Whirlpool No More: A Case of Misdiagnosed Malrotation with Midgut Volvulus

Introduction: Adult intestinal malrotation with midgut volvulus is rare and most often diagnosed on abdominal imaging. Once the diagnosis is made, prompt surgical intervention is necessary. A finding suggestive of malrotation with midgut volvulus on abdominal imaging is the “whirlpool” sign where the superior mesenteric vein and superior mesenteric artery twist at the root of the abdominal mesentery. This sign was once thought to be pathognomonic, but recent studies have shown that it can be seen in asymptomatic patients. Case Report: A 20-year-old female presented to our emergency department with diffuse abdominal pain. Computed tomography demonstrated the “whirlpool” sign with a concern for malrotation with midgut volvulus. Surgical consultation was obtained and the patient was rushed to the operating room for an exploratory laparotomy. Normal mesenteric attachments were seen and no significant pathology was identified during the laparotomy. The patient was eventually diagnosed with gastritis and discharged in stable condition. Conclusion: Emergency physicians and surgeons alike should be cautious in confirming malrotation with midgut volvulus solely due to the “whirlpool” sign on abdominal imaging. Premature diagnostic closure can lead to unnecessary procedures and interventions for patients as in the case we report here.

Prenatal Sonographic Diagnosis and Clinical Management of Fetal Small Bowel Volvulus

Background The purpose of this research is to explore prenatal ultrasound features and clinical managements of fetal small bowel volvulus. At present, researchers mainly focus on the prenatal ultrasound features of fetal small bowel volvulus, and rarely summarize them in combination with the principles of clinical treatment. Methods 11 cases of fetal small bowel volvulus identified by prenatal ultrasound or neonatal surgery in our institution between January 2019 and January 2021 were included. General characteristics of pregnant women, features of prenatal ultrasound, clinical managements and prognosis of neonates were collected. Finally, prenatal ultrasound features and obstetric managements of fetal volvulus was summarized. Results At the first diagnosis, the whirlpool sign and intestinal dilatation were visualized in 11 cases. 3 cases underwent emergency caesarean because of the disappearance of dilated bowel peristalsis, massive ascites and fetal intrauterine hypoxia. The rest 8 cases were followed up by ultrasound, pregnancy outcomes were four regressed intrauterine spontaneously and delivered at term, two underwent emergency caesarean, one premature and one induced labor. 6 cases underwent neonatal surgery immediately after birth and received favorable outcomes.Conclusions Intestinal distention and the whirlpool sign are important ultrasonic features in the diagnosis of fetal small bowel volvulus. The disappearance of intestinal peristalsis of the volvulus segment, massive ascites and intrauterine hypoxia are the main basis for emergency prenatal clinical intervention.

Computed Tomography Appearance of the “Whirlpool Sign” in Ovarian Torsion

Case Presentation: A 28-year-old female presented to the emergency department complaining of right lower abdominal pain. A contrast-enhanced computed tomography (CT) was done, which showed a 15-centimeter right adnexal cyst with adjacent “whirlpool sign” concerning for right ovarian torsion. Transvaginal pelvic ultrasound (US) revealed a hemorrhagic cyst in the right adnexa, with duplex Doppler identifying arterial and venous flow in both ovaries. Laparoscopic surgery confirmed right ovarian torsion with an attached cystic mass, and a right salpingo-oophorectomy was performed given the mass was suspicious for malignancy. Discussion: Ultrasound is the test of choice for diagnosis of torsion due to its ability to evaluate anatomy and perfusion. When ovarian pathology is on the patient’s right, appendicitis is high in the differential diagnosis, and CT may be obtained first. Here we describe a case where CT first accurately diagnosed ovarian torsion by demonstrating the whirlpool sign, despite an US that showed arterial flow to the ovary. Future studies should determine whether CT alone is sufficient to diagnose or exclude ovarian torsion.

Intestinal malrotation with solitary jejunal diverticulum presenting as midgut volvulus in an adult: an unusual presentation

Intestinal malrotation with midgut volvulus presenting in adults is a rare entity, and association with jejunal diverticulum is rarer still. Herein, we report and review such a case of malrotation and volvulus, associated with intestinal band adhesions and a solitary jejunal diverticulum. This 67 years old gentleman had presented with complaints of intermittent abdominal pain for past several years. Imaging of the abdomen revealed twisting of superior mesenteric artery and vein, evidence of midgut volvulus and intestinal malrotation with “whirlpool sign”. Laparotomy revealed a midgut volvulus, extensive adhesions involving the root of the mesentery and a jejunal diverticulum. Adhesiolysis was performed, untwisting of the bowel was done and the jejunal diverticulum was resected. Post-operative period was uneventful. This case is being reported on account of its extreme rarity.

Right paraduodenal hernia accompanying superior mesenteric vein thrombosis: a rare case

A 59-year-old man with abdominal pain was admitted to the emergency department. Investigations had revealed a right-sided paraduodenal hernia and superior mesenteric vein (SMV) twisting around the superior mesenteric artery in rotation, the ‘whirlpool sign’. Owing to the increasing severity of abdominal pain and the presence of SMV thrombosis complicated with strangulated paraduodenal herniation associated with high mortality rates, diagnostic laparoscopy was performed. Resection of the intestines was not needed and paraduodenal hernia was repaired. The patient was uneventfully discharged.

Mesenteric Lymphatic Malformation Causing Midgut Volvulus in an Adult: An Unusual Presentation

Mesentery is an uncommon location for occurrence of lymphatic malformations. Lymphatic malformations causing midgut volvulus are described in pediatric population; however, it is a rare presentation in adults. We present case of 20-year-old man with a large mesenteric lymphatic malformation who presented with acute abdominal complaints. On radiological work up, the lymphatic malformation was seen causing midgut volvulus and closed loop small bowel obstruction with the presence of classical whirlpool sign. The patient underwent emergency surgery and the lymphatic malformation was completely excised along with resection of a segment of small bowel loop.