Whirlpool Sign Research Articles

Adult Presentations of Congenital Midgut Malrotation: A Systematic Review.

Adult midgut malrotation is a rare cause of an acute abdomen requiring urgent intervention. It may also present in the non-acute setting with chronic, non-specific symptoms. The objective of this study is to identify the clinical features, appropriate investigations and current surgical management associated with adult malrotation. A systematic review was conducted according to PRISMA guidelines, identifying confirmed cases of adult malrotation. Patient demographics, clinical features, investigation findings and operative details were analysed. Forty-five reports met the inclusion criteria, totalling 194 cases. Mean age was 38.9years (n = 92), and 52.3% were male (n = 130). The commonest presenting complaints were abdominal pain (76.8%), vomiting (35.1%) and food intolerance (21.6%). At least one chronic symptom was reported in 87.6% and included intermittent abdominal pain (41.2%), vomiting (12.4%) and obstipation (11.9%). Computerised tomography scanning was the most frequent imaging modality (81.4%), with a sensitivity of 97.5%. The whirlpool sign was observed in 30.9%; abnormalities of the superior mesenteric axis were the commonest finding (58.0%). Ladd's procedure was the most common surgical intervention (74.5%). There was no significant difference in resolution rates between emergency and elective procedures (p = 0.46), but length of stay was significantly shorter for elective cases. (p = 0.009). There was no significant difference in risk of mortality, or symptom resolution, between operative and conservative management (p = 0.14 and p = 0.44, respectively). Malrotation in the adult manifests with chronic symptoms and should be considered as a differential diagnosis in patients with abdominal pain, vomiting and food intolerance.

The role of sonography in differentiating congenital intrinsic duodenal anomalies from midgut malrotation: emphasizing the new signs of duodenal and gastric wall thickening and hyperechogenicity

The clinical and plain radiographic differentiation of congenital intrinsic duodenal anomalies (atresia, web, stenosis) from intestinal malrotation is not always clear. Although sonography has been documented as an important diagnostic tool in the differentiation of these two entities, its role is still not widely appreciated and it is still not universally utilized in this clinical setting. To assess the usefulness of sonographic features of the duodenal and gastric wall in the differentiation of congenital intrinsic duodenal anomalies from midgut malrotation in a large series of neonates and to compare them with other features on abdominal radiographs, ultrasound and upper gastrointestinal series. Using the surgical database at our tertiary pediatric hospital, we identified neonates who had surgically proven congenital intrinsic duodenal anomalies or malrotation over a period of 15years (2000-2015). We reviewed imaging findings in both groups of neonates (blinded to the final diagnosis) with attention to the echogenicity and thickness of the wall of the duodenum and stomach, the relationship between the superior mesenteric artery and vein, the position of the third portion of the duodenum and the presence of the whirlpool sign. Findings were compared between the groups using the unpaired t-test and Fisher exact test. We included 107 neonates in the study, 40 with a congenital intrinsic duodenal anomaly, 49 with malrotation (36 with volvulus) and 18 with a combination of both. Duodenal and gastric wall thickening and hyperechogenicity were significantly more common in the group with a congenital intrinsic duodenal anomaly compared to those with malrotation (P<0.0001). Conversely, an abnormal relationship between the superior mesenteric artery and vein, abnormal position of the third part of the duodenum, and the whirlpool sign were significantly more common in neonates with malrotation than in those with congenital intrinsic duodenal anomalies (P<0.0001). Duodenal or gastric wall thickening, and increased wall echogenicity are helpful sonographic features in the differentiation of congenital intrinsic duodenal anomalies from malrotation. Evaluation of the duodenal and gastric wall should thus be added to the features routinely assessed on ultrasound examinations in the clinical setting of suspected duodenal obstruction in the neonate.

Comparison of ovarian torsion between pregnant and non-pregnant women at reproductive ages: sonographic and pathological findings.

Differences in the ultrasonographic features and histological diagnosis of ovarian torsion in pregnant and non-pregnant women have not been defined. A better characterization of these features may help improve the accuracy of preoperative diagnosis. The present study aimed to compare the clinical characteristics, sonographic findings, operative procedures, and histological spectrum of ovarian torsion in pregnant and non-pregnant women. This was a retrospective investigation of female patients at reproductive age with ovarian torsion between January 2010 and May 2017. Each patient received a detailed preoperative ultrasound, and the diagnosis was confirmed by surgery. The clinical characteristics, ultrasonic features, operative procedures, and histological diagnosis of ovarian torsion were retrieved from medical records and were compared in non-pregnant and pregnant patients according to the method of conception. The overall preoperative ultrasonic detection rate of ovarian torsion was 0.84, which was significantly different between pregnant and non-pregnant women. The presence of ovarian edema and abnormal adnexal positions also differed between pregnant and non-pregnant women. The ultrasonic features were not significantly different between the two pregnant sub-groups. The most common histologic diagnoses in the pregnant group and the non-pregnant group were a normal ovary and teratoma, respectively. The incidence of ovarian neoplasm was significantly lower in pregnant women. There were significant differences in the surgical procedures between the groups based on neoplastic or non-neoplastic lesions. Ovarian edema, absence/decreased blood flow in the ovary, and the whirlpool sign were reliable ultrasonic markers for ovarian torsion at reproductive ages. The preoperative ultrasonic detection rate of ovarian torsion was higher in pregnant women, and ovarian edema was more common. The clinical features of ovarian torsion in pregnant women were similar, independent of the method of conception. In women with ovarian torsion, the incidence of non-neoplastic lesions was more frequent in pregnant women, whereas neoplastic lesions were more common in non-pregnant women. Ultrasonography provides useful parameters for the preclinical diagnosis of ovarian torsion to improve patient management.

Diagnosis and treatment of Roux and Y space hernia after Roux-en-Y gastric bypass surgery for gastric cancer patients: a clinical analysis of 12 cases

Clinical data of 12 patients with gastric cancer, in whom the Roux and Y space hernia developed after gastrectomy with Roux-en-Y anastomosis in our hospital from June 2010 to December 2018, were retrospectively analyzed. The clinical symptoms of patients were abdominal pain, distension and ileus. The main CT findings were torsion of mesentery with whirlpool sign, intestinal obstruction and exudants around the small bowels. During the operation it was found that small bowels herniated into the Roux and Y space in all 12 patients, the necrotic small intestines were resected in 4 patients. Ten patients were recovered, and 2 died. No recurrence was observed in all 10 patients during 3 month-follow up. The postoperative Roux and Y space hernia is a internal hernia and difficult to be diagnosed. The CT scan is valuable for diagnosis of Roux and Y space hernia; the main CT signs were swirled appearance of mesentery and small bowel obstruction. Once diagnosis is made the emergency operation is necessary. Key words: Stomach neoplasms; Hernia, abdominal; Anastomosis, Roux-en-Y

Prediction of Adnexal Torsion by Ultrasound in Women withAcuteAbdominal Pain.

To investigate the accuracy of ultrasound in the diagnosis of adnexal torsion. Retrospective cohort analysis of 322women, presenting to a tertiary medical center with acute abdominal pain, who underwent gynecological examination, sonographic evaluation and laparoscopic surgery, between 2010 and 2016. Findings for adnexal torsion were compared among three groups: positive sonographic findings consistent with surgically confirmed adnexal torsion (true positive, n = 228); negative sonographic findings inconsistent with surgically confirmed adnexal torsion (false negative, n = 42); and positive sonographic findings inconsistent with a surgical diagnosis other than adnexal torsion (false positive, n = 52). Outcome measures were sensitivity and positive predictive value of ultrasound, and its specific features, for the diagnosis of adnexal torsion. The sensitivity of ultrasound for adnexal torsion diagnosis was 84.4 %, and the positive predictive value was 81.4 %. Edematous ovary and/or tube, as well as positive whirlpool sign had the highest sensitivity and positive predictive value. The false-negative group had the highest frequency of ovarian cysts (p = 0.0086) and the lowest frequency of ovarian edema (p < 0.0001). The false-positive group had the lowest proportion of pregnant women (p = 0.0022). Significantly more women in the true-positive group had a prior event of adnexal torsion (p = 0.026). Ultrasound examination is highly accurate in the diagnosis of adnexal torsion. Clinicians should be aware of the presence of demographic and clinical characteristics that may positively or negatively affect sonographic diagnostic accuracy.

The recurrence of colonic volvulus due to nonrotation after intestinal resection in adulthood: a case report

BackgroundIntestinal nonrotation is a rare congenital condition that causes fatal colonic volvulus at any age. Once volvulus attack occurs, radical surgical therapy is required for treatment and the prevention of recurrence. This report describes the case of an adult female patient with a recurrence of cecum volvulus due to intestinal nonrotation after transverse colon resection for colonic volvulus.Case presentationA 27-year-old female visited our emergency room (ER) with intermittent abdominal pain and nausea. Enhanced computed tomography (CT) showed enlargement of the level of the ascending and transverse colon and an obstruction with a whirlpool sign at the transverse colon. The small intestine was distributed on the right side of the abdominal cavity, and the large intestine occupied the left side. She was diagnosed with volvulus with intestinal nonrotation, and emergency surgery was performed. Surgical examination indicated that the ascending colon to the transverse colon was not fixed to the retroperitoneum, and the transverse colon was rotated 180° clockwise. The axis of the volvulus was a mesenteric adhesion of the transverse colon. The involved transverse colon was resected, and the intestine was reconstructed by functional end-to-end anastomosis (FEEA). Six years after the initial surgery, the patient presented to the ER with abdominal fullness and lower abdominal pain. Enhanced CT revealed that the cecum, ascending colon, and remaining transverse colon were dilated with an obstruction. The appendix was located in the left upper abdominal cavity. The clinical diagnosis was cecal volvulus with intestinal nonrotation. An emergency laparotomy revealed that the cecum was rotated 180° clockwise. The terminal ileum to the remaining transverse colon was resected, and FEEA was performed. Seven months later, she suffered obstruction of the intestine caused by an operative adhesion, and conservative treatment was successful. The patient has had no abdominal symptoms for one and a half years so far.ConclusionsSurgeons should realize that nonrotation of the intestines induces volvulus in adulthood and should familiarize themselves with its clinical findings, appropriate treatment, and prognosis. Even after surgical treatment, awareness of the recurrence of volvulus should be maintained to avoid a late diagnosis.

Whirlpool sign of adnexal torsion on CT: where can we find it?

Background Whirlpool sign on computed tomography (CT) is pathognomic of adnexal torsion. Purpose To evaluate the visibility and common location of the whirlpool sign in adnexal torsion on CT. Material and Methods This retrospective study included 143 consecutive patients who underwent preoperative CT imaging and subsequent surgically confirmed as adnexal torsion. Two readers independently recorded the presence and location of whirlpool sign in adnexal torsion on CT. Patients with and without whirlpool sign were compared with regard to the size of the adnexal mass and the degree of torsion. Results Whirlpool sign was detected in 60 (42.0%) patients on the transverse CT plane and 79 (55.2%) patients on the coronal CT plane of 143 patients. The sign was significantly better detected on the coronal CT plane than on the transverse CT plane ( P = 0.03). The most common location of the sign included the posterolateral aspect of the adnexal mass on the transverse CT plane (25/60, 41.7%, P = 0.04) and the upper-lateral aspect of the adnexal mass on the coronal CT plane (45/79, 60.0%, P &lt; 0.001). The size of the adnexal mass with whirlpool sign was significantly larger than the mass without whirlpool sign on the transverse CT plane (median 9.6 vs. 8.6 cm, P = 0.03). No significant difference in the degree of torsion was found between patients with and without whirlpool sign on CT ( P = 0.56–0.62). Conclusion Whirlpool sign of adnexal torsion is well detected at the upper-lateral aspect of adnexal mass on the coronal CT plane.

Portal venous gas in intestinal malrotation with mild midgut volvulus

BackgroundPortal venous gas has been considered as a radiological sign requiring urgent operative intervention; however, the reports concerning portal venous gas associated with favorable outcome are recently increasing.Case presentationWe describe a 9-month-old boy with acute onset high fever and vomiting. The ultrasonography demonstrated micro-gas bubbles continuously floating in the intrahepatic portal vein. Contrast-enhanced CT, performed 1 h later from echography, revealed a whirlpool sign suggesting an intestinal malrotation with midgut volvulus, but with no signs of residual intrahepatic gas. Operative findings showed a mild volvulus with neither congestion nor ischemic change of the twisted bowel. Detorsion and Ladd’s procedure were completed laparoscopically.ConclusionsTransient portal venous gas bubbles may be generated even in the mild intestinal volvulus with no bowel ischemia. Ultrasonography can be a sensitive detector to visualize such small amounts of gas.

The role of sonography for depiction of a whirlpool sign unrelated to midgut malrotation in neonates

The sonographic whirlpool sign of volvulus due to midgut malrotation is well recognized. However, variations of the whirlpool sign may be seen in other conditions, but this observation has received little attention in the literature. This study presents a series of neonates with a variety of causes of congenital intestinal obstruction, all associated with a whirlpool sign (unrelated to midgut volvulus), which was correctly recognized preoperatively on sonography. We also emphasize the pivotal role of sonography in managing congenital obstruction of the intestinal tract in neonates. This is a retrospective analysis of clinical, imaging and surgical findings in 11 neonates with congenital intestinal obstruction associated with a whirlpool sign (unrelated to midgut volvulus) that was recognized preoperatively on sonography and in whom the cause for the whirlpool was documented at surgery. Eleven neonates (eight male, three female) had clinical and radiographic evidence of intestinal obstruction in whom sonography depicted a whirlpool sign, which was recognized on the initial sonogram in nine and on a repeat sonogram in two. The whirlpool was located in the upper abdomen in only two, mid-abdomen in five and right lower quadrant in four. The whirlpool was only 1-2cm in diameter. An upper gastrointestinal series in three neonates failed to depict the cause of obstruction. Contrast enema in three cases had findings suggesting the site of obstruction was in the ileum but none depicted the exact cause of the obstruction. At surgery, the whirlpool sign correlated with a segmental volvulus of the small intestine in eight neonates and with the coiled distal small intestine associated with apple-peel atresia in the other three. This study illustrates neonates in whom a whirlpool sign (unrelated to midgut volvulus) was correctly recognized on sonography before surgery. Sonography proved more useful than an upper gastrointestinal series or contrast enema in depicting the exact cause of the obstruction. Pediatric radiologists must make the effort to search throughout the entire abdomen and pelvis for a small whirlpool sign on sonography, even in the absence of midgut malrotation, in neonates with congenital intestinal obstruction. Its recognition preoperatively will facilitate a rapid diagnosis and will obviate the necessity for contrast examinations of the gastrointestinal tract, which require ionizing radiation.

Acute Isolated Tubal Torsion with Hematosalpinx in a Premenopausal Woman: The Importance of the Whirlpool Sign

Isolated tubal torsion is a rare event with an incidence of 1 in 1 500 000 women. It can be seen through different stages of the reproductive period such s adolescence, pregnancy, and perimenopausal and menopausal stages [1]. Predisposing factors attributed to isolated tubal torsion include intrinsic (Morgagni hydatids, tubal ligation, hydrosalpinx, pyosalpinx, adhesions, abnormal peristalsis, long tube, or mesosalpinx) and extrinsic (ovarian cysts, tumors, previous pelvic surgery, hyperstimulated ovaries, pregnancy, venous congestion, and trauma) causes [2,3].

Small-Bowel Volvulus Caused By Mesenteric Lymphangioma

A 6-year-old boy with abdominal pain and vomiting visited the emergency department. He repeated these symptoms once a month from the age of 4 years, which were ameliorated by rest. He had tenderness in the whole abdomen, but no abdominal guarding. Abdominal radiography showed gas in the left upper quadrant. Contrast-enhanced abdominal computed tomography scan showed a snowman-like space-occupying lesion (Figure A, arrow) and a whirlpool sign indicating wrapping of the superior mesenteric vein around the superior mesenteric artery (Figure B, arrow).

“T2-hypointense dot sign”: A novel and highly suggestive clue for the diagnosis of ovarian torsion

PurposeWe aimed to describe “T2-hypointense dot sign” for the diagnosis of ovarian torsion and compare its diagnostic capability with whirlpool sign. MethodsPelvic MRIs of 31 patients with surgically proven ovarian torsion were used for the analysis. The control group was comprised of 30 patients with adnexal neoplasm and 15 patients with tubo-ovarian abscess. The MRIs of all 76 patients were retrospectively evaluated by two independent radiologists for the presence of T2-hypointense dot sign and whirlpool sign using a three-point scale. ResultsThe sensitivity, specificity, positive predictive value, negative predictive value, and accuracy values for the T2-hypointense dot sign for the diagnosis of ovarian torsion for observer 1 and observer 2 were 0.90, 1, 1, 0.93, and 0.96 and 0.87, 1, 1, 0.91, and 0.94, respectively. These same values for the whirlpool sign for observer 1 and observer 2 were 0.58, 1, 1, 0.77, and 0.82 and 0.42, 1, 1, 0.71, and 0.76, respectively. Both signs were definitely negative in patients with adnexal neoplasm and tubo-ovarian abscess. Interobserver agreement was excellent for the T2-hypointense dot sign (κ = 0.83), but poor for the whirlpool sign (κ = 0.31). ConclusionsThe presence of T2-hypointense dot sign could be a valuable clue for the accurate and early diagnosis of ovarian torsion in non-contrast MRI scans.

Twist and shout: magnetic resonance imaging findings in ovarian torsion.

Adnexal torsion is characterized by partial or complete rotation of the suspensory ligament of the ovary and its corresponding vascular pedicle, resulting in vascular impairment that can culminate in hemorrhagic infarction, as well as necrosis of the ovary and fallopian tube. Because there are myriad causes of acute pelvic pain, the differential diagnosis of ovarian torsion is often challenging. Consequently, radiologists should be familiar with the main imaging findings. In this regard, there are typical signs of ovarian torsion on magnetic resonance imaging, including increased ovarian volume with stromal edema and peripheral distribution of the ovarian follicles, as well as thickening of the fallopian tube, an adnexal mass (causal factor) that shifts toward the midline, and the classic, pathognomonic “whirlpool sign”. The objective of this essay was to review and illustrate the various magnetic resonance imaging findings in ovarian torsion.

The Whirlpool Sign in Abdominal Pain: The Hernias that Radiologists Should Never Forget

The Whirlpool Sign in Abdominal Pain: The Hernias that Radiologists Should Never Forget

Usefulness of evaluating testicular heterogeneity in cases of testicular torsion

Introduction Testicular heterogeneity on preoperative ultrasound has been reported to be able to determine testicular viability in patients with testicular torsion. Aim Determine if testicular heterogeneity in the context of testicular torsion can distinguish between testes which atrophy and those that recover. Materials and Methods Patients investigated for testicular torsion with preoperative ultrasound available from 2007 to 2017 were reviewed in this IRB approved retrospective study. Testicular torsion was diagnosed as having reduced/absent testicular vascularity or whirlpool sign on ultrasound. Those presenting with possible testicular torsion who had normal testes on ultrasound served as controls. Testicular texture was quantified with TexRad software. The ratios of the texture of right to left testes were compared in those with normal testes to identify the best texture parameters to use. Based on surgical and follow up ultrasound findings, torted testes were sorted into 3 groups (resected, atrophied, recovered) and their preoperative textures compared against normal testes. Results There were 60 patients who had unilateral testicular torsion of which 19 underwent orchidectomy, 22 had orchidopexy but the torted testes atrophied, 19 had orchidopexy and the torted testes recovered. Control group comprised of 42 patients investigated for testicular torsion with normal testes. Entropy was the least variable texture parameter with right to left ratio of 1.00 +/-0.02 in controls. Preoperative ultrasound average entropy ratio was statistically significantly elevated (p There is much overlap of values between testes which recovered and those that atrophied. Conclusion Heterogeneity of the torted testes as measured by TexRad entropy values can be higher than normal controls on preoperative ultrasound. However there is much overlap of the entropy values between torted testes that recover and those that atrophy.

Signo del remolino: cirugía de urgencia o falacia ad populum

Introduction: The imaging test have become an important piece on the diagnosis of the acute abdomen in emergency, nevertheless medical conduct should be based on contextualized iconographic findings. The tomographic “whirlpool sign” establishes a surgical paradigm for its association with the bowel volvulus. Objetive: To register patients with diagnosis of acute abdomen looking for the “whirlpool sign” in the computed tomography and identify who needed surgical intervention. Methods: Analytical cross-sectional study. 115 tomographies of acute obstructive abdomen have being evaluated. Results: 15 tomographies were excluded. The prevalence of the whirlpool sign was 5%. Diagnoses were intestinal malrotation (2%), midgut volvulus (1%), sigmoid volvulus (1%) and enterocolitis (1%). Only 60% of the patients required surgery. Discussion: The presence of the “whirlpool sign” not always determines a surgical resolution. It is not a pathognomonic sign of a punctual entity; it could represent an ordinary finding in the context of several pathologies. To apply the correct treatment, surgical or medical, for these patients it was important to recognize “whirlpool sign” variants.

Midgut Volvulus as Presentation of Intestinal Malrotation in an Elderly Patient

Congenital intestinal malrotation is an incomplete rotation and fixation of the midgut during embryogenesis. Most commonly diagnosed during infancy, it is rarely reported in adults with an estimated incidence of 0.0001 and 0.2%. A 77 year old man presented to the ED with symptoms of gastrointestinal(GI) bleeding, including, anemia and melena. At prior hospitlizations the patient had several upper and lower endoscopies showing multiple AVMs in the stomach and duodenum. Patient was admitted and subsequently underwent a push enteroscopy that did not reveal any obvious source of bleeding. Six hours post-procedure, he developed diffuse severe abdominal pain with abdominal distention and tenderness over the RUQ. CT abdomen demonstrated a “mesenteric swirl” concerning for mid-gut volvulus. He underwent emergent exploration and was found to have a complete malrotation of the small and large bowel with classic Ladd's bands adhesions and the appendix in the LLQ. Mid-gut volvulus was reduced, the congenital adhesions divided and the appendix removed. The early post-op period was complicated by high-grade small bowel obstruction warranting re-operation on POD#7. Abdominal re-exploration revealed multiple adhesions of the small bowel, which were lysed as well as a severe kink at the 4th portion of the duodenum which was to the right of the SMA. Patient had a complicated, prolonged hospital course requiring TPN and was discharged on POD# 37. Unlike infant population, adult patients with intestinal malrotation present with more vague and chronic symptoms like recurrent abdominal pain associated with nausea, vomiting, frequent diarrhea, bloating, early satiety and upper or lower gastrointestinal bleeding. Acute volvulus can be the initial presentation in 10-15% of adults. CT abdomen with oral and IV contrast is the imaging of choice for diagnosis. The classic “whirl” sign, consisting of mesentery and superior mesenteric vein around the superior mesenteric artery, is highly suggestive of midgut volvulus. Surgical management typically involves counterclockwise detorsion of bowel, lysis of Ladd's bands and appendectomy to prevent morbidity of future diagnostic delay. Non-operative management of asymptomatic patients is reasonable. We present this case to increase awareness of malrotation as a possible cause of chronic abdominal pain and acute volvulus in the adult population.1468_A Figure 1. CT abdomen showing Intestinal malrotation with suspected midgut volvulus1468_B Figure 2. CT abdomen: showing whirlpool sign at coronal view1468_C Figure 3. Findings at exploratory laparotomy

EP19.04: The ultrasonic whirlpool sign combined with plasma d‐dimer level in adnexal torsion

EP19.04: The ultrasonic whirlpool sign combined with plasma d‐dimer level in adnexal torsion

The ultrasonic whirlpool sign combined with plasma d-dimer level in adnexal torsion

ObjectivesThe whirlpool sign (WS) and plasma d-dimer are used as a sonographic marker and laboratory index for adnexal torsion (AT), respectively. The aim of this study was to evaluate whether their combination improved diagnostic efficiency of AT in patients presenting with a benign ovarian mass and abdominal pain and clinically suspected AT. Materials and methodsFifty-four patients with clinically suspected AT with benign ovarian mass and abdominal pain were analyzed and divided into an AT group (n = 28) and control group (n = 26). Ultrasonography and venous blood collection were performed before surgery to observe the WS and plasma d-dimer level. All cases were confirmed by surgery. Diagnostic efficiency of the WS, plasma d-dimer level, and their combination was compared. ResultsThere was a significant increase in the WS and plasma d-dimer level in AT patients (all p < 0.01). The sensitivity, specificity, Youden Index and area under the curve (AUC) of the WS (cut-off value of >1 circle), d-dimer level (cut-off value of 248 ng/ml) and their combinations were 71.43, 67.86 and 96.43%; 92.31, 100 and 100%; 0.637, 0.679 and 0.964; and 0.909, 0.899 and 0.995, respectively. There was a significant difference in AUC between the WS and d-dimer and their combination (all p < 0.01). ConclusionsThe WS and d-dimer were useful for diagnosis of AT in patients with ovarian mass and abdominal pain. Combination of the WS and d-dimer may improve diagnostic efficiency for AT compared with each method alone.

The whirlpool sign in CT scan

The whirlpool sign in CT scan