A 24-year-old man presents to the emergency department with abdominal pain, nausea, and vomiting. The symptoms began towards the end of running a marathon and persisted after finishing the race. The patient is otherwise healthy and has no other medical problems. His temperature is 98.0°F (36.7°C), blood pressure is 105/71 mmHg, pulse is 113/min, respirations are 19/min, and oxygen saturation is 98% on room air. Physical exam reveals a distended and tender abdomen. A radiograph is performed as seen in Figure A. Which of the following is the most likely diagnosis?
Cecal volvulus
Ileus
Sigmoid volvulus
Small bowel obstruction
Cecal volvulus
This young, healthy patient presents with abdominal pain, nausea, vomiting, and a distended, tender abdomen with a radiograph demonstrating the "coffee bean sign," likely has a cecal volvulus.

Cecal volvulus is the second most common cause of volvulus after sigmoid volvulus and presents with abdominal pain, constipation, vomiting, abdominal distention, and a tympanitic abdomen. It is more common in young patients who are active (e.g. marathon runners). The classic conventional radiographic finding in cecal volvulus is the coffee bean sign, in which closed loops of intestine distend with gas, making visible the medial and lateral walls of dilated bowel. Diagnosis of cecal volvulus can be confirmed with a CT scan. Management involves analgesia, intravenous fluids, and surgical detorsion.

Hasbahceci et al. review the presentation, diagnosis, and management of cecal volvulus. The authors find that abdominal radiography has a low sensitivity for cecal volvulus. The authors recommend surgical management of cecal volvulus with resection with right hemicolectomy and primary ileocolic anastomosis.

Figure/Illustration A is a radiograph demonstrating the "coffee bean" sign which is suggestive of a cecal volvulus.

Incorrect Answers:
Answer B: Ileus presents after surgery or manipulation of the intestines with decreased peristalsis of the intestine leading to a failure to pass gas or have bowel movements. Treatment involves treating any electrolyte abnormalities, encouraging ambulation, and avoiding medications that decrease peristalsis (such as opioids).

Answer C: Ogilvie syndrome occurs when the colon wall is not appropriately undergoing peristalsis leading to a dilated colon with abdominal distension. It is more common in the elderly and critically ill patients. Treatment involves the placement of a rectal tube to decompress the intestines and treatment of any underlying medical conditions.

Answer D: Sigmoid volvulus is more common in elderly and critically ill patients and presents with constipation, an absence of bowel movements, and a distended, tympanitic abdomen. Although the coffee bean sign may also be seen in patients with sigmoid volvulus, patients tend to be older. In addition, plain radiography typically demonstrates multiple air-fluid levels in a sigmoid volvulus versus usually only a single air-fluid level in a cecal volvulus. Treatment involves flexible sigmoidoscopy and surgery.

Answer E: Small bowel obstruction presents with a distended and tympanitic abdomen with nausea, vomiting, and an absence of flatus or bowel movements. Radiography may demonstrate distended bowel and air-fluid levels, and the most accurate test is a CT scan of the abdomen. It occurs secondary to adhesions entrapping the bowel. Management involves the placement of a nasogastric tube, intravenous fluids, and surgery.

Bullet Summary:
Cecal volvulus presents in younger patients with abdominal pain, distention, constipation, nausea, vomiting, and the "coffee bean" sign on radiography.