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BMJ Case Rep. 2010; 2010: bcr09.2009.2242.
Published online 2010 March 8. doi:  10.1136/bcr.09.2009.2242
PMCID: PMC3029403
Rare disease

A rare case of adult primary jejunal volvulus

Abstract

Jejunal volvulus is a rare and life threatening presentation of intestinal ischaemia. Clinical features, laboratory investigations and plain abdominal films are non-specific and so computed tomography (CT) scanning is useful in reaching a timely diagnosis. Rapid recourse to surgical intervention is typical and life saving. We report a rare case of primary jejunal volvulus which, after diagnosis on emergency CT scanning, was successfully treated by laparotomy and resection of infarcted bowel.

Background

We present a case of primary adult jejunal volvulus, a rare cause of small bowel obstruction. The case is illustrated by CT images, showing characteristic signs of a volvulus and secondary ischaemia. Timely imaging with CT led to swift progression from diagnosis to surgical intervention. This case supports the recommendation of having a low threshold for using CT as the modality of choice when disproportionate abdominal pain raises suspicion of bowel ischaemia. Early surgical intervention improves outcome significantly by reducing the high mortality rate associated with infarcted bowel.

Case presentation

An 82-year-old man presented to the emergency department with a 1 day history of sudden onset, severe, constant left iliac fossa pain and nausea, but no vomiting. Bowels were opened as normal with no blood per rectum. While there was no surgical history, his past medical history included hypertension, paroxysmal tachycardia, prostate cancer and gout. His medication included aspirin, enalapril, amlodipine, and goserelin injections.

On presentation the patient was obtunded and in severe distress. He was tachycardic with a respiratory rate of 28 breaths/min, but no fever. The abdomen was maximally tender in the left iliac fossa with guarding and rebound tenderness, consistent with peritonitis. Rectal examination was unremarkable.

Investigations

His electrocardiogram (ECG) showed sinus tachycardia and his full blood count revealed a raised white cell count. An abdominal x-ray showed large bowel faecal loading (fig 1) and an erect chest x-ray showed no pneumoperitoneum. Since the severity of pain was out of proportion to initial investigation findings, an urgent CT scan was performed which showed multiple dilated jejunal loops, thickening of small bowel mesentery, and changes suggestive of secondary ischaemia (figs 2 and and3)—all3)—all consistent with a jejunal volvulus.

Figure 1
Abdominal x-ray showing large bowel faecal loading.
Figure 2
Transverse computed tomography (CT) scan image demonstrating dilated loops of jejunum with crowding of mesenteric vessel suggesting volvulus.
Figure 3
Coronal CT scan image demonstrating dilated loops of jejunum with crowding of mesenteric vessel suggesting volvulus.

Differential diagnosis

  • Diverticulitis
  • Bowel perforation
  • Ischaemic bowel
  • Constipation
  • Volvulus
  • Bowel obstruction.

Treatment

The patient underwent emergency laparotomy during which 180 cm of infarcted small bowel 260 cm from the duodenojejunal flexure was resected. Subsequent histology showed full thickness haemorrhage and necrosis of the resected segment consistent with infarction due to volvulus.

Outcome and follow-up

After an uneventful recovery the patient was discharged with no complications on subsequent follow-up.

Discussion

Small bowel volvulus is a rare cause of small bowel obstruction which requires rapid diagnosis and surgical intervention. Volvulus occurs when a loop of bowel twists on the axis of its own mesentery. This can then result in mechanical obstruction with or without mesenteric ischaemia and thence gangrene. The consequences can be fatal: in the elderly mortality from ischaemic necrosis can be as high as 90%.1 In the West incidence is rare; 1.5 to 5.7/1000001 with secondary volvulus accounting for 70–90% of these cases. In Africa and Asia the incidence is higher at 24 to 60/1000002 and primary volvulus accounts for most cases. Our case of a primary adult jejunal volvulus in the West is thus rare and very few published reports were found in our literature search.

Aetiology can be primary or secondary. It is thought that primary volvulus is due to a bulky food bolus in the proximal jejunum pulling the loop down, shifting other empty parts of small bowel upwards and causing the mesentery to twist. Secondary volvulus is caused by peristalsis through an obstructed bowel loop secondary to a predisposing state.

Small bowel volvulus can be difficult to diagnose because the clinical signs are those of obstruction and peritonism and, as such, are non-specific. Laboratory investigations such a leucocytosis, raised amylase, raised lactate dehydrogenase and metabolic acidosis all suggest the diagnosis, but again, are non-specific. Plain abdominal film can show dilated small bowel but will not distinguish viable from non-viable bowel, nor identify volvulus as a cause. Other imaging options such as barium studies and angiography may be more helpful. Barium studies can show the ‘corkscrew’ appearance of volvulus and angiograms the ‘barber pole’ sign from spiralling branches of twisted superior mesenteric artery. However, these modalities do not allow rapid diagnosis.

CT scanning is a widely available non-invasive mode of imaging with good diagnostic ability. The most specific sign present in 75% of small bowel volvuli is the ‘whirl’ sign, which is due to the twisting of mesentery round a point of torsion, although it is only visible when the mesenteric axis is parallel to the CT section.1 The ‘peacock tail’ sign is demonstrated when there is bowel torsion around its mesenteric axis. Both signs are diagnostic. A distended and fluid filled proximal bowel with sudden transition to a collapsed distal loop is also characteristic. At the point of transition, there may be a small bowel/faeces sign—gas and solid within dilated small bowel loops. Other signs suggestive of volvulus are signs representing a closed loop obstruction. A ‘U’ shaped configuration of distended and twisted bowel loops containing contrast, or a radial (‘spoke wheel’) arrangement of mesenteric vessels converging to a central point, are examples. In offering a sensitivity of 94–100% and specificity of 90–95%3,4 CT scanning is powerful in diagnosis and establishing causality.

Furthermore, CT imaging is invaluable for detection of small bowel ischaemia. Small bowel ischaemia is a potentially fatal complication of small bowel volvulus: mortality in non-infarcted bowel is 5–8%5 and in infarcted bowel 40–100%.6,7 Ischaemia is notoriously challenging to diagnose in that bowel enhancement can be normal, increased, decreased or even absent. However, there are other signs to look for. These are bowel wall thickening, mesenteric oedema and ascites. An early but non-specific sign of bowel oedema and inflammation is the target sign. This is where thickened bowel shows an enhanced inner and outer layer, sandwiching a middle layer of low attenuation.

The mainstay of treatment is early laparotomy with resection of non-viable bowel and primary anastomosis.

Learning points

  • Small bowel volvulus is a rare and life threatening cause of small bowel obstruction which requires rapid diagnosis and surgical intervention.
  • CT scanning is a widely available non-invasive mode of imaging with good diagnostic ability, offering a sensitivity of 94–100% and specificity of 90–95% in establishing both the diagnosis and cause of small bowel ischaemia, and allows surgical intervention planning.
  • The ‘whirl’ sign and ‘peacock tail’ sign are diagnostic of small bowel volvulus. Others are suggestive.

Footnotes

Competing interests: None.

Patient consent: Patient/guardian consent was obtained for publication.

REFERENCES

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2. Iwuagwu O, Deans GT. Small bowel volvulus: a review. J R Coll Surg Edinb 1999; 44: 150–5 [PubMed]
3. Maglinte DD, Gage SN, Harmon BH, et al. Obstruction of the small intestine: accuracy and role of CT in diagnosis. Radiology 1993; 188: 61–4 [PubMed]
4. Frager D, Madwid SW, Baer JW, et al. CT of small-bowel obstruction: value in establishing the diagnosis and determining the degree and cause. AJR Am J Roentgenol 1994; 162: 37–41 [PubMed]
5. Barnett WO, Petro AB, Williamson JW. A current appraisal of problems with gangrenous bowel. Ann Surg 1976; 183: 653–9 [PubMed]
6. Desouza LJ. Volvulus of the small bowel. BMJ 1976; 1: 1056. [PMC free article] [PubMed]
7. Deutsch AA, Eviator E, Gutman H, et al. Small bowel obstruction: a review of 264 cases and suggestions for management. Postgrad Med J 1989; 65: 453–67 [PMC free article] [PubMed]

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