Presentation
This patient arrived to the ER with a history of abdominal pain and vomiting since two days. During the last 24 hours a mild fever had developed. Urine samples had indicated urinary tract infection (the patient had a catheter). Upon clinical examination the patient was found to have a tympanitic abdomen, tachycardia and low saturation. The clinical suspicion was that of septicemia - possibly secondary to pyelonephritis.
Patient Data
Non-contrast abdominal CT
The CT examination shows a markedly dilated sigmoid loop, which reaches all the way up to the diaphragm. Both ends of the sigmoid loop merge at a mesenteric swirl, located at the level of the promontorium (best appreciated on the coronal series). The colon proximal to the sigmoid is not particularly dilated, nor is there any small bowel distension. There are small amounts of fluid adjacent to the liver and in the pelvis.
The topogram shows the classic presentation of a sigmoid volvolus on conventional x-ray examination.
Therapeutic barium enema
These images are from the subsequent rectal enema:
Image 1 of 2 before the enema, depicting the massively distended sigmoid loop (lower abdomen).
Image 2 of 2 before the enema, depicting the massively distended sigmoid loop (upper abdomen).
The rectum has been filled with barium contrast. The rectum ends with a characteristic beak-like appearance at the promontorium, corresponding to the mesenteric swirl seen on CT. The rectal catheter has been advanced to the point of transition.
At this stage, the rectal catheter has been advanced past the point of transition to the sigmoid.
The last stack of images depicts the first 15 seconds after the catheter is opened and pressure in the sigmoid is relieved. Scroll through the series from top to bottom. You will see how the distension of the up-until-then closed off sigmoid promptly decreases. Note how the catheter runs in a loop, as it passes through the twisted sigmoid lumen.
Case Discussion
The CT findings are classic for a sigmoid volvulus: A grossly dilated sigmoid running in a closed-off loop, with both ends of the loop merging at a mesenteric swirl corresponding to the axis around which the sigmoid has twisted. The subsequent barium enema shows the characteristic beak sign. The enema is not only a diagnostic but also a therapeutic procedure - one of the rare opportunities a classic radiologist is given to actually cure his patients.
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