Small Bowel Volvulus Following Upper Gastrointestinal Barium Radiography

Abstract

Introduction: Small bowel volvulus is extremely rare in adults. Barium has been associated with obstructive symptoms related to baroliths, but these take several days to weeks to form. Small bowel volvulus has never been reported immediately following a barium study. Case: The patient is a 49-year-old man who presented with persistent gastroesophageal reflux despite treatment with dexlansoprazole. An upper GI series was performed to evaluate for hiatal hernia. The study revealed mid-esophageal reflux with small hiatal hernia and one area of nonspecific proximal small bowel prominence. One hour after the study, he ate lunch, and fifteen minutes later developed nausea, vomiting and diffuse abdominal pain. The pain progressed and his vomiting persisted requiring hospital admission. His past medical history includes bipolar disorder, hypertension and obstructive sleep apnea. He had no prior abdominal surgeries. His medications include depakote, trileptal, seroquel, lisinopril and dexlansoprazole. Exam revealed hypoactive bowel sounds and tenderness in the epigastrium and bilateral upper quadrants. Laboratories were notable for only mild neutrophilia. Abdominal computed topography (CT) scan showed small bowel volvulus and closed loop obstruction without free air. Contrast from the prior day was present in dilated proximal small bowel loops. Nasogastric tube was placed. Repeat abdominal x-ray showed persistent obstruction without any contrast in the colon. Given lack of improvement, laparoscopy was pursued. It revealed torsion of the jejunal mesentery that was corrected. No ischemic changes were noted. His symptoms resolved and he was discharged home without any further issues. Five months later, CT enterography with gastrograffin showed no evidence of intraluminal lesion or mesenteric pathology. Discussion: Small bowel volvulus is generally described in neonates with embryologic malrotation of the midgut. The etiology in this patient is a mystery. Contributing factors may have been slowing of colonic transit as side effect of bipolar medications as evidenced by excessive stool on CT. A large bolus of barium in setting of mild ileus may have caused the jejunal volvulus.