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Case of the Month

By Dr Francis Lau Sing Lee, MBBS (Mal), M Med (Radiology) [UKM], FRCR, AM (Mal)

Answer to Case Of the Month 

Findings 

Plain abdominal radiograph showed mild dilatation of loops of bowel in the abdomen. 

CT Scan
The CT scan images shows a segment of dilated fluid filled loop of bowel with thickened wall in the right iliac fossa extending into the pelvis. No air was noted in the bowel wall or portal veins.

Operative Findings
At laparotomy, volvulus of the small bowel due to a band, probably congenital was found.

 

The congenital band causing the volvulus is at the tip of the forceps

The loop of bowel after release of the band

The resected gangrenous segment of the small bowel

Progress
The post operative recovery was uneventful and the patient was well on discharge.

 

Discussion 
Accurate, early diagnosis of volvulus can be sometimes difficult. Plain films are less sensitive, less specific and findings on plain films may not be confirmatory in 20-52% of cases. The role of CT is increasing in evaluating patients with suspected small bowel obstruction. CT is a highly accurate method in the evaluation of intestinal obstruction especially for determining the level and cause of obstruction and should be the technique of choice when clinical or plain radiographic findings are equivocal.

Small bowel volvulus is usually secondary to conditions such as malrotation, congenital bands, postoperative adhesions, and internal hernias. Primary small bowel volvulus in the adult is a rare, life-threatening emergency and its recognition is paramount. Preoperative diagnosis is difficult, because clinical examinations and plain films are of limited diagnostic value.

CT signs of volvulus are: U-shaped configuration or radial distribution of distended and fluid-filled loops of the small bowel converging toward the point of torsion, tightly twisted mesentery around the point of torsion (whirl sign), fusiform tapering loop (triangular sign in the cross section or beak sign in the longitudinal section), and signs of bowel ischemia or infarct such as attached mesenteric fluid and blurred mesenteric folds. CT enables us to diagnose not only small bowel volvulus but also bowel ischemia or infarct.
 
About the Author 
Dr Francis Lau is currently attached to the Island Hospital, Penang as a Radiologist.

We wish to thank surgeon, Mr T.J Wong for the photos of the operative findings.

 

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Last Updated:
Tuesday, 04 January, 2005