Teaching Case

Epigastric pain with nausea and vomiting. History of caesarean section and cystopexy. Nornal laboratory tests at admission. Elevated white blood cells count after 2 days.

The patient consulted the emergency department for epigastric pain with nausea and vomiting. Past medical history revealed a caesarean section and a cystopexy. Clinical examination showed a distended abdomen with diffuse discomfort. Peristalsis was present but poor. At admission, laboratory tests were normal. Plain films of the abdomen showed air-fluid levels of the small bowel and naso-gastric intubation was performed as the primary treatment. Twenty-four hours later, the general condition of the patient declined, with an increase in abdominal pain, a stop of bowel motility and appearance of signs of peritoneal irritation. Laboratory tests revealed only a white blood cell count at 19.000/mm3. A CT scan of the abdomen was performed with and without intravenous injection of contrast medium.

According to the etiology, volvulus of the small intestine can be differentiated in two types: primary volvulus in which there are no predisposing anatomic abnormalities, and secondary volvulus in which a congenital or acquired abnormality cause rotation of the bowel. Secondary volvulus of the small bowel is ordinarily observed in adults as a result of postoperative adhesions and it occurs when adhesions fix the intestine to a point that acts as a pivot. The key feature indicating a bowel volvulus is the presence of a whirl sign corresponding to the whirlpool arrangement of the mesentery and the mesenteric vessels around the site of torsion. Other CT signs of small bowel volvulus are a radial distribution or a U-shaped configuration of the distended bowel loops, a triangular section or a longitudinal tapering of the collapsed bowel loop at the site of torsion, and a segmental congestion of the mesenteric vessels. All these CT signs may also be observed in a closed-loop obstruction of the small bowel.