Jun 05, 2015 volvulus in midgut volvulus, the classic radiographic finding is a partial duodenal obstruction dilation of both stomach and proximal duodenum, with a small amount of distal bowel gas. The morbidity and mortality associated with acute smallbowel obstruction continue to be significant. Ct findings of sigmoid volvulus request pdf researchgate. Ge, milwauke, wi, usa revealed a swirled pattern of small bowel loops in the midabdomen. Small bowel followthrough sbft examination may be performed as a continuation of an upper gastrointestinal ugi series or as a separate, dedicated study of the small bowel. The colon is approximately 100200 cm long ans is distinguished from small bowel by three longitudinal muscular bands taenia coli omentalis,mesocolica, libera forms the haustral saccualtions conventionally divided into caecum including the appendix, ascending colon, hepatic flexure, transverse colon. Most of the small bowel is located to the right and large bowel to the left, even though the transverse colon crosses the midline to the right.
Stools, fluid, and gas build up inside the intestine. Torsion results in narrowing of the lumen at the point of rotation and compromise of the vessels that supply the torted gut. Two cases of small bowel volvulus with mild clinical symptoms in which upper gastrointestinal series, computed tomography, and magnetic resonance imaging were performed are reported. Small bowel exam bowel radiography is an xray examination of the small intestines that uses a special form of xray called fluoroscopy and an orally ingested contrast material called barium.
Imaging findings of midgut volvulus associated with a large. Volvulus twisting of the colon department of surgery. Frontiers primary segmental volvulus of small intestine. The key finding consists of a dilated loop of pelvic colon, associated with features of smallbowel obstruction and retention of feces in an. Small bowel volvulus rarely occurs in adults, although it has been reported in the presence of small bowel diverticulum.
Small bowel obstruction is the most common disorder of the small bowel which requires hospital admission and surgical intervention. Small bowel exam imaging services sentara healthcare. The ct imaging findings include superior mesenteric artery thrombus, smallcaliber superior mesenteric vein, bowel distension, and focal lack of bowel wall enhancement figs. The detailed imaging findings of organoaxial volvulus of the small intestine. The age distribution and underlying causes for each part of the intestine is quite different and can present the surgeon with a diagnostic dilemma leading to an abdominal catastrophe if the volvulus is not diagnosed and treated promptly. The jejunal and ileal branches supplying this segment are involved in volvulus best seen on the axial images, and as a result bowel perfusion is. It accounts for 1216% of all surgical admissions in patients with acute abdominal conditions. Value of ct in identifying findings associated with the effectiveness of nonsurgical treatment. Transverse images of small intestine are present in the near field. Occasionally, visualization of an adhesional band is possible, although it is rare to be able to do so figs. Ultrasonography may demonstrate the features and causes of small bowel obstruction, and it 12 is of particular value in looking at the dynamics of the small bowel. Obstruction is present if the smallbowel loop is greater than 2. Sigmoid volvulus with coffee bean sign as seen on abdominal xray. Volvulus and intestinal malrotation knowledge for medical.
These examinations were performed with the retrograde insufflation of 1200 ml of air through a foley catheter that was placed in the rectum and with scopolamine to inhibit peristalsis in order to demonstrate the site of bowel obstruction. The sigmoid extends into the upper abdomen above the transverse colon. Magnetic resonance imaging mri has been used successfully in the assessment of largebowel obstruction not specifically in sigmoid volvulus. Two types of psv early and late neonatal have been described previously, especially in preterms. The coffee bean sign is created by the apposition of the medial walls. However, in some cases, it could develop without any other clinical conditions, and this is called primary segmental volvulus psv of the small intestine. Jan 12, 2016 cecal volvulus is usually associated with a small bowel obstruction. Methods patients with small bowel volvulus who underwent operations from january 2001 to december 2015 at. An xray is a noninvasive exam that helps your physician diagnose and treat your medical conditions. The etiologies of ileus are numerous, ranging from inflammation pancreatitis to metabolic hypokalemia to drugs opiates. Abdominal contrast ct has a high sensitivity for demonstrating small bowel obstruction. In comparison to traditional barium fluoroscopic examinations, spatial and temporal resolution is now much more improved partially thanks to modern bowel distending agents. Small bowel obstruction leads to progressive increase in the intraluminal pressure which can exceed the venous pressure and result in bowel ischemia. The massively dilated caecum no longer lies in the right iliac fossa rif.
Volvulus of the small intestine must be considered when a patient presents with smallbowel obstruction, and early operative intervention should be undertaken to prevent vascular compromise. Bowel necrosis, gastrectomy, postoperative, short bowel syndrome, small bowel volvulus introduction small bowel volvulus sbv is a rare condition in which the small bowel and its mesentery are twisted around the mesenteric axis 1, 2. Other common causes include hernias, neoplasms, and crohns disease 1, 2. Epidemiology large bowel volvulus accounts for 5% of all large bowel obstructions, with 60% of intestinal volvulus involving the sigmoid colon 6. University of california san francisco east bay surgery program, and university of. Intestinal volvulus is a broad term that describes the torsion of bowel around its mesentery. The small bowel loops are distended with fluid, and toandfro peristalsis is often visible. Rather this is occupied by small bowel red outline. Midgut malrotation with volvulus, sigmoid volvulus, biliary rupture of hydatid cyst, and small bowel lipomatosis, where fast imaging employing steadystate acquisition fiestaconstructive interference into steady state ciss sequence helped in clinching the diagnosis. It can permit better evaluation of small bowel motility than does enteroclysis small bowel enema. Perioperative findings included location of the duodenojejunal flexure to the right of the spine along with small bowel volvulus. Volvulus of the small bowel and colon remains a significant cause for surgical emergencies in both children and adults.
Jul 28, 2017 twisted bowel medically is termed volvulus and can occur in the small or large intestine. It is a surgical emergency due to the risk of mesoaxial twisting of all the small bowel or a. During laparoscopy, the midgut volvulus was found to have resolved. Small bowel volvulus sbv is defined as torsion of a loop of small bowel about the axis of its mesentery, resulting in partial or complete obstruction. Sigmoid volvulus is the most frequent type of colonic volvulus, representing 6075%, in comparaison to. The mesenteric small bowel gradually tapers in diameter from the duodenojejunal junction to the terminal ileum, so that it normally has a larger caliber in the jejunum up to 3 cm in luminal diameter than in the ileum up to 2 cm on sbft studies. Small bowel volvulus with malrotation radiology case.
Results were limited to humans and english language studies. Diagnosis, treatment and prognosis of small bowel volvulus in adults. Ct findings suggesting bowel compromise were compared with pathologic and. Sigmoid volvulus is thought to account for 25% of cases of largebowel. Sigmoid volvulus is a cause of large bowel obstruction and occurs when the sigmoid colon twists on its mesentery, the sigmoid mesocolon. Diagnosis and treatment of caecal volvulus postgraduate medical.
Small bowel obstructions 0 download 5 pages 1,119 words add in library click this icon and make it bookmark in your library to refer it later. In the last years, mr and ct techniques have been optimized for small bowel imaging and are playing an increasing role in the evaluation of small bowel disorders. Small intestinal volvulus often occurs with malrotation. Malrotation of the intestine occurs when the normal embryologic sequence of bowel development and fixation is interrupted.
A small camera on the tube sends a video image of the intestinal lining to a computer screen. The mesenteric small bowel gradually tapers in diameter from the duodenojejunal junction to the terminal ileum, so that it normally has a larger caliber in the jejunum up to 3 cm in luminal diameter than in the ileum up to 2 cm on sbft. Smallbowel obstruction is caused by postoperative adhesions in 70% of all cases. Neither patient received laparotomy and the diagnosis was based on imaging findings. Abdominal ultrasound using highresolution, linear 7 to 10mhz probe logiq 5 expert. However, it accounts for 2035% of small bowel obstructions in asia, africa, and the middle east. Diagnosis of midgut volvulus was made, and the baby was operated. Health, general acute abdomen care and treatment diagnosis risk factors cat scans health aspects usage ct imaging gastrointestinal diseases complications and side effects.
The most useful aspects of the history and physical examination are a previous history of abdominal surgery, constipation, abnormal bowel sounds, and abdominal. Small bowel volvulus is an uncommon but important cause of small intestinal obstruction. Imaging findings of midgut volvulus associated with a. Gastrointestinal volvulus is mainly classified into two subtypes, mesenteroaxial volvulus and organoaxial volvulus.
This appearance of whirlpool suggested midgut volvulus. Multislice computed tomography angiography findings of. The small bowel is identified by the valvulae conniventes mucosal folds that cross the full width of the bowel arrowheads. Abdominal ct and mri are considered to be useful in the early diagnosis of small bowel volvulus. Mr software and hardware have enabled mr imaging to assume a major role in the evaluation of the small bowel. Objectives small bowel volvulus is a rare disease, which is also challenging to diagnose. In our case, both ct and a small bowel series showed the typical imaging findings of midgut volvulus. Based on cause, small bowel volvulus can be divided into primary and secondary type. Sbv is a rare cause of small bowel obstruction in western countries, comprising 16% of cases. When this happens, the contents of the intestine cannot properly get out of the body.
The recovery of the baby was rapid with disappearance of the symptoms. Jun 12, 20 small bowel obstruction is an uncommon, but serious, presentation to the ed, with an estimated prevalence of approximately 2% of all patients whose chief complaint is abdominal pain. Does the ct whirl sign really predict small bowel volvulus. Herein we present the case of a 44yearold male who presented to us with this condition. Small bowel radiography is an xray examination of the small intestines that uses a special form of xray called fluoroscopy and an orally ingested contrast material called barium. As we discussed previously, it can sometimes be impossible to distinguish between sbo and ileus on imaging studies.
The small bowel feces sign is a result of stasis and mixing of small bowel contents and is present in 82% of cases of small bowel obstruction 2, 3. In addition, a small bowel series showed the underlying intestinal malrotation and a large jejunal diverticulum. The sigmoid is folded back upon itself, and the apposed walls of the redundant sigmoid colon form the seam of the football or coffee bean shape. Unconventional abdominal uses of fiesta ciss sequence.
Obstruction is present if the small bowel loop is greater than 2. Ingrid millet, alban ruyer, chakib alili, fernanda curros doyon, nicolas molinari, emmanuelle pages, marc zins, patrice taourel. Although midgut volvulus is a complication of malrotation of bowel and mesenteric malfixation, primary volvulus of the small bowel is a distinctly different and rare entity characterized by torsion of the entire small bowel with normal mesenteric fixation. Bowel wall layers are readily identified with the hypoechoic mucosal layer m being thickest, surrounded by thin submucosal hyperechoic, muscularis hypoechoic, and serosal hyperechoic layers. The aims of this study were to characterize the clinical and radiological features associated with small bowel volvulus and treatment and to identify risk factors for associated small bowel necrosis. However, most whirl signs detected on ct will not prove to be indicative of small bowel. Sigmoid volvulus is due to a twist at the base of the sigmoid mesentery which is a fixed position in the left iliac fossa. Utility of ct whirl sign in guiding management of smallbowel. Fixation of the bowel loops was done along with excision of a few bands.
On color doppler ultrasound, the superior mesenteric vein was seen swirling with the small bowel loops with centrally placed superior mesenteric artery. A rare cause of sbo is intussusception, responsible for only 1% of cases. This patient actually had intermittent abdominal pain for a few months, and the obstruction looks chronic subobstructive since per os contrast migrated normally in the distal small bowel. Ct may show changes of small bowel diverticulitis in the right lower quadrant or may show volvulus or intussusception. Abdominal xray abnormal bowel gas pattern volvulus. Imaging the obstructed bowel and other intestinal emergencies. Cecal volvulus may be depicted as a grossly distended fluidfilled cecum at a lead point of small bowel obstruction, but the appearances are generally nonspecific.
One classic sign of closedloop obstruction on ct is the whirl sign, a swirl of mesenteric softtissue and fat attenuation with adjacent loops of bowel surrounding. Ct enteroclysis, a relatively new investigational tool for diagnosing smallbowel obstruction, can also be used with multiplanar reconstructions to overcome the unreliability of ct for diagnosing lowgrade obstructions. Gastrointestinal imaging adhesive small bowel obstruction. Ct enteroclysis has a greater sensitivity and specificity 89% and 100%. How is a smallbowel obstruction sbo demonstrated on ct. List the risk factors for development of volvulus of the stomach, small bowel, and colon.
When small bowel herniates through this surgically created defect, causing an sbo, small bowel is seen in an abnormal position lateral to the colon, with omentum and small bowel located directly adjacent to the abdominal wall figure 6. We also did not specifically include studies that looked to diagnose strangulation alone. Contrastenhanced ct is the imaging modality of choice as it has sensitivity of 93. The diagnosis of smallbowel obstruction in children is usually based on the clinical findings, radiographs, or barium examinations. The colon is approximately 100200 cm long ans is distinguished from small bowel by three longitudinal muscular bands taenia coli omentalis,mesocolica, libera forms the haustral saccualtions conventionally divided into caecum including the appendix, ascending.
Ascariasis is a common infestation in developing countries where there is poor hygiene. Sigmoid volvulus is the most frequent type of colonic volvulus, representing 6075%, in comparaison to cecal volvulus that represents 2233% of all cases 1. The explode option was used for the ovid medline search. The ability to provide crosssectional information combined with a lack of ionizing radiation make mr imaging well suited for smallbowel imaging. Learn about how this condition develops and how it can be treated. Barium enema has been the imaging modality traditionally applied for caecal. Ct of the abdomenpelvis was obtained which identified dilated loops of. Diagnostic imaging pathways bowel obstruction suspected. Mar 30, 2016 midgut volvulus is a condition in which the intestine has become twisted as a result of malrotation of the intestine during fetal development.
Diagnosis, treatment and prognosis of small bowel volvulus in. Small bowel obstruction means the small intestine is partially or totally blocked. In this case, emergently operations were not necessarily needed under no inflammatory signs in the intestinal mucosa, even if a typical whirllike pattern was demonstrated. No signs of mucosal ischemia placement of a soft rectal tube for bowel. Original article clinical analysis of acute small bowel. This is a potentially serious condition that requires urgent medical care. In moderate or high grade obstruction, ct is normally performed with intravenous contrast but intraluminal contrast is not required. The small intestine is usually empty or contains minimal fluid andor gas. In 9 of 20 patients that received abdominal ct scans, whirlpool sign on the ct scan was present.
Left supine film of the abdomen shows marked dilation of the sigmoid colon. Figure 12b cecal volvulus in an elderly patient with abdominal cramps. The use of ct in the diagnosis of small bowel obstruction in children has been previously addressed, and ct has been proposed as a useful adjunct diagnostic procedure in detecting the presence of small bowel obstruction, its level, and its cause. Volvulus of the small intestine intestine small volvulus. Bowelwall layers are readily identified with the hypoechoic mucosal layer m being thickest, surrounded by thin submucosal hyperechoic, muscularis hypoechoic, and serosal hyperechoic layers. Multislice computed tomography ct angiography, by demonstrating the mesenteric vessels, can be of help in the diagnosis of small bowel volvulus, especially when ct or gastrointestinal studies fail to show the diverticulum. Imaging in intestinal malrotation and midgut volvulus. Laboratory data confirmed leukocytosis and severe acidosis ph 7. Although volvulus can occur at other sites of the alimentary tract, including the stomach, gallbladder, and small bowel, they most commonly occur in the colon. However, volvulus of the right colon, closedloop small intestinal. Small bowel volvulus is the cause of only 14% of small bowel obstructions in western countries, but up to 2035% of small bowel obstructions in africa and asia. Imaging of acute smallbowel obstruction request pdf. Moreover, there were other cases occurring beyond the neonatal period. A triple contrastenhanced abdominal ct scan revealed a 540 twist of the smallbowel mesentery, which is shown by the clockwise whirllike.
Gastrointestinal imaging adhesive smallbowel obstruction. Delay in diagnosis and surgical intervention increases morbidity and mortality rates. The use of ct in the diagnosis of smallbowel obstruction in children has been previously addressed, and ct has been proposed as a useful adjunct diagnostic procedure in detecting the presence of smallbowel obstruction, its level, and its cause. The diagnosis of small bowel obstruction in children is usually based on the clinical findings, radiographs, or barium examinations. Caecal volvulus is an infrequently encountered clinical condition and an. Twisted bowel medically is termed volvulus and can occur in the small or large intestine. Ultrasound whirlpool sign for midgut volvulus sciencedirect. Small bowel volvulus is a rare clinical entity which presents as recurrent intermittent abdominal pain after consumption of food. Diagnosis, treatment and prognosis of small bowel volvulus.