Multiphasic MDCT in small bowel volvulus

Small bowel volvulus versus adhesive small bowel obstruction: a diagnostic dilemma in a 19-year-old woman

Small bowel volvulus (SBV) is often challenging to diagnose. Research suggests that the clinical presentation of this disease is often very similar to other more common causes of small bowel obstruction (SBO) such as intraabdominal adhesions and no single preoperative diagnostic study is sensitive or specific enough to identify this rare cause of mechanical SBO. This report describes a case of a 19-year-old woman who presented with irretractable vomiting and abdominal pain secondary to SBV. This case is unusual as her history of recurrent adhesive SBO presented a diagnostic dilemma that required a higher degree of clinical suspicion to tease these differential diagnoses apart. She underwent laparoscopy which facilitated successful detorsion and resection of the floppy tongue of jejunum. This report aims to increase the awareness among surgeons.

Cinematic rendering of small bowel pathology: preliminary observations from this novel 3D CT visualization method

3D visualization methods for volumetric CT data have played an important role in diagnostic imaging of the small bowel, a structure which intrinsically crosses numerous slices in any 2D imaging plane. Recently, a new approach to 3D CT image creation has become available-cinematic rendering (CR). CR differs from other 3D methods in making use of a global lighting model that produces high surface detail and realistic shadowing effects that lead to 3D visualizations with photorealistic quality. Although the utility of these images for improving diagnostic accuracy has not yet been established, our group's early experience in regions of complex anatomy and pathology has been encouraging. In this pictorial review, we review the established role of 3D CT in many of the most common small bowel pathologies, provide examples of those pathologies visualized with CR, and suggest future directions for researchers to pursue.

Adhesive internal hernia: multidetector CT findings and clinical relevance

AIM

To review the clinical and multidetector computed tomography (MDCT) features of adhesive internal hernias (IHs) and to ascertain specific MDCT criteria to assist in the diagnosis of adhesive IHs and the early detection of intestinal strangulation.

MATERIALS AND METHODS

Medical records and preoperative abdominal MDCT findings of 34 patients with surgically confirmed abdominal adhesive IHs were analysed retrospectively.

RESULTS

The specific MDCT features of adhesive IHs included the following: dislocating and clustering of intestinal segments (100%); stretching and crowding of the mesenteric vessels (100%); presence of hernial orifice (88.2%), peritoneal adhesive bands (76.5%); and the fat notch sign (85.3%). In addition, the significant MDCT features indicative of intestinal strangulation compared with those without intestinal strangulation were bowel wall thickening (p=0.009), intramural haemorrhage (p=0.007), and abnormal bowel wall enhancement (p=0.023). Furthermore, bowel obstruction occurred in 17 (50%) patients, and mesenteric whirl was apparent in 8 (23.5%) patients.

CONCLUSION

This article illustrates the specific MDCT criteria of adhesive IHs. Knowledge of MDCT findings in adhesive IHs and their complications is essential for making the correct diagnosis and may help guide early clinical management.

Small bowel volvulus around caesarian section scar adhesions

Small bowel obstruction secondary to adhesions is a recognized complication of Caesarian section. However, obstruction due to small bowel volvulus caused by adhesions at the Caesarian-section scar has not been reported. We report such a case identified on computed tomography. We review the literature on small bowel volvulus in pregnant patients and discuss the computed tomography findings.

A Fatal Twist: Volvulus of the Small Intestine in a 46-Year-Old Woman

A 46-year-old woman presented to two emergency departments within 12 hours because of acute abdominal pain. Physical exam demonstrated tenderness and epigastric guarding. An ultrasound was interpreted as negative; she was discharged home. Later that evening, she was found dead. Postmortem exam revealed acute hemorrhagic necrosis of a segment of jejunum secondary to volvulus. Clinical clues suggesting presentations of small bowel volvulus are usually nonspecific; the diagnosis is typically confirmed at surgery. Her unremitting abdominal pain, persistent vomiting, and absolute neutrophilia were consistent with an acute process. The etiology of this volvulus was caused by an elastic fibrous band at the root of the jejunal mesentery. While congenital fibrous bands are rare in adults, this interpretation is favored for two reasons. First, the band was located 20 cm superior to postsurgical adhesions in the lower abdomen and pelvis. Second, there was no history of trauma or previous surgery involving the site of volvulus.

Small bowel volvulus with jejunal diverticulum: Primary or secondary?

Small bowel volvulus, which is torsion of the small bowel and its mesentery, is a medical emergency, and is categorized as primary or secondary type. Primary type often occurs without any apparent intrinsic anatomical anomalies, while the secondary type is common clinically and could be caused by numerous factors including postoperative adhesions, intestinal diverticulum, and/or tumors. Here, we report a rare case of a 60-year-old man diagnosed with small bowel volvulus using multidetector computed tomography (MDCT) angiography. Further discovery by laparotomy showed one jejunal diverticulum, longer corresponding mesentery with a narrower insertion, and a lack of mesenteric fat. This case report includes several etiological factors of small bowel volvulus, and we discuss the possible cause of small bowel volvulus in this patient. We also highlight the importance of MDCT angiography in the diagnosis of volvulus and share our experience in treating this disease.

Barber Pole Sign in CT Angiography, Adult Presentation of Midgut Malrotation: A Case Report

Adult midgut volvulus is a challenging diagnosis because of its low incidence and nonspecific symptoms. Diagnostic delay and long-term complaints are frequent in this clinical scenario. We reported a patient referred to our diagnostic imaging unit with intermittent abdominal pain, bloating and episodic vomiting for several years. He underwent barium gastrointestinal transit and abdominal ultrasound, which revealed severe gastric dilatation, food retention and slow transit until a depressed duodenojejunal flexure, with malrotation of the midgut and jejunal loops being located in the right upper quadrant. Computed tomography angiography was performed, showing rotation of the small intestine around the mesentery root, suggestive of midgut malrotation. In addition, an abnormal twisted disposition of superior mesenteric artery with corkscrew appearance was seen, shaping the pole-barber sign which was evident in volume rendering three-dimensional reconstructions. The patient underwent scheduled surgical treatment without any complication and had good outcome after hospital discharge and follow-up. Computed tomography plays an important role in evaluation of adult midgut volvulus. In addition, angiographic reconstructions can help us to assess the anatomic disposition of mesenteric vascular supply. Both of these assessments are useful in preoperative management.

[Gastrointestinal tract volvulus: diagnosis and correlation between plain-film X-ray and multidetector computed tomography findings]

Gastrointestinal volvuli cause processes that manifest as acute abdomen. Volvuli are important not because they are common, but rather because their possible complications can be severe. All types of volvuli share a common pathophysiology, which consists of intestinal obstruction in a closed loop that results in ischemia. The clinical manifestations are nonspecific, so radiologists play a very important role in the early identification of the most common signs of torsion. These include the "bird's beak sign", the "whirlpool sign", and signs of potentially reversible or irreversible ischemia. The treatment of choice in most cases is surgery, either to correct the torsion and save the organ or to resect it if it is necrotic.

Primary midgut volvulus in adults: report of two cases and review of the literature

INTRODUCTION

This is a report of two male patients (35 and 54 years old, respectively) admitted to our surgical department with signs of small-bowel obstruction.

CASE PRESENTATIONS

Diagnostic workup with plain abdominal radiographs and, more specifically, computed tomography suggested the possibility of bowel rotation. In order to exclude any possibility of associated intestinal ischemia, both patients underwent exploratory laparotomy, which revealed a midgut volvulus without any associated obvious cause or pathology.

DISCUSSION

Both patients had an eventful outcome. Epidemiologic characteristics, clinical presentation, diagnostic workup, surgical treatment, and morbidity-mortality rates of small-bowel volvulus have been reviewed and thoroughly discussed.