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Forensic imaging in an unusual postmortem case of sigmoid volvulus
Journal of Forensic Radiology and Imaging ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Contents lists available at ScienceDirect
Journal of Forensic Radiology and Imaging journal homepage: www.elsevier.com/locate/jofri
Case Report
Forensic imaging in an unusual postmortem case of sigmoid volvulus Rilana Baumeister n, Saskia Gauthier, Stephan A. Bolliger, Michael J. Thali, Steffen G. Ross University of Zurich, Institute of Forensic Medicine, Forensic Medicine and Imaging, Winterthurerstrasse 190/52, CH-8057 Zurich, Switzerland
art ic l e i nf o
a b s t r a c t
Article history: Received 20 March 2015 Received in revised form 27 April 2015 Accepted 16 May 2015
Sigmoid volvulus (SV) is the most common form of intestinal volvulus. It results from a twist at the base of the sigmoid mesentery. The twist causes obstruction of the large bowel and ischemia of the affected portion of the intestine, resulting in necrosis of the intestinal wall, acidosis and subsequent death. While clinical symptoms may vary, they usually include typical signs of a small bowel obstruction, such as nausea, vomiting, and constipation. Some cases of sigmoid volvulus can be more or less clinically silent. Typical radiologic signs of SV are the so-called split-wall sign, the coffee bean sign and the whirlpool sign. In this report, we present the diagnosis of SV in a deceased 52-year-old female, who presented none of the aforementioned clinical key symptoms, using post-mortem computed tomography (PMCT). PMCT examination showed the typical radiologic signs of SV. The findings from the cross-sectional imaging were validated with a traditional autopsy. & 2015 Elsevier Ltd. All rights reserved.
Keywords: Forensic radiology Post-mortem CT PMCT Sigmoid volvulus Split wall sign Virtopsy
1. Introduction Sigmoid volvulus (SV) is the third-leading cause of colon obstruction in adults, after cancer and diverticulitis [1,2], and is the most common form of volvulus in the gastrointestinal tract. The sigma is predisposed to obstruction because of its often redundant sigmoid loop that rotates around its own narrow and mostly elongated mesentery root. The mortality rate of SV ranges from 14% to 45% of patients [3,4]. Diagnosis is made by plain abdominal radiography or computed tomography scan. Magnetic resonance imaging is used to gather additional information if necessary. There is often a significant delay, of 3 to 4 days on average, between the onset and diagnosis of SV. The symptoms are similar to small bowel obstruction and can present as either acute or silent. Abdominal pain with vomiting, distension and obstipation is seen in less than one-third of cases. Complications of SV include perforation, peritonitis, hemorrhagic infarction, intestinal ischemia, septic shock and death [3]. 7Overall, SV occurs predominantly in males and it is more common in developing areas, such as Africa, India, the Middle East and Latin America, where it mostly affects younger patients, than in Western countries, where it predominantly affects the elderly [4]. Major predisposing factors to SV include a high-fiber diet resulting in an increased bulk of stool, elongation and dilatation of the colon [2], and chronic constipation and obtundation from n
Corresponding author. E-mail address: [email protected] (R. Baumeister).
medications (more common in the elderly) with gaseous distention. In addition, comorbidity of SV with psychiatric diseases and medications has been shown [3,5,6]. PMCT is widely used, but the postmortem CT findings of a SV are seldom reported. We report a case of SV in a post-mortem CT examination.
2. Case history We describe the case of a 52-year-old woman of Indian origin from England, who complained about mild gastric pain and flatulence two days before her sudden death. She was observed to be feeling well approximately a half-hour before her body was found lifeless on the bathroom floor. Cardiopulmonary resuscitation was unsuccessful. External inspection of the body showed a prominently bloated abdomen and an older periumbilical scar. We had no knowledge of the patient’s medical history. Because of the unknown cause of death, a medico-legal autopsy was ordered by the state attorney.
3. Materials and methods Prior to the autopsy, a whole-body post-mortem CT (PMCT) was performed using a dual-source CT scanner (Flash Definition, Siemens, Forchheim, Germany). The scan parameters for the torso were as follows: tube voltage 120 kVp; 400 ref mAs using an automatic dose modulation software (CARE dose 4D, Siemens,
http://dx.doi.org/10.1016/j.jofri.2015.05.003 2212-4780/& 2015 Elsevier Ltd. All rights reserved.
Please cite this article as: R. Baumeister, et al., Forensic imaging in an unusual postmortem case of sigmoid volvulus, Journal of Forensic Radiology and Imaging (2015), http://dx.doi.org/10.1016/j.jofri.2015.05.003i
2
R. Baumeister et al. / Journal of Forensic Radiology and Imaging ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Fig. 3. Axial PMCT at the level of the fifth lumbar vertebra. The split-wall sign was caused by apparent separation of sigmoid walls by adjacent mesenteric fat, secondary to incomplete twisting (arrows).
4. PMCT and autopsy findings
Fig. 1. Coronal volume rendering technique (VRT) of the abdomen using PMCT, showing a disproportionate enlargement of the colon in the shape of a coffee bean (asterisks).
The post-mortem CT revealed an unusual enlargement of the colon in the shape of a coffee bean (Fig. 1). Cross-sectional images showed maximal distension in the ascending to descending colon and the sigmoid colon, with a sudden caliber reduction, similar to mechanically caused ileus, in the lower left abdomen (Fig. 2a). As a result, the twisted “whirled” mesentery was found in the lower left abdomen (Fig. 2b). Secondary to incomplete twisting, the splitwall sign was caused by apparent separation of sigmoid walls from the adjacent mesenteric fat (Fig. 3). Although the colon was largely expanded, the PMCT did not reveal free intraperitoneal gas that would indicate a perforation. However, a low-density ascites was
Fig. 2. (a) Axial PMCT at the level of the fifth lumbar vertebra. Distended colon and sigmoid colon (asterisk) with sudden caliber reduction (arrows) in the lower left abdomen (bird’s beak sign is also seen in the left lower abdomen, asterisk and arrows). (b)Axial PMCT at the level of the fifth lumbar vertebra. Whirlpool sign shown by twisted sigmoid mesentery with vascularity in the lower left abdomen (curved arrow). In addition, a large uterus myomatosus was found (circle).
Forchheim, Germany); slice thickness 1.0 mm; increment 0.6 mm; image reconstruction with soft tissue and bone kernels. Image review was conducted using a PACS workstation (IDS 7, Sectra AB, Linköping, Sweden).
observed, indicating a sign of transmigration peritonitis. The autopsy confirmed the PMCT findings by showing a distinctly distended ascending to descending colon and a sigmoid of up to 15 cm in diameter (Fig. 4a), caused by a torsion in the
Please cite this article as: R. Baumeister, et al., Forensic imaging in an unusual postmortem case of sigmoid volvulus, Journal of Forensic Radiology and Imaging (2015), http://dx.doi.org/10.1016/j.jofri.2015.05.003i
R. Baumeister et al. / Journal of Forensic Radiology and Imaging ∎ (∎∎∎∎) ∎∎∎–∎∎∎
3
Fig. 4. (a) Autopsy specimen showing a distinct distended ascending to descending colon and sigmoid up to 15 cm in diameter (asterisk). (b) Autopsy specimen showing a torsion of the sigmoid colon (arrow).
sigmoid colon (Fig. 4b). The sigmoid colon up to the transverse colon was black and necrotic over a range of 60 cm, in the oral and rectal direction colon was normally colored. In addition, bloody intraperitoneal fluid with fibrinous filaments was found in the body, indicating transmigration peritonitis. An incidental finding during the autopsy was a benign tumor in the uterus (uterus myomatosus, Fig. 2b) that had a maximal diameter of 18 cm and may have additionally contributed to obstipation.
The literature also describes the so-called bird’s beak sign, which can be depict on Fig. 2a. Another sign that was not observed in this study is the X-marks-the-spot-sign, which is seen at complete volvulus when two transition points are oriented to the whirl sign in opposite directions [7].
Funding None.
5. Discussion References PMCT was used in the current case to diagnose sigmoid volvulus. The radiologic examination showed the three well-known characteristic signs of SV: 1. The split-wall sign caused by apparent separation of sigmoid walls from adjacent mesenteric fat, secondary to incomplete twisting. 2. The coffee bean sign with the distended ahaustral colon and sigmoid in an inverted U-shape. 3. The whirlpool sign, which is seen when structures twist around themselves. The sign is created when the sigmoid rotates around its mesentery and shows a swirling, whirlpoollike shape.
[1] M. Yigit, K.A. Turkdogan, Coffee bean sign, whirl sign and bird’s beak sign in the diagnosis of sigmoid volvulus, Pan Afr. Med. J. 19 (2014) 56 (accessed 18.02.15). [2] D. Feldman, The coffee bean sign 1, Radiology. 216 (2000) 178–179. [3] S.B. Osiro, D. Cunningham, M.M. Shoja, R.S. Tubbs, J. Gielecki, M. Loukas, The twisted colon: a review of sigmoid volvulus, Am. Surg. 78 (2012) 271–279. [4] T.E. Madiba, S.R. Thomson, The management of sigmoid volvulus, J. R. Coll. Surg. Edinb 45 (2000) 74–80. [5] C. Bruusgaard, Volvulus of the sigmoid colon and its treatment, Surgery 22 (1947) 466–478. [6] V. Raveenthiran, T.E. Madiba, S.S. Atamanalp, U. De, Volvulus of the sigmoid colon, Colorectal Dis. 12 (2010) e1–e17, http://dx.doi.org/10.1111/j.14631318.2010.02262.x. [7] J.M. Levsky, E.I. Den, R.A. DuBrow, E.L. Wolf, A.M. Rozenblit, CT findings of sigmoid volvulus, Am. J. Roentgenol. 194 (2010) 136–143, http://dx.doi.org/ 10.2214/AJR.09.2580.
Please cite this article as: R. Baumeister, et al., Forensic imaging in an unusual postmortem case of sigmoid volvulus, Journal of Forensic Radiology and Imaging (2015), http://dx.doi.org/10.1016/j.jofri.2015.05.003i
Contents lists available at ScienceDirect
Journal of Forensic Radiology and Imaging journal homepage: www.elsevier.com/locate/jofri
Case Report
Forensic imaging in an unusual postmortem case of sigmoid volvulus Rilana Baumeister n, Saskia Gauthier, Stephan A. Bolliger, Michael J. Thali, Steffen G. Ross University of Zurich, Institute of Forensic Medicine, Forensic Medicine and Imaging, Winterthurerstrasse 190/52, CH-8057 Zurich, Switzerland
art ic l e i nf o
a b s t r a c t
Article history: Received 20 March 2015 Received in revised form 27 April 2015 Accepted 16 May 2015
Sigmoid volvulus (SV) is the most common form of intestinal volvulus. It results from a twist at the base of the sigmoid mesentery. The twist causes obstruction of the large bowel and ischemia of the affected portion of the intestine, resulting in necrosis of the intestinal wall, acidosis and subsequent death. While clinical symptoms may vary, they usually include typical signs of a small bowel obstruction, such as nausea, vomiting, and constipation. Some cases of sigmoid volvulus can be more or less clinically silent. Typical radiologic signs of SV are the so-called split-wall sign, the coffee bean sign and the whirlpool sign. In this report, we present the diagnosis of SV in a deceased 52-year-old female, who presented none of the aforementioned clinical key symptoms, using post-mortem computed tomography (PMCT). PMCT examination showed the typical radiologic signs of SV. The findings from the cross-sectional imaging were validated with a traditional autopsy. & 2015 Elsevier Ltd. All rights reserved.
Keywords: Forensic radiology Post-mortem CT PMCT Sigmoid volvulus Split wall sign Virtopsy
1. Introduction Sigmoid volvulus (SV) is the third-leading cause of colon obstruction in adults, after cancer and diverticulitis [1,2], and is the most common form of volvulus in the gastrointestinal tract. The sigma is predisposed to obstruction because of its often redundant sigmoid loop that rotates around its own narrow and mostly elongated mesentery root. The mortality rate of SV ranges from 14% to 45% of patients [3,4]. Diagnosis is made by plain abdominal radiography or computed tomography scan. Magnetic resonance imaging is used to gather additional information if necessary. There is often a significant delay, of 3 to 4 days on average, between the onset and diagnosis of SV. The symptoms are similar to small bowel obstruction and can present as either acute or silent. Abdominal pain with vomiting, distension and obstipation is seen in less than one-third of cases. Complications of SV include perforation, peritonitis, hemorrhagic infarction, intestinal ischemia, septic shock and death [3]. 7Overall, SV occurs predominantly in males and it is more common in developing areas, such as Africa, India, the Middle East and Latin America, where it mostly affects younger patients, than in Western countries, where it predominantly affects the elderly [4]. Major predisposing factors to SV include a high-fiber diet resulting in an increased bulk of stool, elongation and dilatation of the colon [2], and chronic constipation and obtundation from n
Corresponding author. E-mail address: [email protected] (R. Baumeister).
medications (more common in the elderly) with gaseous distention. In addition, comorbidity of SV with psychiatric diseases and medications has been shown [3,5,6]. PMCT is widely used, but the postmortem CT findings of a SV are seldom reported. We report a case of SV in a post-mortem CT examination.
2. Case history We describe the case of a 52-year-old woman of Indian origin from England, who complained about mild gastric pain and flatulence two days before her sudden death. She was observed to be feeling well approximately a half-hour before her body was found lifeless on the bathroom floor. Cardiopulmonary resuscitation was unsuccessful. External inspection of the body showed a prominently bloated abdomen and an older periumbilical scar. We had no knowledge of the patient’s medical history. Because of the unknown cause of death, a medico-legal autopsy was ordered by the state attorney.
3. Materials and methods Prior to the autopsy, a whole-body post-mortem CT (PMCT) was performed using a dual-source CT scanner (Flash Definition, Siemens, Forchheim, Germany). The scan parameters for the torso were as follows: tube voltage 120 kVp; 400 ref mAs using an automatic dose modulation software (CARE dose 4D, Siemens,
http://dx.doi.org/10.1016/j.jofri.2015.05.003 2212-4780/& 2015 Elsevier Ltd. All rights reserved.
Please cite this article as: R. Baumeister, et al., Forensic imaging in an unusual postmortem case of sigmoid volvulus, Journal of Forensic Radiology and Imaging (2015), http://dx.doi.org/10.1016/j.jofri.2015.05.003i
2
R. Baumeister et al. / Journal of Forensic Radiology and Imaging ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Fig. 3. Axial PMCT at the level of the fifth lumbar vertebra. The split-wall sign was caused by apparent separation of sigmoid walls by adjacent mesenteric fat, secondary to incomplete twisting (arrows).
4. PMCT and autopsy findings
Fig. 1. Coronal volume rendering technique (VRT) of the abdomen using PMCT, showing a disproportionate enlargement of the colon in the shape of a coffee bean (asterisks).
The post-mortem CT revealed an unusual enlargement of the colon in the shape of a coffee bean (Fig. 1). Cross-sectional images showed maximal distension in the ascending to descending colon and the sigmoid colon, with a sudden caliber reduction, similar to mechanically caused ileus, in the lower left abdomen (Fig. 2a). As a result, the twisted “whirled” mesentery was found in the lower left abdomen (Fig. 2b). Secondary to incomplete twisting, the splitwall sign was caused by apparent separation of sigmoid walls from the adjacent mesenteric fat (Fig. 3). Although the colon was largely expanded, the PMCT did not reveal free intraperitoneal gas that would indicate a perforation. However, a low-density ascites was
Fig. 2. (a) Axial PMCT at the level of the fifth lumbar vertebra. Distended colon and sigmoid colon (asterisk) with sudden caliber reduction (arrows) in the lower left abdomen (bird’s beak sign is also seen in the left lower abdomen, asterisk and arrows). (b)Axial PMCT at the level of the fifth lumbar vertebra. Whirlpool sign shown by twisted sigmoid mesentery with vascularity in the lower left abdomen (curved arrow). In addition, a large uterus myomatosus was found (circle).
Forchheim, Germany); slice thickness 1.0 mm; increment 0.6 mm; image reconstruction with soft tissue and bone kernels. Image review was conducted using a PACS workstation (IDS 7, Sectra AB, Linköping, Sweden).
observed, indicating a sign of transmigration peritonitis. The autopsy confirmed the PMCT findings by showing a distinctly distended ascending to descending colon and a sigmoid of up to 15 cm in diameter (Fig. 4a), caused by a torsion in the
Please cite this article as: R. Baumeister, et al., Forensic imaging in an unusual postmortem case of sigmoid volvulus, Journal of Forensic Radiology and Imaging (2015), http://dx.doi.org/10.1016/j.jofri.2015.05.003i
R. Baumeister et al. / Journal of Forensic Radiology and Imaging ∎ (∎∎∎∎) ∎∎∎–∎∎∎
3
Fig. 4. (a) Autopsy specimen showing a distinct distended ascending to descending colon and sigmoid up to 15 cm in diameter (asterisk). (b) Autopsy specimen showing a torsion of the sigmoid colon (arrow).
sigmoid colon (Fig. 4b). The sigmoid colon up to the transverse colon was black and necrotic over a range of 60 cm, in the oral and rectal direction colon was normally colored. In addition, bloody intraperitoneal fluid with fibrinous filaments was found in the body, indicating transmigration peritonitis. An incidental finding during the autopsy was a benign tumor in the uterus (uterus myomatosus, Fig. 2b) that had a maximal diameter of 18 cm and may have additionally contributed to obstipation.
The literature also describes the so-called bird’s beak sign, which can be depict on Fig. 2a. Another sign that was not observed in this study is the X-marks-the-spot-sign, which is seen at complete volvulus when two transition points are oriented to the whirl sign in opposite directions [7].
Funding None.
5. Discussion References PMCT was used in the current case to diagnose sigmoid volvulus. The radiologic examination showed the three well-known characteristic signs of SV: 1. The split-wall sign caused by apparent separation of sigmoid walls from adjacent mesenteric fat, secondary to incomplete twisting. 2. The coffee bean sign with the distended ahaustral colon and sigmoid in an inverted U-shape. 3. The whirlpool sign, which is seen when structures twist around themselves. The sign is created when the sigmoid rotates around its mesentery and shows a swirling, whirlpoollike shape.
[1] M. Yigit, K.A. Turkdogan, Coffee bean sign, whirl sign and bird’s beak sign in the diagnosis of sigmoid volvulus, Pan Afr. Med. J. 19 (2014) 56 (accessed 18.02.15). [2] D. Feldman, The coffee bean sign 1, Radiology. 216 (2000) 178–179. [3] S.B. Osiro, D. Cunningham, M.M. Shoja, R.S. Tubbs, J. Gielecki, M. Loukas, The twisted colon: a review of sigmoid volvulus, Am. Surg. 78 (2012) 271–279. [4] T.E. Madiba, S.R. Thomson, The management of sigmoid volvulus, J. R. Coll. Surg. Edinb 45 (2000) 74–80. [5] C. Bruusgaard, Volvulus of the sigmoid colon and its treatment, Surgery 22 (1947) 466–478. [6] V. Raveenthiran, T.E. Madiba, S.S. Atamanalp, U. De, Volvulus of the sigmoid colon, Colorectal Dis. 12 (2010) e1–e17, http://dx.doi.org/10.1111/j.14631318.2010.02262.x. [7] J.M. Levsky, E.I. Den, R.A. DuBrow, E.L. Wolf, A.M. Rozenblit, CT findings of sigmoid volvulus, Am. J. Roentgenol. 194 (2010) 136–143, http://dx.doi.org/ 10.2214/AJR.09.2580.
Please cite this article as: R. Baumeister, et al., Forensic imaging in an unusual postmortem case of sigmoid volvulus, Journal of Forensic Radiology and Imaging (2015), http://dx.doi.org/10.1016/j.jofri.2015.05.003i