Small bowel volvulus diagnosed by the CT "whirl sign"

Primary Segmental Small Bowel Volvulus in an Adolescent Female

Small bowel volvulus is a rare but important cause of abdominal pain and small bowel obstruction in children and adults. In the neonate, small bowel volvulus is a well-known complication of malrotation. Segmental small bowel volvulus is a lesser-known condition, which occurs in children and adults alike and can rapidly progress to bowel ischemia. Primary segmental small bowel volvulus occurs in the absence of rotational anomalies or other intraabdominal lesions and is rare in Europe and North America. Clinical presentation can be misleading, causing a delay in diagnosis and treatment, in which case the resection of necrotic bowel may become necessary.

We report on a 14-year-old girl who presented with severe colicky abdominal pain but showed no other signs of peritoneal irritation or bowel obstruction. An emergency magnetic resonance imaging was highly suspicious for small bowel volvulus. Emergency laparotomy revealed a 115 cm segment of strangulated distal ileum with no underlying pathology. We performed a detorsion of the affected bowel segment. Despite the initial markedly ischemic appearance of the affected bowel segment, the patient achieved full recovery without resection of bowel becoming necessary.

Torsional Necrosis of an Output Loop Internal Hernia After Roux-en-Y Choledochojejunostomy: A Case Report

Ultra-short bowel syndrome (USBS) refers to a clinical condition characterized mainly by severe diarrhea and nutritional disorders caused by the residual small intestine length of <30 cm (1). After Roux-en-Y choledochojejunostomy, the output loop herniated from the back of the anti-reverse peristalsis loop, resulting in intestinal torsion and necrosis, and leading to this rare case of internal hernia. Patients with torsion often show severe abdominal pain and persistent aggravation, but this symptom lacks specificity, making it easy to be misdiagnosed. Acute intestinal torsion and necrosis often lead to large-scale small bowel resection, resulting in USBS. We report a case of torsional necrosis of an output loop internal hernia after Roux-en-Y choledochojejunostomy, providing certain reference for the diagnosis and management of such cases.

Primary adult midgut volvulus mimicking acute appendicitis: A case report and review of the literature

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Adult midgut volvulus is a rare but important cause of small bowel obstruction.

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Our patient, 35 year old male, was clinically suspected to have acute appendicitis.

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Intra-operatively, we found a normal appendix and jejunal volvulus with adhesions.

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If in doubt, early contrast CT scan should be performed.

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Delay to diagnosis and surgical intervention may result in bowel ischemia.

Introduction

Adult midgut volvulus is a rare surgical disease but remains an important cause of small bowel obstruction. It is most commonly secondary to postoperative adhesions. Primary cases may be due to congenital malformations.

Presentation of case

We report the case of an adult primary midgut volvulus in a 35-year-old Chinese male. Based on the clinical presentation and investigations, the patient was presumed to have acute appendicitis. An open appendectomy was performed. During the operation, the appendix appeared normal. Instead a jejunal volvulus was found secondary to extensive adhesions.

Discussion

The epidemiology, embryology and etiology of jejunal volvulus are highlighted. Clinical presentation includes acute colicky abdominal pain usually in the peri-umbilical or epigastric regions, with possible signs of small bowel obstruction. Radiologic diagnosis is confirmed with the ultrasonic ‘whirpool’ sign or via computed tomography (CT) scan. Early surgical intervention is necessary to avert bowel ischemia in the presence of a closed loop obstruction.

Conclusion

While rare, adult midgut volvulus has the potential for morbidity and mortality if not diagnosed early with intestinal ischaemia and related sequlae. Clinicians should consider this and if in doubt, perform an early contrast CT scan.

A Fatal Twist: Volvulus of the Small Intestine in a 46-Year-Old Woman

A 46-year-old woman presented to two emergency departments within 12 hours because of acute abdominal pain. Physical exam demonstrated tenderness and epigastric guarding. An ultrasound was interpreted as negative; she was discharged home. Later that evening, she was found dead. Postmortem exam revealed acute hemorrhagic necrosis of a segment of jejunum secondary to volvulus. Clinical clues suggesting presentations of small bowel volvulus are usually nonspecific; the diagnosis is typically confirmed at surgery. Her unremitting abdominal pain, persistent vomiting, and absolute neutrophilia were consistent with an acute process. The etiology of this volvulus was caused by an elastic fibrous band at the root of the jejunal mesentery. While congenital fibrous bands are rare in adults, this interpretation is favored for two reasons. First, the band was located 20 cm superior to postsurgical adhesions in the lower abdomen and pelvis. Second, there was no history of trauma or previous surgery involving the site of volvulus.

Barber Pole Sign in CT Angiography, Adult Presentation of Midgut Malrotation: A Case Report

Adult midgut volvulus is a challenging diagnosis because of its low incidence and nonspecific symptoms. Diagnostic delay and long-term complaints are frequent in this clinical scenario. We reported a patient referred to our diagnostic imaging unit with intermittent abdominal pain, bloating and episodic vomiting for several years. He underwent barium gastrointestinal transit and abdominal ultrasound, which revealed severe gastric dilatation, food retention and slow transit until a depressed duodenojejunal flexure, with malrotation of the midgut and jejunal loops being located in the right upper quadrant. Computed tomography angiography was performed, showing rotation of the small intestine around the mesentery root, suggestive of midgut malrotation. In addition, an abnormal twisted disposition of superior mesenteric artery with corkscrew appearance was seen, shaping the pole-barber sign which was evident in volume rendering three-dimensional reconstructions. The patient underwent scheduled surgical treatment without any complication and had good outcome after hospital discharge and follow-up. Computed tomography plays an important role in evaluation of adult midgut volvulus. In addition, angiographic reconstructions can help us to assess the anatomic disposition of mesenteric vascular supply. Both of these assessments are useful in preoperative management.

"Venous cut-off sign" as an adjunct to the "whirl sign" in recognizing acute small bowel volvulus via CT scan

INTRODUCTION

A young adult patient was admitted for signs and symptoms of acute abdomen.

MATERIALS AND METHODS

Urgent CT scan was performed and small bowel volvulus was confirmed. The "whirl sign" diagnostic of small bowel volvulus was present.

RESULTS

Furthermore, the accompanying superior mesenteric vein was noted to be truncated at the point of torsion.

CONCLUSION

The "venous cut-off sign" can be a useful adjunct sign to the diagnosis.

Primary midgut volvulus in adults: report of two cases and review of the literature

INTRODUCTION

This is a report of two male patients (35 and 54 years old, respectively) admitted to our surgical department with signs of small-bowel obstruction.

CASE PRESENTATIONS

Diagnostic workup with plain abdominal radiographs and, more specifically, computed tomography suggested the possibility of bowel rotation. In order to exclude any possibility of associated intestinal ischemia, both patients underwent exploratory laparotomy, which revealed a midgut volvulus without any associated obvious cause or pathology.

DISCUSSION

Both patients had an eventful outcome. Epidemiologic characteristics, clinical presentation, diagnostic workup, surgical treatment, and morbidity-mortality rates of small-bowel volvulus have been reviewed and thoroughly discussed.

Volvulus of the Small Bowel in Adults

The volvulus of the small bowel is a surgical emergency, causing small bowel obstruction. We performed a retrospective study of all the patients diagnosed and treated with small bowel volvulus between 1977 and 2007 at our institution. One hundred twenty-nine patients were analyzed. Thirty-nine patients presented primary volvulus and 90 secondary ones. The most frequent symptom was sudden abdominal pain. CT scan was the best diagnostic method with an accuracy of 83 per cent. Necrotic small bowel loops appeared in 46.5 per cent of the patients. Eighteen patients had postoperative complications (14%). Mortality rate was 9.3 per cent. A higher mortality is observed among patients with previous abdominal surgeries and cardiopathies. Necrotic loops are associated with higher mortality and incidence of surgical complications; patients with diabetes are associated with a higher incidence of necrotic loops. Cardiopathies are associated with more frequent medical and surgical complications. Recurrence rate was 3.9 per cent associated with simple devolvulation. Primary volvulus are more frequent among males and patients with diabetes. Jejunal location is associated with primary volvulus and these correlate with a higher incidence of necrotic loops. Primary volvulus presents a higher incidence of surgical complications. A bowel obstruction with sudden abdominal pain must be suspicious of small bowel volvulus. The main aim is to achieve an early diagnosis to prevent a necrotic small bowel. CT scan is the imaging test with the best diagnostic accuracy. Primary volvulus, the presence of necrotic loops, and patients with cardiopathies, diabetes mellitus, and with previous abdominal surgery are associated with a worse outcome.

Multiphasic MDCT in small bowel volvulus

OBJECTIVE

Evaluate the use of MDCT with 3D CT angiography (CTA) and CT portal venography (CTPV) reconstruction for the diagnosis of small bowel volvulus (SBV).

METHODS

Multiphasic MDCT findings in nine patients (seven males and two females, age range 2-70) with surgically proven SBV were retrospectively reviewed. Non-contrast and double phase contrast enhanced MDCT including 3D CTA and CTPV reconstruction were performed in all the patients. Two experienced abdominal radiologists evaluated the images and defined the location, direction and degree of SBV.

RESULTS

On axial MDCT images, all cases show segmental or global dilatation of small intestine. Other findings include circumferential bowel wall thickening in eight cases, halo appearance and hyperemia in seven cases, whirl sign in six cases, beak-like appearance in six cases, closed loops in six cases and ascites in one case. CTA/CTPV showed abnormal courses involving main trunks of superior mesenteric artery (SMA) and superior mesenteric vein (SMV) in seven cases, with or without distortion of their tributaries. Normal course of SMA but abnormal course of SMV was seen in the other two cases. Of all the nine cases, whirl sign was seen in six cases and barber's pole sign in five cases. Dilated SMV was observed in eight cases and abrupt termination of SMA was found in one case. Compared with surgical findings, the location, direction and degree of SBV were correctly estimated in all cases based on CTA/CTPV.

CONCLUSION

Multiphasic MDCT with CTA/CTPV reconstruction can play an important role in the diagnosis of SBV. The location, direction and degree of SBV can all be defined preoperatively using this method.

A lethal case of pneumatosis intestinalis complicated by small bowel volvulus

Pneumatosis intestinalis (PI) is a condition characterised by gas-filled cystic malformations on the intestinal wall. It is often secondary to an underlying disease process. We describe the case of a 76-year-old gentleman who presented with intermittent abdominal pain, altered bowel habits and weight loss. Barium enema was unremarkable, apart from sigmoid diverticulosis. CT scan found evidence of pneumatosis on small bowel walls with benign pneumoperitoneum. As there was no sign of intra-abdominal crisis, he was initially treated conservatively. Unfortunately, he required re-admission 6 weeks later with symptoms of bowel obstruction and clinical signs of perotinitis. At laparotomy, he was found to have extensive small bowel infarction due to volvulus from 'twisting' around the axis of superior mesenteric vessels. Evidently, this occurred secondary to a congenitally long small bowel mesentery that predisposed him to volvulus. Extensive small bowel resection was performed. The postoperative course was complicated by persistent hypotension, which proved fatal. This case report draws attention to the rare association between PI and small bowel volvulus predisposed by a congenitally long mesentery, which can present initially with a benign picture (intermittent, reversible volvulus), but subsequently be complicated by lethal bowel infarction (irreversible volvulus). This case raises several issues about the management of this rare condition. Clinicians must realise that PI, though often benign, can present with lethal complications, and early recognition of such complications can be life-saving.