Midgut volvulus with "whirlpool" signs

Primary adult midgut volvulus mimicking acute appendicitis: A case report and review of the literature

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Adult midgut volvulus is a rare but important cause of small bowel obstruction.

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Our patient, 35 year old male, was clinically suspected to have acute appendicitis.

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Intra-operatively, we found a normal appendix and jejunal volvulus with adhesions.

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If in doubt, early contrast CT scan should be performed.

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Delay to diagnosis and surgical intervention may result in bowel ischemia.

Introduction

Adult midgut volvulus is a rare surgical disease but remains an important cause of small bowel obstruction. It is most commonly secondary to postoperative adhesions. Primary cases may be due to congenital malformations.

Presentation of case

We report the case of an adult primary midgut volvulus in a 35-year-old Chinese male. Based on the clinical presentation and investigations, the patient was presumed to have acute appendicitis. An open appendectomy was performed. During the operation, the appendix appeared normal. Instead a jejunal volvulus was found secondary to extensive adhesions.

Discussion

The epidemiology, embryology and etiology of jejunal volvulus are highlighted. Clinical presentation includes acute colicky abdominal pain usually in the peri-umbilical or epigastric regions, with possible signs of small bowel obstruction. Radiologic diagnosis is confirmed with the ultrasonic ‘whirpool’ sign or via computed tomography (CT) scan. Early surgical intervention is necessary to avert bowel ischemia in the presence of a closed loop obstruction.

Conclusion

While rare, adult midgut volvulus has the potential for morbidity and mortality if not diagnosed early with intestinal ischaemia and related sequlae. Clinicians should consider this and if in doubt, perform an early contrast CT scan.