“Whirl” in the abdomen: Beware

Excerpt

This abdominal contrast-enhanced computed tomography (CECT) image of a 35-year-old gentleman with a 4-day history of abdominal pain shows the “whirl” sign characteristic of midgut volvulus (Fig. 1). Clinical examination was unremarkable except for tachycardia, and the abdomen was soft and nontender. There was no evidence of bowel wall ischemia, and flow in the mesenteric vessels was not compromised. A diagnosis of small bowel volvulus (midgut) should be suspected when pain is out of proportion to abdominal findings unlike pancreatitis and peritonitis where the abdomen is tender with or without guarding and rigidity. Other clinical features could include bilious vomiting, bloody diarrhea, chylous ascites, and malabsorption. If bowel wall ischemia and gangrene sets in, signs of peritonitis will be seen. Midgut volvulus is sometimes associated with Down’s syndrome, nonrotation or malrotation of midgut, cardiac and urogenital anomalies, diaphragmatic hernias, etc. Up to two-third of cases are reported in children less than 1 year of age with a slight male preponderance. As survival is inversely proportional to length of necrosed bowel, early recognition and intervention is important. This patient underwent Ladd’s procedure and had an uneventful recovery.

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