Key Clinical Message
Small bowel volvulus is a rare cause of small bowel obstruction, but
must be considered as the likely diagnosis when mesenteric ‘whirlpool
sign’ is present on imaging. Peritonism with such imaging findings
warrants prompt intervention.
A 65 year-old female presented to hospital with 3 days of abdominal pain
and distension. She had a background of diverticular disease and
previous hysterectomy for symptomatic fibroids. Her white-cell-count was
19.5 x 109/L and lactate 3.1mmol/L. Computed tomogram (CT) of the
abdomen/pelvis revealed abnormal, oedematous distal small bowel (Figure
1). The mesentery was congested alongside demonstrating the ‘whirlpool
sign’ of small bowel volvulus. Small bowel distal to this loop was
collapsed whereas proximally the bowel was dilated and fluid-filled.
Closed-loop small bowel obstruction was diagnosed secondary to small
bowel volvulus. At laparotomy, there was internal herniation from
mesenteric twisting. 100cm of ileum was gangrenous (Figure 2). Resection
was performed with stapled side-to-side primary anastomosis. Discharge
was at day 10 post-operatively.
Small bowel volvulus is rare in the West, accounting for 1-6% of small
bowel obstructions1. It is predominantly associated
with post-surgical adhesions, congenital midgut malrotation and
fibrinous bands across the mesentery2. Diagnosis is
made via CT scan, which will show a ‘whirlpool sign’ with twisting of
the small bowel and vessels around its mesentery1.
Whirlpool sign on CT scan indicates an odds ratio of 25.3 with regards
to operative intervention2. Swift diagnosis and
intervention is vital to prevent frank ischaemia.