completed at journal 29 Oct, 2024 First submitted to journal 28 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Note the kidney-shaped appearance with preserved haustrations.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5348911/v1/1e5de664763aaf930e403893.png"},{"id":69356374,"identity":"f1d834c9-30ea-425e-9449-808dd0c48c1c","added_by":"auto","created_at":"2024-11-19 13:49:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":502907,"visible":true,"origin":"","legend":"\u003cp\u003eCECT (coronal view) sequential images showing the distended large bowel loop (embryo sign) with whirlpool sign, mesenteric oedema (yellow arrowhead) and free fluid (white arrowhead).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5348911/v1/4e8bd80322b894c9a3c01835.png"},{"id":69356369,"identity":"c50dcf2a-2af2-452f-895f-1899b157c1ad","added_by":"auto","created_at":"2024-11-19 13:49:23","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":344576,"visible":true,"origin":"","legend":"\u003cp\u003eCECT (axial view) sequential images showing the anterior position of the markedly distended cecum abutting the anterior abdominal wall denoting hypermobility. Note the twist in the mesentery (white asterisk) and the mesenteric oedema (short blue arrow).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5348911/v1/a230f629ca7a1bd499bb718e.png"},{"id":69358143,"identity":"8777c796-dcc0-4ef7-b91b-ca5047c774fc","added_by":"auto","created_at":"2024-11-19 13:57:23","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":309331,"visible":true,"origin":"","legend":"\u003cp\u003eCECT-axial view (left) \u0026amp; oblique MPR with MIP (right) showing normal anatomical relation of the mesenteric vessels. Superior mesenteric artery (black arrow), superior mesenteric vein (blue arrowhead), portal vein (red arrow) and splenic vein (yellow arrowhead).\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5348911/v1/5e179e9e88cc7434317856dc.png"},{"id":69356373,"identity":"46df9596-a91a-40d6-a1b4-3663af17b2d9","added_by":"auto","created_at":"2024-11-19 13:49:23","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1141016,"visible":true,"origin":"","legend":"\u003cp\u003eOperative room image showing Ladd’s band with the twisted caecum\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-5348911/v1/d2210a65b6492088fba3520f.png"},{"id":69358145,"identity":"f53787a2-edb0-4ee7-ad2a-877ee6507dde","added_by":"auto","created_at":"2024-11-19 13:57:23","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":784058,"visible":true,"origin":"","legend":"\u003cp\u003eOperative room image showing gangrenous perforated caecum after untwisting and division of Ladd's band.\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-5348911/v1/9c6b09d9977f06fbbf2a5a42.png"},{"id":69358422,"identity":"76b43f5d-099d-4b8b-baab-978862ed1fbf","added_by":"auto","created_at":"2024-11-19 14:05:23","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":33234,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of the items to be fulfilled during reporting of bowel obstruction\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-5348911/v1/944265cd4dda551b86bc00d8.png"},{"id":83068019,"identity":"76fbe190-8e7b-45cc-895f-2045632805c7","added_by":"auto","created_at":"2025-05-19 16:09:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5526533,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5348911/v1/1c24b5d8-143e-4363-a014-cae6bfba8f69.pdf"},{"id":69356367,"identity":"4e6c7173-7c7f-45a6-8320-efda0a3fbf30","added_by":"auto","created_at":"2024-11-19 13:49:23","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":81757,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklist11102024.docx","url":"https://assets-eu.researchsquare.com/files/rs-5348911/v1/629d366f6cc726529cdde919.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cecal volvulus on top of Ladd’s band: a case report and review of literature","fulltext":[{"header":"Background","content":"\u003cp\u003eIntestinal obstruction is one of the common scenarios encountered in the emergency clinical setting \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/sup\u003e. Volvulus is among the important causes of bowel obstruction. Although sigmoid volvulus (SV) is the most common type of colonic volvulus \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/sup\u003e, cecal volvulus (CV), on the other hand, is much less common \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e. CV has a relatively poor prognosis, particularly when treatment is delayed as the bowel ischemia develops rapidly and subsequently may lead to bowel necrosis and perforation \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAmong the predisposing factors for colonic volvulus are intestinal malrotation, Ladd\u0026rsquo;s band, mobile cecum, elongated mesentery, chronic constipation, abdominal masses and high-fibre diet \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/sup\u003e. Intestinal malrotation occurs due to failure of the complete (270-degree) bowel rotation as it retracts from the umbilical cord. This may result in increased cecal mobility or abnormal sub-hepatic position of the cecum that predisposes to volvulus \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eImaging plays an important role in the diagnosis and management of CV. Being readily available, a plain radiograph represents the primary diagnostic modality \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/sup\u003e. Unlike small bowel obstruction, large bowel obstruction usually displays no air-fluid levels. Contrast-enhanced computerised tomography (CECT) is the mainstay investigation in the management of CV \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/sup\u003e. In CT images, the signs suggestive of CV are: markedly dilated cecum (\u0026gt;\u0026thinsp;9 cm), bird beak sign with tapering proximal and distal ends of the affected loop (denoting closed loop obstruction) and whirlpool sign (due to the twisting of the two ends of the closed loop around a fulcrum in the bowel mesentery) \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eCecal volvulus and SV both represent closed-loop obstruction and manifest as dilated loops. That is why the radiologist needs to differentiate between both entities. In SV, the distended loop is U-shaped with both ends in the pelvis pointing to the left lower quadrant while in CV, the loop is kidney-shaped with a notch at its middle representing the ileocecal valve \u003csup\u003e(\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e. The main differentiating points between both types of volvuli are mentioned in table (1).\u003c/p\u003e\n\u003cp\u003eTable 1: Differentiating points between cecal and sigmoid volvulus\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\" style=\"width: 880px;\" width=\"880\" height=\"277\"\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eWe present a rare scenario of a CV on top of Ladd\u0026rsquo;s band and intend to share our experience in diagnosing and managing this rare closed-loop bowel obstruction. We also aim to alert the radiologist to the possible signs suggestive of the diagnosis and the important items to be fulfilled during reporting.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eHistory and presentation:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA thirty-six-year-old female patient with no past medical or surgical history presented to our emergency department complaining of acute abdominal pain, bile-stained vomiting abdominal distension and absolute constipation for the previous 3 days. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eClinical findings\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt the time of presentation, the patient looked ill, dehydrated, and in pain. She was febrile with an oral temperature of 38.6 \u0026deg;C, tachycardiac with a pulse of 110/minute; a BP of 100/60 mm Hg and a respiratory rate of 25 breaths per minute. On examination, there was abdominal distention, mainly at the upper right abdominal quadrant, with generalised and rebound tenderness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLaboratory Investigations:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient\u0026rsquo;s leukocytic count was 17.24 10\u003csup\u003e3\u003c/sup\u003e/ml, the haemoglobin was 11.1 g/dL and the platelet count was 240 x 10\u003csup\u003e3\u003c/sup\u003e/mcL. Liver functions, renal function and coagulation profile were all normal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRadiology:\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient underwent a plain x-ray which revealed a markedly dilated large bowel loop with preserved haustrations extending from the right lower quadrant (RLQ) of the abdomen to the left upper quadrant (LUQ) (Fig. 1). The dilated loop appeared kidney-shaped and the rest of the bowel appeared gasless (Fig. 1). No pneumoperitoneum was identified. A provisional diagnosis of colonic volvulus was made and the patient underwent a CECT (with oral and intravenous contrast), which revealed markedly dilated large bowel loops extending from the cecum to the mid-transverse colon with free fluid and mesenteric oedema (Fig. 2). The rest of the large bowel was collapsed. The root of the involved mesentery was twisted and edematous (Fig. 3) with normal contrast-filling of the mesenteric vessels. The anatomical relation between the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) was preserved (Fig. 4). No pneumoperitoneum was detected by radiology. The patient was diagnosed with CV based on the mentioned radiology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eManagement\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFollowing prompt resuscitation with 2 litres of normal saline and the administration of intravenous antibiotics (cefotaxime and metronidazole), as well as the insertion of a nasogastric tube and urinary catheter, the patient underwent an urgent laparotomy performed through a midline incision. Intraoperatively, the cecum was found distended, in an abnormal anatomical position, lying in the right upper abdominal quadrant, twisted over a fibrous band (Ladd\u0026apos;s band) which is connected to the retro-peritoneum (Fig. 5), confirming the diagnosis of cecal volvulus with Ladd\u0026rsquo;s band as the underlying cause. A perforation in the wall of the caecum with blackish discolouration denoting gangrene of the affected part with spillage of bowel contents was also identified presumably as a result of intense dilatation due to Caecal volvulus (Fig. 6). The decision was taken for Ladd\u0026rsquo;s band release and right hemicolectomy with ileo-transverse colostomy because of copious feculent peritonitis.\u003c/p\u003e\n\u003cp\u003eThe excised specimen was sent for histopathology. Microscopic examination of the prepared slides revealed focal ischemic changes in the colonic wall, ulcerated mucosa and congested vessels. The ileal safety margin showed an intact wall and mucosa with inflammatory changes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFate: \u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo days post-surgery, the patient\u0026apos;s condition took a turn for the worse, ultimately succumbing to cardiorespiratory failure.\u003c/p\u003e\n\n"},{"header":"Discussion","content":"\u003cp\u003eThe adequate reporting of intestinal obstruction cases is one of the most important skills a radiologist should master \u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/sup\u003e. Although SV may be encountered as a frequent cause of large bowel obstruction \u003csup\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/sup\u003e, CV is uncommon and hardly reported. Unaware of the peculiar radiological features of such a cause of intestinal obstruction, a radiologist may find it difficult to diagnose this rare entity. \u003csup\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCecal volvulus usually affects the younger population between thirty and sixty years of age \u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/sup\u003e. Our patient (aged thirty-six years) falls in this category, agreeing with the case report mentioned by Sikakulya FK and Abdulmuttaleb AT and their colleagues who mentioned similar age \u003csup\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/sup\u003e. Al Khalifa A. and Sedik A. mentioned different age of presentation (seventy-five years) \u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e. We concluded that the young age of presentation is a useful reminder to suspect cecal volvulus when encountering closed-loop obstruction in the young.\u003c/p\u003e \u003cp\u003eA CV usually appears in plain radiographs as a dilated gas-filled loop extending from the RLQ of the abdomen to the LUQ \u003csup\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/sup\u003e. This characteristic appearance is called \u0026ldquo;embryo sign\u0026rdquo; and is one of the radiographic signs suggestive of CV \u003csup\u003e(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e. The bowel loop orientation in our patient showed a similar orientation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) matching the case presented by Moore CJ and his colleagues \u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e. In the case report mentioned by Al Khalifa A. and Sedik A., there was a localized dilated loop to the right side of the midline \u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e. There was haustral preservation of the affected loop in the previously mentioned articles \u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e matching the appearance of the loop in our case (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). We concluded that the preserved bowel haustra is a very important sign to differentiate between SV and CV being preserved in the latter. We also concluded that the position of the dilated loop is variable in CV, with the most common being oriented from the RLQ to LUQ.\u003c/p\u003e \u003cp\u003eBy CECT, the lesion in our case appeared as a markedly dilated bowel loop with a twist in the bowel mesentery (whirlpool) (Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e \u0026amp; \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Although this finding may be encountered in different types of closed-loop obstruction, the anterior position of the cecum (cecal bascule or hyper-mobile cecum) was suggestive of the diagnosis. This description matches that of Tonerini M. et al. \u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/sup\u003e and Rosenblat JM et al. \u003csup\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e. It also matches the case report presented by Abbassi I. et al. \u003csup\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe signs of severity in CT include low attenuation mesentery at the eye of the twist with hyper-enhancing vessels that represent marked engorgement, extra-luminal air, free fluid and lack of wall enhancement that may indicate perforation \u003csup\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/sup\u003e. In our case, there was mesenteric oedema and minimal free fluid (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), yet the colonic wall was intact with adequate enhancement. During surgical exploration, cecal perforation was identified although there were no signs of frank perforation by radiology. We concluded that signs of severity particularly mesenteric oedema should be mentioned as a separate item in the report, being one of the earliest signs of ischemia and impending peroration. The items to be fulfilled in the reporting of bowel obstruction are summarized in (Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe cause of CV in our case was Ladd\u0026rsquo;s band which was the same aetiology in the case report of Kabongo KMC et al. \u003csup\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e. However, in the previously mentioned case report the duodenum didn\u0026rsquo;t cross the midline and there was some degree of intestinal mal-rotation in contrast to our case in which the duodenum crossed the midline normally and there was a preserved relationship between the SMA and SMV (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The cecum in our case was hypermobile similar to the same mentioned case report \u003csup\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e. We concluded that even in the absence of frank signs of intestinal mal-rotation, the presence of the cecum in the centre of the abdomen is suggestive of the presence of Ladd\u0026rsquo;s band as an underlying cause of CV particularly in the young age.\u003c/p\u003e \u003cp\u003eIn our case, the patient underwent open-surgical exploration and underwent RT colonic resection and Ladd\u0026rsquo;s band ligation, together with ileo-transverse colostomy, which was the same procedure carried out by Kabongo KMC et al. \u003csup\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e. However, in the previously mentioned case report, colopexy was performed. In the case report of Al Khalifa A. and Sedik A., right hemicolectomy was also performed but instead of direct ileo-transverse colostomy, both ends were left stapled for a second look \u003csup\u003e(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/sup\u003e. Despite surgical interference, the patient passed away shortly post-operative. We concluded that a high level of suspicion is essential for early diagnosis and prompt intervention for closed-loop obstruction.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eEven though it is rare, the radiologist should suspect CV when the imaging features suggest it. Signs of severity should be reported, even if there is no obvious perforation. When reporting cases of bowel obstruction, all relevant findings should be addressed. Imaging may suggest the presence of Ladd\u0026rsquo;s band if the cecum is hypermobile, even without radiological signs of malrotation. CECT is the primary imaging modality for managing closed-loop bowel obstruction.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eSigmoid volvulus: SV\u003c/li\u003e\n \u003cli\u003eCecal volvulus: CV\u003c/li\u003e\n \u003cli\u003eContrast-enhanced computerised tomography: CECT\u003c/li\u003e\n \u003cli\u003eRight lower quadrant: RLQ\u003c/li\u003e\n \u003cli\u003eLeft upper quadrant: LUQ\u003c/li\u003e\n \u003cli\u003eSuperior mesenteric artery: SMA\u003c/li\u003e\n \u003cli\u003eSuperior mesenteric vein: SMV\u003c/li\u003e\n \u003cli\u003eMultiplanar reformat: MPR\u003c/li\u003e\n \u003cli\u003eMaximum intensity projection: MIP\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e Informed consent was obtained from the patient\u0026rsquo;s relatives (as the patient passed away shortly after surgery).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eThe patient\u0026rsquo;s relatives gave informed consent to use the necessary data for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe data used in the article are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no funding sources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the manuscript for publishing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMS: Analyzed the patient\u0026rsquo;s data, interpreted the radiological findings, prepared the figures and wrote the article.\u003c/p\u003e\n\u003cp\u003eAA (One of the operators): revised the manuscript before submission.\u003c/p\u003e\n\u003cp\u003eMR (One of the operators): revised the manuscript before submission.\u003c/p\u003e\n\u003cp\u003eAAB (One of the operators): revised the manuscript before submission and collected the patient\u0026rsquo;s operative data.\u003c/p\u003e\n\u003cp\u003eSK: Collected and organised the patient\u0026rsquo;s data.\u003c/p\u003e\n\u003cp\u003eAAZ: Shared in writing the case presentation section, gave an\u0026nbsp;opinion on other sections during writing, revised the manuscript before submission and prepared the operative room images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eNelms DW, Kann BR. Imaging modalities for evaluation of intestinal obstruction. \u003cem\u003eClinics in colon and rectal surgery.\u003c/em\u003e 2021 Jul;34(04):205-18.\u003c/li\u003e\n \u003cli\u003eVandendries, C., C Jull\u0026egrave;s, M., Boulay-Coletta, I., Loriau, J. and Zins, M., 2010. Diagnosis of colonic volvulus: findings on multidetector CT with three-dimensional reconstructions. \u003cem\u003eThe British Journal of Radiology\u003c/em\u003e, \u003cem\u003e83\u003c/em\u003e(995), pp.983-990.\u003c/li\u003e\n \u003cli\u003eAtamanalp, S.S., Ozogul, B. and Kisaoglu, A., 2012. Cecal volvulus: a rare cause of intestinal obstruction/Cekal volvulus: bagirsak tikanikliginin nadir bir nedeni. \u003cem\u003eEurasian Journal of Medicine\u003c/em\u003e, \u003cem\u003e44\u003c/em\u003e(2), p.115.\u003c/li\u003e\n \u003cli\u003eSolis Rojas, C., Vidrio Duarte, R., Garc\u0026iacute;a Vivanco, D.M. and Montalvo-Jav\u0026eacute;, E.E., 2020. Cecal volvulus: a rare cause of intestinal obstruction. \u003cem\u003eCase Reports in Gastroenterology\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(1), pp.206-211.\u003c/li\u003e\n \u003cli\u003eAl Khalifa A, Sedik A. Cecal Volvulus: A Report of a Challenging Case. \u003cem\u003eCureus\u003c/em\u003e. 2023 Sep;15(9).\u003c/li\u003e\n \u003cli\u003eCervantes-Guti\u0026eacute;rrez O, Cervantes-Mill\u0026aacute;n G, Sorsby-Vargas A, de la Cajiga Le\u0026oacute;n A, Armenta JF. Intestinal malrotation and cecum volvulus. Case presentation and bibliographic review. \u003cem\u003eCirujano General\u003c/em\u003e. 2023 Jan 20;43(4):259-64.\u003c/li\u003e\n \u003cli\u003eSoliman M, Magnetta M, Salinas A, Feinn RS, Velichko YS, Miller FH, Kelahan LC. Evaluation of 18 CT signs in diagnosing cecal volvulus: a multi-reader retrospective study. \u003cem\u003eAbdominal Radiology.\u003c/em\u003e 2024 Feb;49(2):357-64.\u003c/li\u003e\n \u003cli\u003eMoore CJ, Corl FM, Fishman EK. CT of cecal volvulus: unravelling the image. \u003cem\u003eAmerican Journal of roentgenology.\u003c/em\u003e 2001 Jul;177(1):95-8.\u003c/li\u003e\n \u003cli\u003eWortman JR, Dhyani M, Ali SM, Scholz FJ. Pearls and pitfalls in multimodality imaging of colonic volvulus. \u003cem\u003eRadiographics\u003c/em\u003e. 2020 Jul;40(4):1039-40.\u003c/li\u003e\n \u003cli\u003eTonerini M, Pancrazi F, Lorenzi S, Pacciardi F, Ruschi F, Turturici L, Bemi P. Cecal volvulus: what the radiologist needs to know. \u003cem\u003eGlob Surg\u003c/em\u003e. 2015;1:15-8.\u003c/li\u003e\n \u003cli\u003eSikakulya FK, Kiyaka SM, Masereka R, Onyai P, Okedi XF, Anyama P. Cecal volvulus in an adult male: a rare cause of intestinal obstruction: a case report. \u003cem\u003eInternational Journal of Surgery Case Reports.\u003c/em\u003e 2021 Aug 1;85:106186.\u003c/li\u003e\n \u003cli\u003eAbdulmuttaleb AT, Al-Habbal Z, Ahmed F. Caecal volvulus in a 35-year-old man: a case report. \u003cem\u003ePan African Medical Journal\u003c/em\u003e. 2023 Dec 5;44(1).\u003c/li\u003e\n \u003cli\u003eAbbassi I, Triki W, Trigui R, Salah RB, Itaimi A, Ayed K, Sebri H, Baraket O, Bouchoucha S. Case Report: Caecal volvulus management from diagnosis to treatment in a young patient\u003cem\u003e. F1000Research.\u003c/em\u003e 2022;11.\u003c/li\u003e\n \u003cli\u003eWismayer R. Study about caecal volvulus in East Africa: a rare cause of bowel obstruction. \u003cem\u003eCurr Pract Med Sci.\u003c/em\u003e 2022 Aug 26;10:133-41.\u003c/li\u003e\n \u003cli\u003eRosenblat JM, Rozenblit AM, Wolf EL, DuBrow RA, Den EI, Levsky JM. Findings of cecal volvulus at CT. \u003cem\u003eRadiology\u003c/em\u003e. 2010 Jul;256(1):169-75.\u003c/li\u003e\n \u003cli\u003ePouli S, Kozana A, Papakitsou I, Daskalogiannaki M, Raissaki M. Gastrointestinal perforation: clinical and MDCT clues for identification of aetiology. \u003cem\u003eInsights into imaging.\u003c/em\u003e 2020 Dec; 11:1-9.\u003c/li\u003e\n \u003cli\u003eKabongo KM, Mbewe C, Lupasha M. Cecal Volvulus in Malrotation at 41 years. \u003cem\u003eAnnals of African Surgery.\u003c/em\u003e 2021;18(4):252-7.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bulletin-of-the-national-research-centre","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnrc","sideBox":"Learn more about [Bulletin of the National Research Centre](https://BNRC.springeropen.com)","snPcode":"42269","submissionUrl":"https://submission.springernature.com/new-submission/42269/3","title":"Bulletin of the National Research Centre","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cecal Diseases, General Surgery, Imaging, Intestinal Obstruction, Volvulus","lastPublishedDoi":"10.21203/rs.3.rs-5348911/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5348911/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eCecal volvulus is a rare cause of bowel obstruction that represents a challenge in both diagnosis and management. This unique form of closed-loop obstruction occurs due to a twist in the mesentery with subsequent dilatation of the cecum. As a result of the massive distension of the large bowel, many radiologists find it difficult to recognise the signs suggestive of cecal volvulus. In this article, we highlight the role of imaging in the management of this form of bowel obstruction.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA thirty-six-year-old female patient presented to our emergency department with symptoms of acute abdomen. Imaging revealed a massively dilated large bowel loop in an abnormal distribution in the centre of the abdomen with a whirlpool in the mesentery. Cecal volvulus was suspected. Surgical exploration confirmed the diagnosis and an abnormal band connected to the cecum (Ladd\u0026rsquo;s band) was also identified. The patient underwent division of the band with ileo-transverse colostomy. Unfortunately, the patient passed away due to cardiorespiratory failure two days after the operation.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eThe radiologist should always consider cecal volvulus in the differential diagnosis of closed-loop obstruction particularly at a young age. A hypermobile cecum on imaging may suggest Ladd's band, even without signs of malrotation. All relevant items should be addressed when reporting bowel obstruction cases.\u003c/p\u003e","manuscriptTitle":"Cecal volvulus on top of Ladd’s band: a case report and review of literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-19 13:49:18","doi":"10.21203/rs.3.rs-5348911/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-15T11:13:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-31T03:54:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4912285071413621708219352526299037430","date":"2025-01-31T01:58:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296562448315383970097662483189640393966","date":"2025-01-29T13:34:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147635421643037146619124591815089165803","date":"2025-01-29T05:03:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-22T11:04:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332431146959932253859010994705440900087","date":"2024-12-16T22:08:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-04T04:32:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-03T16:42:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-29T04:48:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"Bulletin of the National Research Centre","date":"2024-10-28T17:07:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bulletin-of-the-national-research-centre","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnrc","sideBox":"Learn more about [Bulletin of the National Research Centre](https://BNRC.springeropen.com)","snPcode":"42269","submissionUrl":"https://submission.springernature.com/new-submission/42269/3","title":"Bulletin of the National Research Centre","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6f440986-72d1-47b1-b5c8-90a2b8dd2c23","owner":[],"postedDate":"November 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-19T16:05:45+00:00","versionOfRecord":{"articleIdentity":"rs-5348911","link":"https://doi.org/10.1186/s42269-025-01322-6","journal":{"identity":"bulletin-of-the-national-research-centre","isVorOnly":false,"title":"Bulletin of the National Research Centre"},"publishedOn":"2025-05-13 15:57:20","publishedOnDateReadable":"May 13th, 2025"},"versionCreatedAt":"2024-11-19 13:49:18","video":"","vorDoi":"10.1186/s42269-025-01322-6","vorDoiUrl":"https://doi.org/10.1186/s42269-025-01322-6","workflowStages":[]},"version":"v1","identity":"rs-5348911","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5348911","identity":"rs-5348911","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}