The mobility of colonic segments may cause false-negative examinations. In particular, the sigmoid, transverse colon, and right colon have loosely attached mesentery and can demonstrate mobility with a change in position from supine to prone (see
Figures 6.24,
6.25,
6.26 and
6.27). The mobility may be complex in orientation about the x-, y-, or z-axis. Rotation about the z-axis can occur with little change in position in the other planes. The 3D transparency view is helpful for demonstrating mobility of a colonic segment. Residual stool is usually differentiated from polyps by internal heterogeneity and demonstration of mobility with a change in patient position. However, homogeneous stool can be differentiated from a sessile polyp because it is often mobile. Rotated or mobile colonic segments may cause the reader to misinterpret a true polyp as mobile homogeneous stool (see
Figure 6.28).
Laks et al. performed a study evaluating positional change in colon polyps on CTC.
22 Eleven of 41 polyps (27%) measuring 5 mm or larger demonstrated movement with a change in patient position. Five of the 11 polyps were pedunculated and movement was due to the stalk. The remaining six polyps were sessile and located in mobile segments (sigmoid, transverse colon, ascending colon, and cecum) so that polyp movement was related to positional changes of the colon in the mesentery and was not true mobility of the polyp. It was concluded that a mobile lesion should not be assumed to be stool at CTC.
The cecum usually lies in the right iliac fossa, inferior and anterior to the ascending colon.
23 Approximately 10% of the population have an incompletely fixed cecum and ascending colon permitting a wide range of mobility including a number of variant anatomic positions, such as medial, anteflexed, or retroflexed in location
24 (see
Figure 6.29). Patients with a mobile cecum may present with chronic right lower quadrant pain with associated abdominal distention. Cecopexy, using a lateral peritoneal flap for fixation, can relieve symptoms and prevent subsequent cecal volvulus.
25 Chen and Dachman studied the mobility of the cecum on supine and prone data sets in 21 patients.
26 The authors analyzed the position of the cecum based on the ICV and the appendiceal orifice. The measurement of a line along an axis connecting the ICV and appendiceal orifice relative to a vertical was used to determine cecal motion between the two data sets. Axial rotation was also assessed by comparing a line drawn through the center of the cecum and another from the
center of the cecum to the ICV. Any degree of rotation of this line was interpreted as axial mobility. Rotation that could impact the diagnosis was found to occur in 9/21 (43%) cases with an average rotation of 78.9 +/−27.4 degrees. In the 12 cases that did not pose a diagnostic dilemma, the average rotation was still 22.5+/−12 degrees. In addition, the main axis of rotation was varied, occurring predominantly in coronal (6 cases), sagittal (4 cases), or axial (11 cases) planes. It was concluded that rotation of the colon occurs frequently, is geometrically complex, and occurs in several planes. Multiplanar reformatted views are helpful when solid stool is suspected in the cecum to assess for rotation.