Presentation
Left sided abdominal pain with recurrent vomiting for one day, background history of chronic constipation.
Patient Data
Supine abdominal radiograph showed coffee bean shape appearance of dilated large colon which is relatively lack of haustration. Absent rectal gas.
No pneumoperitoneum in abdominal radiograph and erect chect radiograph.
Grossly distension of the sigmoid colon with gas-fluid levels, lacking haustra forming a closed-loop obstruction. The transition point is at the distal sigmoid colon,measuring 25cm from the anal verge (external anal sphincter). Two points of obstruction noted at this transition point.
Whirl sign noted at the left iliac fossa, twisting/whirlpool appearance of the mesentery and mesenteric vessels of sigmoid mesocolon. On coronal reconstruction and abdominal radiograph, these dilated bowel loops formed a closed loop with coffee bean sign.
Crossing loops of bowel at the site of transition in the left iliac fossa at the level of distal sigmoid colon giving rise to X-marks-the-spot sign. The distended sigmoid colon does not have thickened bowel wall, unable to assess the bowel wall enhancement reliably due to portovenous phase rather than the proper arterial phase.
No pneumoperitoneum, intramural gas or portal venous gas.
The rest of large colon and small bowel loops are not dilated and without bowel wall thickening or mass.
Stomach is collapsed with contracted wall. No gastric volvulus with normal positioned gastro-esophageal junction. Nasogastric tube in situ with the distal tip located at D1 of duodenum.
Minimal free fluid at the pelvic region and pouch of Douglas, which can be physiological for child bearing age woman.
Case Discussion
Imaging features are in keeping with sigmoid volvulus, which was confirmed with intra-operative findings. X-marks-the-spot sign improves the diagnostic confidence of sigmoid volvulus. It usually indicates complete volvulus rather than partial volvulus.
Patient went on for explaratory and sigmoid colectomy with side to side anastomosis.
Intraoperative findings:
Hugely dilated sigmoid colon
Needle decompression done using 21 Gauge needle, however, sigmoid colon was very redundant and dilated in caliber, decided for sigmoid colectomy.
Twisted 2 times at mesocolic axis
Axis of volvulus entrapped by adhesion band of omentum to left lateral abdominal wall-released
Distal to obstruction, no mass felt.
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