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Year : 2001  |  Volume : 11  |  Issue : 4  |  Page : 205-206
Image : Whirlpool sign-midgut volvulus (An US diagnosis)


Department of Radiology and Paediatric Surgery, Pt. B.D. Sharma PGIMS, Rohtak, India

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Keywords: Whirlpool sign, volvulus

How to cite this article:
Magu S, Rattan K N, Sharma N. Image : Whirlpool sign-midgut volvulus (An US diagnosis). Indian J Radiol Imaging 2001;11:205-6

How to cite this URL:
Magu S, Rattan K N, Sharma N. Image : Whirlpool sign-midgut volvulus (An US diagnosis). Indian J Radiol Imaging [serial online] 2001 [cited 2019 Nov 22];11:205-6. Available from: http://www.ijri.org/text.asp?2001/11/4/205/28403

   Introduction Top


Midgut Volvulus is an abdominal surgical emergency occurring mainly in the neonatal period but sometimes presenting late [1] .

It is a potential complication of midgut malrotation that can be either nonrotation or an incomplete rotation of the primitive intestinal loop during the fetal life [2] . Midgut volvulus is usually secondary to a clockwise rotation around the axis of the superior mesenteric artery. Volvulus due to midgut malrotation can be detected by "whirlpool" US sign [3] .

A two-and-a-half month old boy presented with distension of the abdomen, bilious vomiting and a clinical diagnosis of intestinal obstruction. Plain radiographs done showed no abnormality. US transverse section at the level of SMA showed SMV coiled around the SMA in clockwise rotation - "whirlpool sign" [Figure - 1] along with a heterogeneous tumor mass surrounding the SMA - mesentery and gut.

An upper GI study showed a cork-screw (pig tail) appearance of the duodenum and jejunum, with obstruction at the distal duodenum, with proximal dilatation and displacement of duodeno-jejunal junction [Figure - 2].

A diagnosis of midgut mal-rotation associated with volvulus was made and confirmed on surgery.


   Discussion Top


Abnormal orientation of superior mesenteric vessels has been reported with intestinal malrotation with the superior mesenteric vein (SMV) immediately ventral or to the left of the superior mesenteric artery (SMA) [4],[5],[6],[7],[8] . Weinberger et al conducted a study of 343 infants suspected for pyloric stenosis where they sonographically assessed the position of SMA and SMV [9] . They observed abnormality of SMA and SMV in nine infants. In five of the infants, SMV was located to the left of the artery and all five had intestinal malrotation. In four, SMV was directly ventral to the artery and one of these had malrotation. They concluded that sonographic assessment of relative positions of the mesenteric artery and vein is an important adjunct in the examination of infants with pyloric stenosis. Patients in whom sonograms show an abnormal position of the vessels should have further examination to detect malrotation.

Midgut malrotation is a potentially lethal condition usually presenting as small bowel obstruction in the neonate. Occasionally the presentation is atypical or the conventional barium examination difficult to interpret [6] . The typical findings are:

  • A duodeno-jejunal flexure in an abnormal position (usually to the right of the midline but occasionally just to the left)
  • Obstruction of the second or third part of the duodenum by the Ladd's bands
  • A small bowel volvulus if present
  • The small bowel lying entirely on the right side of the abdomen and
  • An abnormally positioned caecum [4].
An upper gastro-intestinal series may confirm the diagnosis of volvulus showing a pigtail aspect of the distal duodenum and proximal jejunum [3] . The US diagnosis of dilated duodenum is not a specific sign of midgut volvulus and may be absent in a vomiting patient [10] . Pracros et al have suggested that volvulus due to midgut malrotation can be detected by the "whirlpool" US sign [3] . The sign appeared specific for midgut volvulus since it was not observed in other complications of midgut malrotation, such as isolated Ladd's bands [3] . The sonographic "whirlpool" pattern of the superior mesenteric vein and mesentery around the superior mesenteric artery was detected in 15 of the 18 patients with midgut volvulus, and was best seen using Color Doppler [3]

The normal anatomical position of the SMV is on the right side of the SMA, but sometimes also in front. In order to appreciate completely the respective position of the SMV and the SMA, superior mesenteric vessels must be studied by US as caudally as possible. When the SMV is located on the left side of SMA, intestinal malrotation is frequently associated with complete absence of embryological rotation of the primitive intestinal loop (non rotation) [3] . The mal-position of SMV and SMA is not only specific of midgut malrotation, but can also be included by tumors or tumor like lesions [4]

 
   References Top

1.Spigland N, Brandt ML, Yazbeck S. Malrotation presenting beyond the neonatal period. J Pediatr Surg 1990; 25: 1139   Back to cited text no. 1    
2.Bill AH. Malrotation of the intestine. In: Rivitch MM (ed) Pediatric Surg, 3rd ed. Vol 2. Year Book Medical, 912-913   Back to cited text no. 2    
3.Pracros JP, Sann L, Genin G, et al. Ultrasound diagnosis of midgut volvulus: the "whirlpool" sign. Pediatr Radiol 1992; 22: 18-20  Back to cited text no. 3    
4.Gaines PA, Saunders AJ, Drake D. Midgut malrotation diagnosed by ultrasound. Clin Radiol 1987; 38: 51-53   Back to cited text no. 4    
5.Loyer E, Eggli KD. Sonographic evaluation of superior mesenteric vascular relationship in malrotation. Pediatr Radiol 1989; 19: 173-175   Back to cited text no. 5    
6.Nichols DM, Li DK. Superior mesenteric vein rotation: a CT sign of midgut malrotation. AJR 1983; 141: 707-708   Back to cited text no. 6    
7.Shatzkes D, Gordon DH, Haller JO, Kantor A, DeSilva R. Malrotation of the bowel: malalignment of the superior mesenteric artery - vein complex by CT and MR. J Comput Assist Tomogr 1990; 14: 93-95.   Back to cited text no. 7    
8.Zerin JM, Dipietro MA. Mesenteric vascular anatomy at CT: normal and abnormal appearances. Radiology 1991; 179: 739-742   Back to cited text no. 8    
9.Weinberger ED, Winters WD, Liddell RM, Rosenbaum DM, Krauter D. Sonographic diagnosis of intestinal malrotation in infants: importance of the relative positions of the superior mesenteric vein and artery. AJR 1992; 159: 825-828.  Back to cited text no. 9    
10.Hayden CK, Boulden TF, Swischuk LE, Lobe TE. Sonographic diagnosis of duodenal obstruction with midgut volvulus. AJR 1984; 143:9  Back to cited text no. 10    

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Correspondence Address:
S Magu
22/8 FM, Medical Campus, Rohtak 124001
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2]

This article has been cited by
1 Signs: "Whirlpool Sign" in midgut volvulus
Taori, K.B., Mahajan, S., Dhomne, S., Manikpure, S.
Indian Journal of Radiology and Imaging. 2004; 14(2): 189-190
[Pubmed]



 

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