Duodenal volvulus in an elderly patient: A rare case report

A 77-year-old woman presented with acute onset of epigastric pain, nausea, and bilious vomiting. Previous surgeries included a hysterectomy for leiomyomas, an aortobifemoral bypass because of peripheral artery disease, and a laparoscopic cholecystectomy in the context of acute lithiasic cholecystitis. She had diabetes but was a non-smoker, no alcohol abuser, and had no cancer history. On clinical examination, she presented with a distended abdomen, diffuse abdominal tenderness, and audible succussion splash.

An ultrasound examination was conducted and identified marked luminal distension of the gastric chamber, associated with luminal distention of the duodenal arch, filled with liquid content; persistent peristaltic waves were also observed during the study (Figure 1). There was no evidence of abnormal distension of downstream small bowel loops.

For better characterisation of a possible proximal obstructive condition, the decision was made to obviate an abdominal radiography, so a straight contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis was performed. There was marked distension of the gastric chamber and the entire duodenal arch up to the 4th portion, where a point of abrupt transition of calibre is observed (Figures 2 and 3). A spiral aspect of the mesenteric vessels was observed (“whirlpool sign”), with inversion of the usual superior mesenteric vein/artery relationship, although their patency was maintained, and there was no evidence of local fat stranding (Figure 3). The findings were suggestive of proximal bowel volvulus occlusion. There were no unequivocal signs of hypoperfusion of the gastric, duodenal, or small bowel wall and no free fluid, intra-abdominal collections, or signs of pneumoperitoneum.

Background

Volvulus is a condition characterised by intestinal blockage due to a loop that wraps or rotates around itself and its mesentery, leading to a partial or complete occlusion of its lumen and vascular supply. There are three primary types of volvulus: sigmoid, cecal, and midgut, with sigmoid volvulus being the most frequent [1–3]. Here, we present a case of midgut volvulus. Small bowel volvulus is rare, but there are several predisposing factors, such as an abnormally mobile intestinal loop or fixed intestinal segments due to adhesions, which can cause rotation. It can occur at any age [1,3,4].

This condition specifically affects bowel segments that are mobile due to their mesentery. The duodenum, which is largely fixed in position, is typically not susceptible. The duodenojejunal junction, anchored by the ligament of Treitz, is typically fixed (L1 level). However, the duodenal bulb and the upper part of the second portion of the duodenum tend to descend with ageing [3]. We present a case of duodenal volvulus (DV).

Clinical Perspective

The clinical manifestation of a small bowel obstruction can vary depending on the extent of rotation and the degree of vascular compromise. Symptoms can range from mild abdominal distention to intense pain and ischemia. Diagnosis can be challenging as the symptoms are non-specific [2,3].

Imaging Perspective

Plain abdominal films may be diagnostic, but the imaging modality of choice is CT scanning. Abdominal radiographs may show gastric and proximal duodenal distention and air-fluid levels.

Ultrasound may contribute to and suggest the diagnosis with findings of rotation and dilatation of the duodenum and increased peristaltic motion (Figure 1). Additionally, vascular compression or obstruction and the presence of free fluid can indicate complications such as bowel perforation. Moreover, US may help to assess the position and relationship of the mesenteric vessels.

CT is the gold standard for diagnosing and evaluating its severity. It identifies the same findings as ultrasound but also a characteristic whirl-like pattern, with transposed mesenteric vessels in a circular pattern in the preaortic region [3]. It may also show signs of complications such as hypoperfusion of the gastric, duodenal, or small bowel wall, free fluid, intra-abdominal collections, or pneumoperitoneum.

Outcome

In this case, considering an elderly patient with significant comorbidities and decreased functional capacity, the initial management involved the placement of a nasogastric tube. A large volume of bile-stained fluid was drained for 3 days, resolving the symptoms. A radiograph obtained after 96 hours showed a non-distended stomach and no significant hydroaerial levels. The patient was discharged and remained well during follow-up.

If the patient had not responded to conservative management, surgical intervention would have been necessary. Treatment options in such a case would have included resection of nonviable segments, untwisting the duodenum and attaching it to the abdominal wall, or plication of the ligament of Treitz [1–3]. It is important to note that the patient’s previous surgeries were not related to the development of the current condition.