- Email: [email protected]
The Whirl Sign and Small Intestinal Volvulus
The Whirl Sign and Small Intestinal Volvulus
A
2-year-old girl presented with a 4-day history of persistent abdominal pain, localized to the periumbilical region and associated with vomiting. Her medical history included successful intestinal resection and primary anastomosis for necrotized enterocolitis at 15 days of age. Physical examination showed normal vital signs and mild upper abdominal tenderness without rebound. Abdominal radiography showed incomplete small intestinal obstruction. Ultrasonography revealed a corkscrew-like mass in the upper abdomen and a whirlpool-flow pattern of the superior mesenteric vein circling the superior mesenteric artery. Abdominal computed tomography demonstrated small intestinal and mesenteric pedicle twisting, with the superior mesenteric artery encircled by the superior mesenteric vein in a counter-clockwise rotation (Figures 1-4; Figures 2-4 available at www.jpeds.com), creating the whirl sign. Laparotomy confirmed small intestinal volvulus, in a counter-clockwise rotation around the mesenteric root
due to intestinal adhesion. Adhesion lysis and intestinal reduction were performed; the postoperative course was uneventful. Diagnosis of small intestinal volvulus is difficult because symptoms, signs, laboratory investigations, and plain radiography findings are nonspecific. Computed tomography is preferred. The key radiological feature indicating intestinal volvulus is the whirl sign, which occurs when bowel loops rotate around a fixed point of obstruction.1 The whirl sign appears as a soft-tissue mass with an internal architecture of swirling strands of soft tissue and fat attenuation.2 The affected mesenteric vessels are typically at a different anatomic level because a closed loop obstruction is “pinched off” at the constriction site.2 The whirl sign is important in assessing treatment options for patients with clinical and radiologic signs of small intestinal obstruction. Patients with the whirl sign are more likely to have small intestinal obstruction necessitating surgery.3 n Tianyou Yang, MD Jiahao Li, MD Jiliang Yang, MD Jing Pan, MD Mingjie Zhang, MD Yan Zou, MD Department of Pediatric Surgery Guangzhou Women and Children’s Medical Center Affiliated Women and Children’s Medical Center of Guangzhou Medical University Guangzhou, China
References
Figure 1. Twisting loops of intestine in a whirl-like pattern (arrow).
1. Fisher JK. Computed tomographic diagnosis of volvulus in intestinal malrotation. Radiology 1981;140:145-6. 2. Khurana B. The whirl sign. Radiology 2003;226:69-70. 3. Duda JB, Bhatt S, Dogra VS. Utility of CT whirl sign in guiding management of small-bowel obstruction. Am J Roentgenol 2008; 191:743-7.
J Pediatr 2016;173:265. 0022-3476/$ - see front matter. ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2016.02.041
265
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Volume 173
Figure 2. Twisting of the mesenteric pedicles.
Figure 4. The superior mesenteric artery whirling 3 circles in the counter-clockwise pattern.
Figure 3. The superior mesenteric vein (long arrow) circling the mesenteric artery (short arrow). 265.e1
Yang et al
A
2-year-old girl presented with a 4-day history of persistent abdominal pain, localized to the periumbilical region and associated with vomiting. Her medical history included successful intestinal resection and primary anastomosis for necrotized enterocolitis at 15 days of age. Physical examination showed normal vital signs and mild upper abdominal tenderness without rebound. Abdominal radiography showed incomplete small intestinal obstruction. Ultrasonography revealed a corkscrew-like mass in the upper abdomen and a whirlpool-flow pattern of the superior mesenteric vein circling the superior mesenteric artery. Abdominal computed tomography demonstrated small intestinal and mesenteric pedicle twisting, with the superior mesenteric artery encircled by the superior mesenteric vein in a counter-clockwise rotation (Figures 1-4; Figures 2-4 available at www.jpeds.com), creating the whirl sign. Laparotomy confirmed small intestinal volvulus, in a counter-clockwise rotation around the mesenteric root
due to intestinal adhesion. Adhesion lysis and intestinal reduction were performed; the postoperative course was uneventful. Diagnosis of small intestinal volvulus is difficult because symptoms, signs, laboratory investigations, and plain radiography findings are nonspecific. Computed tomography is preferred. The key radiological feature indicating intestinal volvulus is the whirl sign, which occurs when bowel loops rotate around a fixed point of obstruction.1 The whirl sign appears as a soft-tissue mass with an internal architecture of swirling strands of soft tissue and fat attenuation.2 The affected mesenteric vessels are typically at a different anatomic level because a closed loop obstruction is “pinched off” at the constriction site.2 The whirl sign is important in assessing treatment options for patients with clinical and radiologic signs of small intestinal obstruction. Patients with the whirl sign are more likely to have small intestinal obstruction necessitating surgery.3 n Tianyou Yang, MD Jiahao Li, MD Jiliang Yang, MD Jing Pan, MD Mingjie Zhang, MD Yan Zou, MD Department of Pediatric Surgery Guangzhou Women and Children’s Medical Center Affiliated Women and Children’s Medical Center of Guangzhou Medical University Guangzhou, China
References
Figure 1. Twisting loops of intestine in a whirl-like pattern (arrow).
1. Fisher JK. Computed tomographic diagnosis of volvulus in intestinal malrotation. Radiology 1981;140:145-6. 2. Khurana B. The whirl sign. Radiology 2003;226:69-70. 3. Duda JB, Bhatt S, Dogra VS. Utility of CT whirl sign in guiding management of small-bowel obstruction. Am J Roentgenol 2008; 191:743-7.
J Pediatr 2016;173:265. 0022-3476/$ - see front matter. ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2016.02.041
265
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Volume 173
Figure 2. Twisting of the mesenteric pedicles.
Figure 4. The superior mesenteric artery whirling 3 circles in the counter-clockwise pattern.
Figure 3. The superior mesenteric vein (long arrow) circling the mesenteric artery (short arrow). 265.e1
Yang et al