Whirl Sign Research Articles

The Late Diagnosed Intestinal Malrotation by Abdominal Tomography In An Adolescent

Introduction: Intestinal malrotation is an anomaly that often manifests in newborn and infant childhood. This anomaly, which is rarely seen in older children and adults, is usually detected incidentally during imaging studies or during laparotomy. This article is presented with the aim of emphasizing the Computarised Tomography (CT) imaging for intestinal malrotation an adolescent patient with mesenteric volvulus. Case Report: A sixteen-year-old male patient presented with epigastric pain and bilious vomiting after feeding. In ultrasonography (US), intestinal loops were surrounding along the superior mesenteric artery (SMA) and venous (SMV) vessels tract. In CT, it was noted that SMA marks a whirl sign in the midline of the abdomen. At laparotomy, there were found 360° torsion of small intestine, due to intestinal malrotation. Ladd procedure was performed. Conclusion: In cases of intestinal malrotation, preoperative diagnosis can be difficult because of the lack of specific findings in the physical examination. The delayed diagnosis may be lead to volvulus and intestinal necrosis. The diagnosis of malrotation can brought to mind at an early age but it may be delayed in later ages. In practiced hand, the evaluation of vessels traseries by detailed US and contrast-enhanced CT are characteristics of malrotation diagnosis.

Small bowel volvulus presenting as lower abdominal pain

A 38-year-old healthy female presented to emergency department with acute onset of lower abdominal pain. Due to progressive lower abdominal pain after conservative therapy, the patient was investigated using a contrast-enhanced abdominal computed tomography (CT) for cause identification. The CT scan showed a “whirl sign”, a sunshine-like picture that bowel loops and mesentery rotate around a fixed point, and ischemic changes of the small intestine. Thus the patient was diagnosed as a small bowel volvulus (SBV) and operated on immediately. At surgery, a band between uterus and mesentery causing overriding on a loop of terminal ileum with strangulation was found. Fortunately, she subsequently recovered well nine days later.

Progressive atrophy in a deformed liver as a contributor to sigmoid volvulus

The effect of a prior defect on secondary liver atrophy is unknown. We describe a case of sigmoid volvulus that was facilitated by progressive atrophy in a deformed liver. A 75-year-old man with abdominal pain and fullness was referred to our hospital. Computed tomography (CT) revealed reduced left hepatic lobe volume and a whirl sign, characteristic of sigmoid volvulus. The sigmoid volvulus was successfully detorted with endoscopy. Retrospective evaluation of liver morphology on CT and magnetic resonance imaging showed that the portal vein at the liver hilum was denuded due to a parenchymal defect of the medial segment, with compression by the crossing artery. As pulse Doppler ultrasonography demonstrated reduced portal blood flow in the region where liver atrophy developed, compression of the denuded portal vein presumably facilitated secondary atrophy and contributed to sigmoid volvulus. The present case shows that a deformed liver itself can be a cause of secondary atrophy. Therefore, continued monitoring of liver morphology and evaluation of portal blood flow to predict liver atrophy may be required, when an individual with a partial liver defect is encountered.

Sigmoid volvulus in pictures: from the exam table to the operating table

Sigmoid volvulus is a frequent cause of large bowl obstruction. If it is not recognized in time, it can be hazardous with a high risk of mortality. Otherwise, simple exams could help to reach the correct diagnosis in time, which may completely change the prognosis and even avoid surgery in some cases. A 58-year-old man presented to the emergency room with acute abdominal pain associated with distal intestinal obstruction syndrome. The physical examination revealed a remarkable distention of the abdomen and the sigmoid colon whose limits could be discerned under the skin since the patient was thin (A) as well as a depression at the left iliac fossa (B). The plain abdominal radiography showed the « Coffee bean » sign (C). A CT-scan was performed showing a « Whirl sign » (D,E). The patient underwent emergency surgery. Intraoperatively, the sigmoid colon was markedly dilated and volvulated (F). We performed a resection of the sigmoid colon and primary anastomosis with simple outcomes. Through this case, we can conclude the multiple sings of sigmoid volvulus like the pathognomonic triad of Von Wahl, present in 68.84% of cases. The CT scan permits to confirm the diagnosis by showing the whirl sign: twisting of the mesenteric vessels and search for complications. Regarding the risk of recurrence of 18-90% for the endoscopic decompression, the most considered treatment is sigmoid non-surgical decompression followed by an elective sigmoid resection.

Single-Institution Case Series of Patients Undergoing Cholecystectomy for Gallbladder Torsion

Gallbladder torsion is one subtype of acute cholecystitis. Because of the very low incidence of the condition, there are few reports analyzing multiple cases of gallbladder torsion. The preoperative diagnosis is difficult and reported to be made in only 26% of patients. Herein, we report 6 consecutive cases of gallbladder torsion in 7 years and highlight the clinical and radiologic findings that facilitate preoperative diagnosis. Between 2005 and 2011, a total of 6 patients received a diagnosis of and were treated for gallbladder torsion in Toyonaka Municipal Hospital. A total of 5 patients received a diagnosis of gallbladder torsion or were suspected of having gallbladder torsion preoperatively, and 1 additional patient was diagnosed intraoperatively. The computed tomography findings of both excessive gallbladder swelling and rotation of the gallbladder fundus were observed in 5 patients, which were indicative findings of gallbladder torsion. The remaining 1 patient received a diagnosis intraoperatively. The twisted cystic duct and artery had been observed as a “whirl sign” preoperatively in 2 patients. Emergency cholecystectomy was performed: laparoscopic cholecystectomy was performed in 4 patients and open cholecystectomy in 2 patients. The patients treated by laparoscopic approach showed more rapid recovery and shorter postoperative hospital stay before discharge. The radiologic findings of both excessive gallbladder swelling and rotation of the gallbladder fundus are indicative of gallbladder torsion. The laparoscopic cholecystectomy approach could be considered the first choice for patients with gallbladder torsion.

CT findings of adnexal torsion: A matched case-control study.

ObjectiveThe purpose of our study was to assess computed tomographic (CT) findings of adnexal torsion through a matched case-control analysis.Materials and methodsThis retrospective, single-institution case-control study included 43 women with adnexal torsion and 43 age- and ovarian mass-matched control women. CT images were evaluated independently by two readers for the following: prominent peripheral follicles, uterine deviation, thickened pedicles, a whirl sign, and a navel sign. Comparisons of CT findings were performed using the Chi square test and receiver operating characteristic (ROC) curves were obtained to assess the diagnostic performance. Differences between the areas under the ROC curves (AUCs) were compared by using a Delong test.ResultsThe CT findings significant for adnexal torsion were uterine deviation toward the side of the affected ovary (P = < .01 for reader 1 and P = .02 for reader 2) and thickened pedicles with ancillary findings including a whirl sign, a navel sign, and uterine deviation facing thickened pedicles (P < .01 for both readers). Thickened pedicles with ancillary findings had the highest diagnostic accuracy, as measured with ROC curves (AUC, 0.86 in reader 1 and 0.85 in reader 2). Combining uterine deviation toward the side of the affected ovary with thickened pedicles with ancillary findings did not increase the performance relative to that of thickened pedicles with ancillary findings alone.ConclusionsThickened pedicles with ancillary findings including a whirl sign, a navel sign, and uterine deviation facing thickened pedicles could be helpful for the diagnosis of adnexal torsion.

A rare case of secondary small bowel volvulus laparoscopically repositioned: literature review and classification

BackgroundSecondary small bowel volvulus is a rare condition caused by adhesions after laparotomy or tumors. There are no clear guidelines for indication of laparoscopic surgery.Case presentationA 69-year-old male visited our hospital complaining of epigastric pain. He had a history of hypopharyngeal carcinoma treated via pharyngolaryngoesophagectomy with restoration of esophageal continuity by harvesting a free jejunal autograft 6 years ago.Enhanced computed tomography revealed the whirl sign. An emergency laparoscopic operation was performed following a diagnosis of small bowel volvulus. This revealed rotation of the whole small bowel, involving the superior mesenteric artery as the center, and originating at the adhesion of the proximal and distal small bowel. Laparoscopic manipulation of volvulus and lysis of the adhesion were performed. The patient’s postoperative course was uneventful, and he was discharged on hospital day 5.ConclusionsLaparoscopic surgery may be useful for treating small bowel volvulus; however, the patient’s treatment indications should be judged carefully.

Use of Postmortem Computed Tomography to Detect Bowel Obstruction and its Relationship to the Cause of Death.

Bowel distension frequently indicates bowel obstruction, which is a common diagnosis in clinical radiology. Typically, symptoms and complaints lead to radiological examinations and the detection of the etiology. Untreated intestinal obstructions can lead to a fatal outcome through cardiac failure due to septic shock. Certain of these cases undergo medicolegal investigations depending on the case history, the condition of the decedent, the location of the finding, or recent visits to medical professionals. Computed tomography (CT) is a recommended method in clinical radiology for the detection of bowel obstruction, which is indicated by bowel distension and further radiological signs (eg, the whirl sign, which indicates a volvulus). Postmortem CT (PMCT) has increased worldwide, but PMCT differs from clinical CT; thus, the question of whether PMCT is also reliable for the detection of bowel obstruction in decedents or is negatively affected by postmortem modifications should be discussed. This study consists of 10 cases displaying radiological signs of bowel obstruction. Apart from bowel distension, the most common radiological signs (whirl sign, coffee bean sign, bird beak sign, and u-shape sign) are described and depicted. All decedents underwent autopsy and had a postmortem interval of less than 72 hours. Based on these cases, we assess the reliability of PMCT for detecting bowel obstruction and determining its relationship to the cause of death.

Computed tomography whirl sign: An image-based indication for surgery

Adhesive closed-loop small bowel obstruction can lead to volvulus and ischemia with risk of necrosis. The vital prognosis and bowel viability are highly dependent on rapid management. The physical examination is often insufficient to establish the diagnosis and computed tomography is ordered. The whirl sign provides the best imaging evidence of volvulus and can be sufficient to establish the indication for surgery.

Internal hernia after proximal gastrectomy with jejunal interposition.

Although internal hernia (IH) has been reported after laparoscopic distal or total gastrectomy with Roux-en-Y reconstruction, there are few reports of IH after proximal gastrectomy with jejunal interposition (PG-JI). The aim of this study was to analyze the incidence and clinical features of IH after PG-JI. This study retrospectively reviewed 71 patients who underwent PG-JI for gastric cancer at a single institution between July 2007 and December 2016. The median follow-up period after PG-JI was 50months. Four patients (5.6%) developed IH. IH occurred in 3 of 38 patients after open PG (7.9%) and 1 of 33 after laparoscopic PG (3.1%; p=0.38). The site of IH was Petersen in all cases, where the Petersen defect was not closed. All patients had abdominal pain at onset, and the CT revealed a whirl sign. Bowel resection was required in three patients (75%). There was no morbidity. IH after PG-JI occurred regardless of operative approach (open or laparoscopic). A high degree of suspicion for IH should be maintained in patients after gastrectomy with abdominal pain and a whirl sign on CT. Closure of the mesenteric defects should be considered to reduce the incidence of IH after surgery.

Hooking intestine sign: a typical diagnostic CT finding of Petersen's hernia.

To clarify typical diagnostic computed tomography (CT) findings of Petersen's hernia for differentiation from other causes of internal hernia observed in patients having undergone gastrectomy with Roux-en-Y gastric bypass. We retrospectively reviewed CT findings of internal hernia in patients who had undergone both gastrectomy and Roux-en-Y reconstruction and a second surgery for bowel obstruction. Thirteen patients with Petersen's hernia and 6 with internal hernia other than Petersen's hernia were investigated. Six CT findings, viz. whirl sign, mesenteric fat haziness, intestinal distension in the upper abdomen, herniated intestinal loop above the gastric level, middle/distal ileum courses downwards from the left hypochondrium, and hooking intestine sign, which means two or more intestines pass through the inner side of J-shaped vessels consisting of mesenteric vessels of the elevated jejunum, were scored and evaluated regarding their diagnostic performance. The hooking intestine sign showed the highest sensitivity, specificity and accuracy (100%, 100% and 100%). We could detect J-shaped vessels in all Petersen's hernia patients. Inside the J-shaped vessels there were two or more intestinal tracts passing through in the Petersen's hernia group. There was only transverse colon inside the J-shaped vessels in the control group. The hooking intestine sign may be useful for diagnosing Petersen's hernia on CT.

Utility of CT Findings in the Diagnosis of Cecal Volvulus.

The objective of our study was to assess the utility of CT features in the diagnosis of cecal volvulus. Forty-three patients undergoing CT for cecal volvulus and with surgical or clinical follow-up were included. Two radiologists (11 years and 1 year of experience) evaluated CT examinations for the following: whirl sign, abnormal cecal position, "bird beak" sign, severe cecal distention, mesenteric engorgement, a newly described "central appendix" sign (defined as abnormal appendix position near midline), and overall impression for cecal volvulus. Univariable and multivariable assessments were performed. Patients with CT examinations in which the appendix was not visible were excluded from calculations involving the central appendix sign. Fifty-one percent (n = 22) of patients had cecal volvulus. All CT findings were significantly more common in patients with cecal volvulus (p < 0.01) other than mesenteric engorgement for reader 1 (p = 0.332). Readers 1 and 2 identified the central appendix sign in 92.9% and 92.3% of patients with volvulus versus in 37.5 and 31.1% of patients without volvulus. The whirl sign exhibited a sensitivity for cecal volvulus of 90.9% for reader 1 and 95.5% for reader 2, and a specificity of 61.9% for both readers. Abnormal cecal position exhibited a sensitivity of 90.0% for reader 1 and 100.0% for reader 2 and a specificity of 66.7% and 38.1%. The bird beak sign exhibited a sensitivity of 86.4% for reader 1 and 100.0% for reader 2 and a specificity of 85.7% and 71.4%. Severe cecal distention exhibited a sensitivity of 100.0% for both readers and a specificity of 81.0% and 61.9%. Mesenteric engorgement exhibited a sensitivity of 40.9% for reader 1 and 100.0% for reader 2 and a specificity of 76.2% and 71.4%. The central appendix sign exhibited a sensitivity of 92.9% for reader 1 and 92.3% for reader 2 and a specificity of 62.5% and 68.8%. Overall impression exhibited a sensitivity of 100.0% for both readers and a specificity of 76.2% and 57.1%. At multivariable analysis, the AUC for cecal volvulus ranged from 0.787 to 0.931, and the whirl sign was an independent predictor of volvulus for both readers (p ≤ 0.014); the central appendix sign was also an independent predictor in patients with a visualized appendix for reader 2 (p ≤ 0.001). CT exhibited high diagnostic performance and very high sensitivity for cecal volvulus. The whirl sign was a significant independent predictor of volvulus for both readers.

Splenic torsion presenting as splenic vein thrombosis

Abstract We present the case of a 13-year old female presenting with abdominal pain and splenomegaly. CT scan revealed splenic vein thrombosis but no whirl sign to indicate torsion. Her pain persisted, hypercoagulability workup was negative, and she underwent laparoscopic splenectomy. Intraoperatively she was found to have splenic torsion with absent ligamentous attachments. Further review of CT images revealed the spleen anterior to the hilum on sagittal views, a sign not previously described as characteristic of splenic torsion.

Less Common Causes of Acute Abdomen

In this presentation, less common causes of acute abdomen are reviewed. Emphasis is on three topics. First, the anatomy of the superior mesenteric vein and mesentery is reviewed, together with the anatomical basis and clinical/radiological presentation of midgut volvulus. Emphasis is on diagnostic clues (whirl sign, abnormal position of cecum, small bowel, and third part of duodenum) and pitfalls (positional variation of small bowel loops with pseudo-twisting of mesenteric vessels). Second, atypical presentations of acute appendicitis and appendagitis, as well as their mimics, are discussed. Finally, an overview is given of uncommon but important causes of free intraperitoneal fluid in patients with acute abdominal pain.

Torsion of the Gallbladder

An otherwise-healthy 82-year-old woman presented to the emergency department with abdominal pain gradually migrating to the right and vomiting. Her body temperature was 37.2°C, abdominal examination showed tenderness in the right lower abdomen, and her WBC was 8,400/μL no plasma levels of enzymes were elevated. She was thin (body mass index 20.4 kg/m2 ) with scoliosis. Non-enhanced Computed Tomography (CT) revealed a massively swollen gallbladder with high dense (Figure 1) and contrast enhanced CT demonstrated poorly-enhanced edematous wall thickening (Figure 2), with twisted pedicle detached from the liver, suggesting gallbladder torsion. Emergent cholecystectomy was performed, revealing a 270° counterclockwise torsion of the gallbladder. Gallbladder torsion is more prevalent in thin elderly females with spinal deformation [1]. Characteristic contrast enhanced CT findings are poorly-enhanced and thickened gallbladder wall, pericholecystic fluid, and twisted pedicle (whirl sign) [2]. Contrast enhanced CT can help establish the preoperative diagnosis of gallbladder torsion in cases involving elderly females complaining abdominal pain.

Internal hernia after laparoscopic-assisted proximal gastrectomy with jejunal interposition for gastric cancer: a case report.

Internal hernia after gastrectomy is a rare complication. It can progress rapidly to vascular disturbance, necrosis, and perforation, therefore early diagnosis and surgical treatment is essential. We present a case of internal hernia following laparoscopic-assisted proximal gastrectomy with jejunal interposition reconstruction in a 68-year-old man, who presented with acute abdominal pain and vomiting. Computed tomography showed a whirl sign, ascites, and a closed-loop formation of the small intestine. We diagnosed an internal hernia and performed emergency surgery. Laparotomy revealed chyle-like ascites and extensive small intestine with poor color. We recognized that about 20 cm of jejunum from the ligament of Treitz was strangulated behind the pedicle of the jejunum lifted during laparoscopic-assisted proximal gastrectomy. We relieved the strangulation, whereupon the color of the strangulated intestine was restored. Therefore, we did not perform intestinal resection and reconstruction. Finally, we fixed the jejunal pedicle and mesentery of the transverse colon. We report this case as there are few reported cases of internal hernia after laparoscopic-assisted proximal gastrectomy.

Prenatal MRI diagnosis of fetal bowel obstruction

Objective To investigate the clinical value of prenatal MRI in the diagnosis of fetal bowel obstruction. Methods Pregnant women suspected to have fetal abdominal abnormalities by ultrasonography were suggested to undergo MRI examinations within two days. Scanning sequence included FIESTA, SSFSE and T1WI SPGR sequence, with field of view focused on the fetal abdomen. After the final diagnoses of the cases were obtained by induced labor pathological examination or postpartum imaging or operation, the imaging data and the clinical data were reviewed and analyzed retrospectively. Results A total of 23 cases with bowel obstruction were included in the study. Four fetuses with duodenal atresia showed low T1 signal, high T2 signal characterized by double-bubble sign on MRI. There were 10 fetuses with jejunoileal atresia, showing bowel dilatation and hyperintense micro-colon on T1WI. Five cases of them depicted expansion of the terminal ileum with high T1 meconium signal.One each fetus had colonic atresia, intestinal malrotation with double-bubble and whirl sign. Annular pancreas with double-bubble sign and pressure trace of the bracket shape was detected in 3 fetuses. Meconium peritonitis was present in 4 fetuses, with 2 of them showing dilatation of intestine, ascites and pseudocysts. Conclusions According to the signal characteristics of amniotic fluid and meconium in the gastrointestinal tract on MRI, the obstructive level and development status of the distal bowel can be determined with MRI. It can provide additional information to ultrasonography, which brings clinical significance to prenatal diagnosis and intrapartum surgical operation. Key words: Magnetic resonance imaging; Fetus; Intestinal obstruction

Adhesive small-bowel obstruction: value of CT in identifying findings associated with the effectiveness of nonsurgical treatment.

To identify computed tomographic (CT) findings that are associated with the effectiveness of nonsurgical treatment in patients with adhesive small-bowel obstruction ( SBO small-bowel obstruction ) that was initially treated medically. The local institutional review board approved this retrospective study; the informed consent requirement was waived. Multi-detector row CT studies in 159 patients (64 women, 95 men; median age, 69 years) with adhesive SBO small-bowel obstruction that was initially treated medically were reviewed retrospectively and independently by two emergency radiologists to identify numerous CT findings that could be associated with the effectiveness of nonsurgical treatment. Results were compared according to the success or failure of nonsurgical treatment. Univariate statistical analyses were performed for qualitative and quantitative data, as appropriate, and each significant parameter was entered in a multivariate logistic regression analysis. The κ statistic and correlation coefficients were used to assess interobserver agreement, as appropriate. Nonsurgical treatment succeeded in 113 patients (71%) and failed in 46 patients (29%). At univariate analysis, an anterior parietal adhesion, a feces sign, and the lack of a beak sign were associated with successful nonsurgical treatment, whereas two beak signs or more, a whirl sign, a C- or U-shaped appearance of the bowel loop, and a high degree of obstruction were associated with nonsurgical treatment failure. At multivariate analysis, fewer than two beak signs and the presence of an anterior parietal adhesion were independent predictors of the effectiveness of nonsurgical treatment, with odds ratios of 0.27 and 0.11, respectively. The number of beak signs and the location of the transition zone in relation to the anterior peritoneal layer are independent signs associated with the success or failure of nonsurgical treatment.

Diagnosis and treatment of mesenteric volvulus in a red kangaroo (Macropus rufus)

An 8-year-old male red kangaroo (Macropus rufus) was evaluated with a 2-week history of vomiting and anorexia. Four days prior, the patient became refractory to medical management. The kangaroo was admitted for diagnostic testing and treatment including whole body CT, blood work, and emergency laparotomy. CT findings of a severely enlarged stomach, splenic displacement, and a whirl sign were indicative of mesenteric volvulus with gastric dilatation-volvulus (GDV). Contrast enhancement of abdominal viscera suggested intact arterial blood supply; however, compression of the caudal vena cava and portal vein indicated venous obstruction. Results of preoperative blood work suggested biliary stasis without evidence of inflammation. Additionally, a tooth root abscess was diagnosed on the basis of results of CT. Exploratory laparotomy confirmed the diagnosis of mesenteric volvulus and GDV. The volvuli were corrected by clockwise derotation, and a gastropexy was performed. Tissue samples were obtained from the spleen and liver for evaluation. The kangaroo recovered from surgery, and the abscessed tooth was extracted 6 days later. Eight days after initial evaluation, the kangaroo was discharged. In the present report, the CT whirl sign was used to diagnose volvulus of the abdominal viscera, which suggests that this diagnostic indicator has utility in veterinary patients. Mesenteric volvulus with GDV was successfully treated in a nondomestic species. The tooth root abscess, a common condition in macropods, may explain the historic episodes of anorexia reported by the owner and may have contributed to the development of mesenteric volvulus and GDV in this kangaroo.

Features on MDCT That Predict Surgery in Patients with Adhesive-Related Small Bowel Obstruction

PurposeThe purpose of this study was to determine the contribution of multidetector-row computed tomography (MDCT) in the management of adhesion-related small bowel obstruction (SBO) and to identify its predictive value for surgery.MethodsWe conducted a retrospective review of 151 patients over a 5-year period with the diagnosis of SBO caused by adhesion. These patients were divided into two groups: surgery (n = 63) and observation group (n = 88). Two radiologists blinded to the outcome of the patients evaluated MDCT images retrospectively, recording the bowel diameter, bowel wall thickness, degree of obstruction, air-fluid level, mesenteric fatty stranding, transitional zone, intraperitoneal fluid, close loop, whirl sign, and faeces sign. Statistical analyses were performed using univariate and multivariable analyses.ResultsMultivariable analysis showed that MDCT demonstrated presence of intraperitoneal fluid (Odds ratio, OR, 4.38), high-grade or complete obstruction (OR, 3.19) and mesenteric fatty stranding (OR, 2.81), and absence of faeces sign (OR, 2.11) were the most significant predictors. When all of the four criteria were used in combination, high sensitivity of 98.4% and specificity of 90.9% were achieved for the prediction for surgery.ConclusionMDCT is useful to evaluate adhesion-related SBO and to predict accurately patients who require surgery. Use of the four MDCT features in combination is highly suggestive of the need for early surgical intervention.