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Pictorial Essay
CT of Cecal Volvulus: Unraveling the Image
Carolyn J. Moore 1, Frank M. Corl 1, Elliot K. Fishman 1,2

olvulus of the cecum is a torsion

of the bowel around its own mesentery that often results in a closedloop obstruction. Cecal volvulus can only
occur in the small percentage (1125%) of
the population who have a developmental
failure of peritoneal fixation, allowing the
proximal colon to be free and mobile [1].
The second requirement is restriction of the
bowel at a fixed point within the abdomen
that serves as a fulcrum for rotation, such as
an adhesion, abdominal mass, or scarring
from calcified lymph nodes [2].
Recognition of the CT signs of cecal volvulus is critical because the findings at clinical
examination are often vague and because CT
is usually the imaging technique of choice for
patients presenting with acute abdominal pain
[3]. Furthermore, diagnosis may be difficult:
The images on the patients abdominal radiographs could be obscured if the closed loop is
filled with fluid, oriented in an anteroposterior
plane, or overlain by loops of air-distended
bowel [4]. CT reveals the presence and location of the volvulus and gives the added benefit
of allowing early identification of potentially
fatal complications, such as ischemia and perforation. Three-dimensional (3D) reconstructions may further improve diagnostic
capabilities by allowing visualization of the
entire bowel in a single image. This pictorial
essay uses schematic diagrams and cases of
representative patients to describe the CT ap-

pearance of cecal volvulus and the diagnostic

benefit of 3D imaging.

Technique

This report is based on data collected from five

patients with cecal volvulus that had been con-

firmed either by surgery or colonoscopic decompression. The CT technique varied because the
images were obtained from several different
scanners. We currently scan the abdomen and
pelvis after the IV administration of 100120
mL of iodinated contrast medium injected at a
rate of 23 mL/sec. Scanning is performed on a

Fig. 1.Drawing shows loop-type cecal volvulus. Cecum may twist either clockwise or counterclockwise and
then inverts upward. Twisted terminal ileum is seen tangled with cecum. Lower left illustration shows point of
torsion as it would appear on axial CT images. Lg. = large, Sm. = small.

Received October 20, 2000; accepted after revision January 9, 2001.

1

Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287.

Department of Radiology, Johns Hopkins Hospital, 601 N. Caroline St., Baltimore, MD 21287. Address correspondence to E. K. Fishman.

AJR 2001;177:9598 0361803X/01/177195 American Roentgen Ray Society

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Moore et al.
Somatom Plus 4 or Volume Zoom scanner (Siemens, Forchheim, Germany). We scan either
with 5-mm collimation, 5-mm scan increments,
and a table speed of 810 mm/sec or with 3-mm
collimation, 5-mm scan increments, and a table
speed of 15 mm/sec.
Clinical Background

Cecal volvulus accounts for 11% of all intestinal volvulus, generally occurring in pa-

tients who are 3060 years old. Medical

history of these patients may include prior
abdominal surgery, presence of a pelvic
mass, violent coughing, atonia of the colon,
extreme exertion, unpressurized air travel, or
third-trimester pregnancy [1]. Patients
present with nausea, vomiting, constipation,
and acute cramping pain [1]. The clinical differential diagnosis is usually bowel obstruction versus appendicitis, inflammatory bowel

B
Fig. 2.Two patients with cecal volvulus located in the left upper quadrant.
A, Topogram in 33-year-old woman
reveals markedly air-distended
cecum in shape of coffee bean.
B, Axial CT image of same patient as A
shows inferiorly placed transverse colon separate from the cecal volvulus.
C, Axial CT image shows coffee
bean sign in 55-year-old man.

disease, irritable bowel syndrome, or peptic

ulcer disease [1].
Two Types of Twists

When torsion of bowel results in obstruction, the term volvulus is used. In approximately half of the patients, the cecum twists
in the axial plane, rotating clockwise or
counterclockwise around its long axis and
appearing in the right lower quadrant [3, 5].
The other half of patients have what is
known as the loop type of cecal volvulus, in
which the cecum both twists and inverts, occupying the left upper quadrant of the abdomen [3, 5] (Fig. 1). The terminal ileum is
usually twisted along with the cecum. Visualization of a gas-filled appendix confirms
the diagnosis [5]. There is a variant of cecal
volvulus termed a cecal bascule, which occurs when the cecum folds anteriorly without
any torsion. Cecal bascule is often seen as a
dilated loop in the mid abdomen [3].
Coffee Bean, Bird Beak, and
Whirl Signs

On axial CT images, cecal volvulus is suggested by the extreme dilatation of the cecum.
When seen on conventional radiographs or tomograms, the cecal volvulus is seen as a
rounded focal collection of air-distended
bowel with haustral creases in the left upper
quadrant that resembles a coffee bean (Figs. 2
and 3). The two limbs of the looped obstruction gradually taper and converge at the site of
the torsion, resulting in the appearance of a
birds beak. This bird beak sign, originally
applied to the appearance of sigmoid volvulus
on conventional radiographs, can also be appreciated on axial CT images of the loop-type
cecal volvulus [4] (Fig. 4). A specific CT sign
for volvulus is the whirl (Fig. 5), which has

Fig. 3.Cecal volvulus in 81-yearold woman.

A, Axial CT scan of air-distended cecum
in left upper quadrant with decompressed descending colon (arrow).
B, Axial CT scan obtained inferior to
region in A reveals that transverse colon is separate from cecal volvulus.

A
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B
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CT of Cecal Volvulus
been described in volvulus of the midgut,
cecum, and sigmoid colon [2, 4]. The whirl is
composed of spiraled loops of collapsed
cecum and sigmoid colon. Low-attenuating
fatty mesentery with enhancing engorged ves-

sels radiate from the twisted bowel. In the central eye of the whirl, a soft-tissue density
pinpoints the source of the twist [2]. The degree of cecal rotation can even be predicted by
the tightness of the whirl [6].

Fig. 4.Axial CT images of 33-year-old

woman seen in Figures. 2A and 2B.
AC, Progressive tapering of efferent and afferent loops terminating at
site of torsion in bird beak equivalent (C, arrowhead).

Treatment

Colonoscopy has been a highly rated tool

in diagnosing and reducing the occurrence of
sigmoid volvulus, but it is often not ideal for
use in treating volvulus of the cecum. The reduction rates in cecal volvulus achieved
through use of colonoscopy are much lower
than those achieved in sigmoid volvulus, and
in patients with cecal volvulus, the recurrence
rate exceeds 50% [1]. In patients with uncomplicated cecal volvulus, surgical options include cecopexy, which has a low rate of
morbidity (08%) and volvulus recurrence.
Gangrene or perforation requires surgical resection, which eliminates the possibility of recurrence and also has low morbidity and
mortality rates [1, 7]. CT findings change patient treatment by revealing the signs of bowel
ischemia, including thickening of bowel wall,
mesenteric hemorrhage, and pneumatosis intestinalis [1].
The Role of 3D Imaging

Diagnosing the cause of bowel obstruction

on axial images requires following the course
of several air-distended bowel loops with varying diameters over many consecutive images.
If the bowel collapses or is oriented anteroposteriorly, visualization of the bowel becomes
limited, thereby increasing the difficulty in locating the exact transition point. Performing a
barium enema circumvents this problem by
isolating the involved loop and accurately revealing the point of obstruction. However, use

Fig. 5.Axial CT scan shows cecal volvulus in 57-year-old man.

A, Whirl sign is composed of spiraled loops of collapsed cecum, distal ileum, and enhancing engorged vessels. Soft-tissue center corresponds to source of volvulus
(long arrow). Note radiating mesenteric fat (short arrow).
B, Schematic diagram of whirl sign. Lg. = large, Sm. = small.

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Moore et al.

Fig. 6.66-year-old woman with cecal torsion. Three-dimensional reconstructions use volume rendering to define presence of cecal volvulus. Volume display of entire
data set has potential advantages over review of multiple axial images by defining entire colon and areas of transition.
A, Image rendering simulates a single-contrast barium study.
B, Image rendering simulates a double-contrast barium study.
C, In this sagittal reconstruction, adjacent bowel loops can be distinguished and site of volvulus can be defined.

of the barium enema is somewhat limited because it may yield no information about emergent complications such as bowel ischemia or
other disease processes outside the bowel wall.
Three-dimensional imaging is ideal because,
like a barium enema, the entire bowel can be
visualized in a single image, separating the
volvulus from other dilated loops (Figs. 6A
and 6B). Three-dimensional displays allow radiologists to select the optimal plane for viewing the volvulus and to locate the precise

98

source of the torsion (Fig. 6C). In effect, the

ability to analyze an image in multiple planes
allows one to unravel twisted bowel and confirm the diagnosis of volvulus.
References
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5. Field S. Alimentary tract radiology, 5th ed., vol.
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