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Lepage Saucier2010 2
Lepage Saucier2010 2
Review
Small and large bowel volvulus: Clues to early recognition and complications
Marianne Lepage-Saucier, An Tangÿ, Jean-Sébastien Billiard,
Jessica Murphy-Lavallee, Luigi Lepanto
Department of Radiology, Saint-Luc Hospital, Montreal University Hospital Center (CHUM), 1058 rue
Saint-Denis, Montreal, Quebec, Canada H2X 3J4
Article history: Small and large bowel volvulus are uncommon causes of bowel obstruction with nonspecific clinical
Received 27 July 2009 manifestations which may delay the diagnosis and increase morbidity. Therefore, radiologists play an
Received in revised form
important role in promptly establishing the diagnosis, recognizing underlying congenital or acquired risk
11 November 2009
factors and detecting potentially life-threatening complications. Multidetector CT performed with intravenous
Accepted 11 November 2009
contrast is currently the preferred modality for the evaluation of volvulus, which is best appreciated when
This paper was presented at RSNA 2008 meeting imaging is perpendicular to the axis of bowel rotation, hence the benefit of multiplanar reformations. In this
as an electronic education exhibit and was awarded a pictorial essay we review the pathophysiology of the different types of intestinal volvulus, discuss diagnostic
“Cum Laude Award”. It was listed as “LL-GI4942: Twist criteria for prompt diagnosis of volvulus and emphasize early recognition of the complications.
and Shout!
Pictorial Essay: Small and Large Bowel Crown Copyright © 2009 Published by Elsevier Ireland Ltd. All rights reserved.
Volvulus Clues to Early Recognition and
Complications.”
Keywords:
Midgut volvulus
Cecal volvulus
Sigmoid volvulus
ÿ Corresponding author. Tel.: +1 514 890 8000; fax: +1 514 412 7359.
Fluoroscopy may be used in children when malrotation is sus-pected and can
E-mail address: duotango@gmail.com (A. Tang). reveal a duodenojejunal junction located on midline
0720-048X/$ – see front matter. Crown Copyright © 2009 Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/
j.ejrad.2009.11.010
Machine Translated by Google
Fig. 3. Forty-five-year-old male with a normal anatomy. Axial contrast-enhanced CT image shows the
normal relationship between the superior mesenteric vein (SMV) (arrow) located anteriorly and to the right
of the superior mesenteric artery (SMA) (arrowhead).
Fig. 1. In small bowel volvulus, the torsion occurs around the dorsal mesentery (arrow).
Fig. 2. Fixed segments are represented in orange, transition segments in yellow and mobile segments at
risk of being involved in volvulus in red (asterisks).
Table 2
Summary of large bowel volvulus signs.
Fig. 5. Sixty-five-year-old woman with an asymptomatic malrotation. (a) Transverse US shows the SMA (arrowhead) on right side of the SMV (long arrow). (b) Duplex US image at the same level confirms the diagnosis.
Fig. 6. Fifty-year-old man with a distal small bowel volvulus caused by an adhesion from a previous partial gastrectomy for gastric cancer. (a) Axial contrast-enhanced CT image shows distended proximal small bowel loops, free
fluid between loops of small bowel (arrowhead) and transition point (long arrow). (b) Axial CT image shows beaking of the afferent (short arrow) and efferent (long arrow) small bowel loops. (c) Coronal MIP shows whirl sign of the
mesenteric vessels (arrow).
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or on the right side of the abdomen. A lowered ligament of Treitz can also around a fixed point of obstruction. The presence of any one of these three
be found. If a volvulus is present, the “corkscrew” sign has been described findings at CT revealed volvulus with a sensitivity of 94% and the presence
and if there are peritoneal bands, dilatation of proximal duodenum may be of all three signs had a specificity of 100% [8]
seen [6,7]. (Fig. 6).
Ultrasound can show small-bowel malrotation (Fig. 5). A whirl sign can The signs of small bowel volvulus are summarized in Table 1.
be found in the pediatric population if a volvulus is present, described as
wrapping of the superior mesenteric vein (SMV) and the mesentery around 4. Cecal volvulus
the superior mesenteric artery (SMA).
The following three signs were validated for the diagnosis of small bowel Three subtypes of cecal volvulus have been described, distin-guished
volvulus: multiple transition points, transition points located ÿ7 cm from the by the presence of cecal rotation along the longitudinal axis of the colon,
spine in the antero-posterior plane and a whirl sign: swirl extending ÿ180ÿ cecal folding to the center of the abdomen, or combination of both [9].
including both bowel and vessels
Fig. 7. Thirty-three-year-old woman with a cecal volvulus who presented with acute abdominal pain. (a) Standing AP radiograph shows distended cecum displaced to the center of the abdomen and pointing to the left upper quadrant
(arrow). (b) Axial contrast-enhanced CT image shows torsion of ileo-cecal vessels (arrowhead) and beaking of ascending colon (arrow). (c) Subsequent right hemicolectomy specimen revealed edema, ischemia and parietal hemorrhage
on 21 cm of cecum and ascending colon.
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Fig. 9. Seventy-six-year-old woman with a sigmoid volvulus. AP scout shows sig-moid distension
(arrowheads), with inverted “U” pointing toward right upper quadrant.
Fig. 8. Sixty-four-year-old woman with a cecal volvulus. Thick coronal contrast-enhanced MIP shows
«Barber-Pole» sign. SMA branches (arrowheads) rotate around the main SMV (long arrow).
5. Sigmoid volvulus
Fig. 11. Sixty-seven-year-old woman with a sigmoid volvulus who presented with severe abdominal pain. (a)
Axial contrast-enhanced CT image with rectal contrast shows beaking at transition point (arrow). (b) Antero-
posterior 3D volume rendering shows the markedly distended sigmoid volvulus loop (white arrows), the mildly
distended ascending colon (black arrows) and the small bowel loops clumped in the left flank (arrowheads).
Fig. 12. Seventy-five-year-old woman with recurrent sigmoid volvulus who was previously treated by
decompression colonoscopy. (a) Coronal contrast-enhanced CT image shows torsion of sigmoid vessels
(arrows) in a background of mesenteric fat (arrowheads). (b) Axial CT image shows the sigmoid proximal (arrow)
Treatment options vary according to the type of volvulus. If mal-rotation and and distal to the obstruction (arrowhead).
8. Conclusion
Conflict of interest
Acknowledgement
Fig. 13. Fifty-two-year-old man with a small bowel volvulus. Axial contrast-enhanced CT
image shows small bowel wall edema (arrowheads).
We acknowledge Mrs Mireille Bricault for producing the illus-
trations and Mr Éric Fournier for the 3D reconstructions.
Contribution: The manuscript provides a one-stop shop review
article for radiologists interested in the topic of midgut, cecal or sig-moid volvulus.
We summarized the pathophysiology, risk factors,
imaging findings, potential complications, treatment and progno-sis of each entity. A
thorough pictorial essay including diagrams,
radiographs, ultrasound, doppler, CT and surgical specimen was
included for educational purpose. We emphasized key imaging fea-tures revealed
by MDCT and multiplanar reformations to promptly
recognize the diagnosis and potentially life-threatening complica-tions.
References
[1] Federle MP, Jeffrey RB, Desser TS, Anne VS, Eraso A. Abdomen. Salt Lake City,
Utah: Amersys; 2004.
[2] Williams H. Green for danger! Intestinal malrotation and volvulus. Archives of
Disease in Childhood 2007;92(3):ep87–91.
[3] Breda R, Mathieu L, Mlynski A, Montagliani L, Duverger V. Cecal volvulus. Jour-nal de
chirurgie 2006;143(5):330–2.
[4] Lal SK, Morgenstern R, Vinjirayer EP, Matin A. Sigmoid volvulus an update.
Gastrointestinal Endoscopy Clinics of North America 2006;16(1):175–87.
[5] Matsumoto S, Mori H, Okino Y, Tomonari K, Yamada Y, Kiyosue H. Computed
Fig. 14. Forty-eight-year-old woman with a small bowel volvulus. Axial contrast-enhanced tomographic imaging of abdominal volvulus: pictorial essay. Canadian Associa-tion of
CT image shows poor enhancement of ischemic loops (arrowhead) Radiologists Journal (Journal l’Association canadienne des radiologistes)
contrasting with normal enhancement in adjacent loops (arrow). 2004;55(5):297–303.
[6] Leonidas JC, Magid N, Soberman N, Glass TS. Midgut volvulus in infants: diag-nosis
with US. Work in progress. Radiology 1991;179(2):491–3.
[7] Ortiz-Neira CL. The corkscrew sign: midgut volvulus. Radiology 2007;242(1):
315–6.
[8] Sandhu PS, Joe BN, Coakley FV, Qayyum A, Webb EM, Yeh BM. Bowel tran-sition
points: multiplicity and posterior location at CT are associated with
small-bowel volvulus. Radiology 2007;245(1):160–7.
[9] Delabrousse E, Sarlieve P, Sailley N, Aubry S, Kastler BA. Cecal volvulus:
CT findings and correlation with pathophysiology. Emergency Radiology
2007;14(6):411–5.
[10] Mindelzun RE, Stone JM. Volvulus of the splenic flexure: radiographic features.
Radiology 1991;181(1):221–3.
[11] Ingoe R, Lange P. The Ladd’s procedure for correction of intestinal malrotation
with volvulus in children. AORN Journal 2007;85(2):300–8, quiz 9-12.
[12] Inberg MV, Havia T, Davidsson L, Salo M. Acute intestinal volvulus. A report of
238 cases. Scandinavian Journal of Gastroenterology 1972;7(3):209–14.
[13] Rabinovici R, Simansky DA, Kaplan O,Mavor E,Manny J. Cecal volvulus. Diseases
of the Colon and Rectum 1990;33(9):765–9.
[14] Tejler G, Jiborn H. Volvulus of the cecum. Report of 26 cases and review of the
literature. Diseases of the Colon and Rectum 1988;31(6):445–9.
Fig. 15. Twenty-four-year-old woman with a cecal and ascending colon volvulus
who developed post-operative hemodynamic instability. Axial contrast-enhanced
CT image shows pneumatosis (arrowheads).