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ABDOMINAL Table of Contents   
Year : 2006  |  Volume : 16  |  Issue : 1  |  Page : 83-84
Images: CT whirl sign - midgut volvulus


Department of Radiodiagnosis and Pediatric Surgery, Pt. B.D. Sharma PGIMS, Rohtak - 124001 Haryana, India

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Keywords: CT whirl sign, Volvulus

How to cite this article:
Magu S, Ratan K N, Agrawal K. Images: CT whirl sign - midgut volvulus. Indian J Radiol Imaging 2006;16:83-4

How to cite this URL:
Magu S, Ratan K N, Agrawal K. Images: CT whirl sign - midgut volvulus. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Jul 24];16:83-4. Available from: http://www.ijri.org/text.asp?2006/16/1/83/29055

   Introduction Top


Midgut malrotation has been estimated to occur in approximately one in 500 live birth [1],[2]. Reportedly 64-80% of these patients present within the first month of life, but these figures generally do not take into account those who remain undiagnosed after childhood [1],[2]. Midgut volvulus is a complication of malrotation in which clockwise twisting of the bowel around the superior mesenteric artery (SMA) axis occurs because of the narrowed mesenteric attachment [3]. The CT whirl or whirlpool sign describes the swirling appearance of bowel and mesentery twisted around the SMA axis [4].

A 13 year old male presented with pain abdomen for 3 days, vomiting (bilious in nature) for 3 days, non-passage of stools and flatus for 3 days. An ultrasound done showed dilated gut loops with "whirlpool sign" in the mesenteric vessels suggestive of malrotation with volvulus. Stomach was grossly distended. CT done [Figure - 1][Figure 2][Figure 3] demonstrated characteristic clockwise twisting of bowel (three and half turns), mesentery and superior mesenteric vein around the axis of superior mesenteric artery. No bowel resection was necessary at surgery that promptly followed imaging. Associated band of Ladd was also found.


   Discussion Top


Congenital malrotation of the midgut often presents within the first month of life. Pediatric radiologists are, therefore, consciously attuned to this malady and its associated imaging features. The overall incidence of malrotation, however, is unknown because some patients will present years later or remain asymptomatic for life [4]. The radiologist may encounter this important diagnosis in several different clinical settings such as an incidental imaging finding, the cause of acute abdominal symptoms, or a condition associated with abdominal situs abnormalities.

Many cases of quiescent malrotation in adults are currently being detected on cross sectional imaging (particularly CT) performed for various unrelated reasons [5]. In most patients with quiescent malrotation, the SMA and superior mesenteric vein (SMV) will assume a vertical relationship or show left right inversion [5].

Midgut volvulus is a complication of malrotation in which clockwise twisting of the bowel around the SMA axis occurs because of the narrowed mesenteric attachment [3]. Recurrent epsodes of colicky abdominal pain, with vomiting over a period of months or years are typical and may eventually lead to imaging [5]. The CT whirl or whirpool sign describes the swirling appearance of bowel and mesentery twisted around the SMA axis [4]. Low attenuating fatty mesentery with enhancing engorged vessels radiate from the twisted bowel. In the central eye of the whirl, a soft tissue density pinpoints the source of the twist [6]. Additional CT findings include duodenal obstruction, congestion of the mesenteric vasculature, and evidence of underlying malrotation [3].

Recognition of the CT signs of volvulus is critical because the findings at clinical examination are often vague and because CT is usually the imaging technique of choice for patients presenting with acute abdominal pain [7]. Furthermore diagnosis may be difficult: the images on the patient's abdominal radiographs could be obscured if the closed loop is filled with fluid, oriented in an anteroposterior plane, or overlain by loops of air - distended bowel [8]. CT reveals the presence and location of the volvulus and gives the added benefit of allowing early identification of potentially fatal complications, such as ischemia and perforation [9].

 
   References Top

1.Torres AM, Ziegler MM. Malrotation of the intestine. World J Surg 1993;17:326-31.  Back to cited text no. 1  [PUBMED]  
2.Maxon RT, Franklin PA, Wagner CW. Malrotation in the older child: surgical management, treatment, and outcome. Am Surg 1995;61:135-8.  Back to cited text no. 2    
3.Pickhardt PJ, Bhalla S. Intestinal malrotation in adolescents and adults: spectrum of clinical and imaging features. AJR 2002;179:1429-35.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Bernstein SM, Russ PD. Midgut volvulus: a rare cause of acute abdomen in an adult patient. AJR 1998;171:679-41.  Back to cited text no. 4  [PUBMED]  
5.Zissin R, Rathaus V, Oscadchy A, et al. Intestinal malrotation as an incidental finding on CT in adults. Abdom Imag 1999;24:550-55.  Back to cited text no. 5    
6.Frank AJ, Goffner LB, Fruauff AA, Losada RA, Cecal volvulus: the CT whirl sign. Abdom Imag 1993;18:288-9.  Back to cited text no. 6    
7.Perter RS, Kunberger LE. Cecal volvulus. AJR 1998;171:860.  Back to cited text no. 7    
8.Catalano O. Computed tomographic appearance of sigmoid volvulus. Abdom Imag 1996;21:314-7.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Moore CJ. Corl FM, Fishman EK. CT of cecal volvulus: Unraveling the image. AJR 2001;177:95-8.  Back to cited text no. 9    

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Correspondence Address:
S Magu
22/8FM, Medical Enclave, Pt. B.D. Sharma PGIMS, Rohtak - 124001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.29055

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