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Heidtmann F, Eckoldt F, Mentzel HJ, Alhussami I. Primary Segmental Small Bowel Volvulus in an Adolescent Female. European J Pediatr Surg Rep 2021; 9:e76-e79. [PMID: 34849329 PMCID: PMC8612868 DOI: 10.1055/s-0041-1735808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 06/05/2021] [Indexed: 11/07/2022] Open
Abstract
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.
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Affiliation(s)
- Friederike Heidtmann
- Department of Pediatric Surgery, Universitätsklinikum Jena, Klinik für Kinderchirurgie, Universitätsklinikum Jena, Jena, Germany
| | - Felicitas Eckoldt
- Department of Pediatric Surgery, Universitätsklinikum Jena, Klinik für Kinderchirurgie, Universitätsklinikum Jena, Jena, Germany
| | - Hans-Joachim Mentzel
- Section of Pediatric Radiology, Institute of Diagnostic and Interventional Radiology I, Universitätsklinikum Jena, Jena, Thüringen, Germany
| | - Ilmi Alhussami
- Department of Pediatric Surgery, Universitätsklinikum Jena, Klinik für Kinderchirurgie, Universitätsklinikum Jena, Jena, Germany
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Bourbos A, Liotta AP, Piola V, Cinti F, Pisani G. Urinary bladder torsion in a dog with an extraluminal tumor of the bladder apex. VETERINARY RECORD CASE REPORTS 2021. [DOI: 10.1002/vrc2.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Alexandros Bourbos
- Clinica veterinaria Pisani Carli Chiodo ‐ Surgery Ortonovo Italy
- Staff Clinician in Small Animal Surgery Langford Veterinary Services ‐ Surgery Langford Small Animal Referral Hospital Bristol Bristol UK
| | - Annalisa Pia Liotta
- Diagnostic Imaging Centro Diagnostico Veterinario TAC Luni Mare s.r.l. ‐ Diagnostic imaging section La Spezia Italy
| | - Valentina Piola
- Vet Ct Specialists St John's Innovation Centre Vet Ct Specialists Ltd Cambridge UK
| | - Filippo Cinti
- Clinica Veterinaria Pisani Carli Chiodo ‐ Surgery Luni Italy
- Surgery Eastcott Veterinary Referrals ‐ Surgery Swindon UK
| | - Guido Pisani
- Clinica Veterinaria Pisani Carli Chiodo ‐ Surgery Luni Italy
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Huang C, Ning Z, Zhu Z. Torsional Necrosis of an Output Loop Internal Hernia After Roux-en-Y Choledochojejunostomy: A Case Report. Front Surg 2019; 6:51. [PMID: 31555660 PMCID: PMC6742713 DOI: 10.3389/fsurg.2019.00051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 08/13/2019] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Chao Huang
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhikun Ning
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Zhengming Zhu
- Department of Gastrointestinal Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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Wong KH, Ho SC. Computed tomography film quiz: A woman with severe epigastric pain and vomiting. HONG KONG J EMERG ME 2017. [DOI: 10.1177/1024907917724733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Kin Hoi Wong
- Department of Radiology, North District Hospital, Hong Kong
| | - Sai Chung Ho
- Department of Radiology, North District Hospital, Hong Kong
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Ricciardi M, Campanella A, Martino R. Computed tomographic features of urinary bladder torsion in two dogs. J Small Anim Pract 2017; 59:188-195. [DOI: 10.1111/jsap.12694] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 07/29/2016] [Accepted: 08/01/2016] [Indexed: 11/29/2022]
Affiliation(s)
- M. Ricciardi
- Pingry Veterinary Hospital, via Medaglie d'Oro 5; Bari 70126 Italy
| | - A. Campanella
- Pingry Veterinary Hospital, via Medaglie d'Oro 5; Bari 70126 Italy
| | - R. Martino
- Pingry Veterinary Hospital, via Medaglie d'Oro 5; Bari 70126 Italy
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Leow JJ, Huey T, Low JK. Primary adult midgut volvulus mimicking acute appendicitis: A case report and review of the literature. Int J Surg Case Rep 2016; 24:182-4. [PMID: 27266831 PMCID: PMC4908610 DOI: 10.1016/j.ijscr.2016.05.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 04/30/2016] [Accepted: 05/15/2016] [Indexed: 11/19/2022] Open
Abstract
Adult midgut volvulus is a rare but important cause of small bowel obstruction. Our patient, 35 year old male, was clinically suspected to have acute appendicitis. Intra-operatively, we found a normal appendix and jejunal volvulus with adhesions. If in doubt, early contrast CT scan should be performed. 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.
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Affiliation(s)
- Jeffrey J Leow
- Department of General Surgery, Tan Tock Seng Hospital, Singapore.
| | - Terence Huey
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Jee Keem Low
- Department of General Surgery, Tan Tock Seng Hospital, Singapore
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A Fatal Twist: Volvulus of the Small Intestine in a 46-Year-Old Woman. Case Rep Med 2015; 2015:391093. [PMID: 26612989 PMCID: PMC4647019 DOI: 10.1155/2015/391093] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 10/12/2015] [Accepted: 10/15/2015] [Indexed: 02/07/2023] Open
Abstract
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.
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Garcelan-Trigo JA, Tello-Moreno M, Rabaza-Espigares MJ, Talavera-Martinez I. Barber Pole Sign in CT Angiography, Adult Presentation of Midgut Malrotation: A Case Report. IRANIAN JOURNAL OF RADIOLOGY 2015; 12:e17853. [PMID: 26557278 PMCID: PMC4632560 DOI: 10.5812/iranjradiol.17853v2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 03/21/2014] [Accepted: 04/26/2014] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Juan Arsenio Garcelan-Trigo
- Diagnostic Imaging Unit, Hospital San Agustin, Linares (Jaen), Spain
- Corresponding author: Juan Arsenio Garcelan Trigo, Diagnostic Imaging Unit, Hospital San Agustin, Linares (Jaen), Spain. Tel: +34-618177483, E-mail:
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Knafo SE, Rosenblatt AJ, Morrisey JK, Flanders JA, Thompson MS, Knapp-Hoch HM. Diagnosis and treatment of mesenteric volvulus in a red kangaroo (Macropus rufus). J Am Vet Med Assoc 2014; 244:844-50. [DOI: 10.2460/javma.244.7.844] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Koh YX, Chng JK, Tan HC, Chung YF. Intestinal torsion causing chylous ascites: a rare occurrence. Singapore Med J 2013; 54:e88-90. [DOI: 10.11622/smedj.2013089] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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11
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Dukic-Stojanovic L, Kessler M, Schenk JP, Weber MA. [Cystic abdominal space-occupying lesion with ileus and whirl sign]. Radiologe 2012; 53:141-4. [PMID: 23254308 DOI: 10.1007/s00117-012-2438-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- L Dukic-Stojanovic
- Diagnostische und Interventionelle Radiologie, Radiologische Klinik, Universitätsklinikum Heidelberg, Deutschland.
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Tanaka K, Yamada M, Hatoh T, Adachi T, Matsui K, Tomita H, Osada S, Yoshida K. “Whirl Sign”: Small Bowel Volvulus in Patients after Gastrectomy. Am Surg 2012. [DOI: 10.1177/000313481207801105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kaori Tanaka
- Department of Gastrointestinal Surgery Gifu Municipal Hospital Gifu, Japan; and Department of Surgical Oncology Gifu University Graduate School of Medicine Gifu, Japan
| | - Makoto Yamada
- Department of Gastrointestinal Surgery Gifu Municipal Hospital Gifu, Japan
| | - Tsuneaki Hatoh
- Department of Gastrointestinal Surgery Gifu Municipal Hospital Gifu, Japan
| | - Takahito Adachi
- Department of Gastrointestinal Surgery Gifu Municipal Hospital Gifu, Japan
| | - Koji Matsui
- Department of Gastrointestinal Surgery Gifu Municipal Hospital Gifu, Japan
| | - Hiroyuki Tomita
- Department of Tumor Pathology Gifu University Graduate School of Medicine Gifu, Japan
| | - Shinji Osada
- Department of Surgical Oncology Gifu University Graduate School of Medicine Gifu, Japan
| | - Kazuhiro Yoshida
- Department of Surgical Oncology Gifu University Graduate School of Medicine Gifu, Japan
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Ho YC. "Venous cut-off sign" as an adjunct to the "whirl sign" in recognizing acute small bowel volvulus via CT scan. J Gastrointest Surg 2012; 16:2005-6. [PMID: 22580843 DOI: 10.1007/s11605-012-1910-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 04/30/2012] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Yuen Chi Ho
- Department of Radiology, Queen Mary Hospital, 102, Pokfulam Road, Hong Kong, China.
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Papadimitriou G, Marinis A, Papakonstantinou A. Primary midgut volvulus in adults: report of two cases and review of the literature. J Gastrointest Surg 2011; 15:1889-92. [PMID: 21512851 DOI: 10.1007/s11605-011-1534-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Accepted: 04/01/2011] [Indexed: 01/31/2023]
Abstract
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.
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Ruiz-Tovar J, Morales V, Sanjuanbenito A, Lobo E, Martinez-Molina E. Volvulus of the Small Bowel in Adults. Am Surg 2009. [DOI: 10.1177/000313480907501206] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Jaime Ruiz-Tovar
- From the Department of Surgery, University Hospital Ramon y Cajal, Madrid, Spain
| | - Vicente Morales
- From the Department of Surgery, University Hospital Ramon y Cajal, Madrid, Spain
| | | | - Eduardo Lobo
- From the Department of Surgery, University Hospital Ramon y Cajal, Madrid, Spain
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Feng ST, Chan T, Sun CH, Li ZP, Guo HY, Yang GQ, Peng ZP, Meng QF. Multiphasic MDCT in small bowel volvulus. Eur J Radiol 2009; 76:e13-8. [PMID: 19926241 DOI: 10.1016/j.ejrad.2009.10.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Revised: 10/15/2009] [Accepted: 10/15/2009] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Shi-Ting Feng
- Department of Radiology, The First Affiliated Hospital, Sun Yat-Sen University, 58th The Second Zhongshan Road, Guangzhou, China.
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A lethal case of pneumatosis intestinalis complicated by small bowel volvulus. Clin J Gastroenterol 2009; 2:22-26. [PMID: 26191803 DOI: 10.1007/s12328-008-0038-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2008] [Accepted: 08/28/2008] [Indexed: 10/21/2022]
Abstract
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.
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