Spontaneous resolution of symptomatic secondary small bowel volvulus during pre-operative single contrast upper gastrointestinal study

Abstract

Small bowel volvulus is a rare occurrence in adults as it most commonly occurs within the first year of life as a complication of malrotation, an embryologic anomaly. When occurring in any age group, restriction of blood flow can lead to ischemia and eventual infarction of bowel making any suspected volvulus a surgical emergency. We present a case of a middle-aged patient with acute small bowel obstruction with small bowel volvulus. Following oral administration of water-soluble contrast as part of a single contrast upper gastrointestinal tract (UGI) study and changes in positioning, the patient experienced spontaneous resolution of the small bowel volvulus.

Introduction

Small bowel volvulus is a rare occurrence in adults as it most commonly occurs within the first year of life as a complication of malrotation, an embryologic anomaly [1]. When occurring in any age group restriction of blood flow can lead to ischemia and eventual infarction of the bowel making any suspected volvulus a surgical emergency [1]. The physiologic definition of small bowel volvulus is a twisting >180 degrees about the bowel mesentery with resulting intestinal obstruction and impediment of blood flow through mesentery vasculature [3]. A small bowel volvulus can be primary or secondary. Primary volvulus is when there is no underlying anatomic abnormality contributing to the affected bowel and secondary volvulus is when there is abnormal anatomy. Causes of secondary volvulus include congenital defects such as malrotation, Meckel's diverticulum, pregnancy, and surgical complications such as adhesions [4]. We present a case of a middle-aged patient who presented with acute small bowel obstruction secondary to small bowel volvulus.

Case report

The middle-aged patient presented to the emergency department with acute onset severe abdominal pain, nausea, vomiting, shortness of breath, and diarrhea. Computed Tomography (CT)-Abdomen/Pelvis with intravenous contrast showed proximal small bowel obstruction with a transition point in the descending and transverse duodenum. The duodenum did not cross the midline and the superior mesenteric artery descended posterior to the right of the portal and superior mesenteric veins, suggestive of volvulus. Surgical consultation was recommended. Whirl sign was apparent. Multiple small bowel diverticula of varying sizes were noted (Fig. 1).

Fig. 1.

Axial images from CT-Abdomen/Pelvis with IV Contrast show distended prominent fluid and gas filled loops of bowel with classic Whirl sign indicative of volvulus. Multiple small bowel diverticula are apparent.

Subsequently, a single contrast upper gastrointestinal study (UGI), with water-soluble Omnipaque 300 mg/mL, was done to assess the proximal small bowel. The study showed delayed transit through the stomach and proximal small bowel. Initially, contrast did not cross the midline and was only apparent in the proximal duodenum (Fig. 2). The patient was repositioned while further ingesting contrast. Then contrast was seen crossing midline and the duodenojejunal junction was now in an expected left upper abdominal quadrant. Multiple duodenal and jejunal diverticula were seen again (Fig. 3). The patient's pain improved. Discussed with the patient and their surgeon. The patient was taken for a repeat CT abdomen pelvis. This showed interval decreased gastric distention. The proximal jejunal loops were now located within the left upper quadrant. Swirling of the mesenteric root was no longer present. Findings suggested transient volvulus and spontaneous reduction (Fig. 4). Follow-up imaging after nasogastric tube placement demonstrated contrast-filled loops of bowel in the proper orientation (Fig. 5). The patient was taken to surgery for intermittent small bowel obstruction secondary to intermittent kinking of the proximal jejunum at the ligament of Treitz. This was believed to be secondary to large-sized dilated jejunal diverticula. The patient underwent exploratory laparotomy with resection of a portion of the jejunum (approximately 45 cm) that contained multiple diverticula of varying sizes (Fig. 6). Diagnosis of small bowel obstruction due to intermittent secondary small bowel volvulus from large-sized small bowel diverticula was agreed upon.

Fig. 2.

Static and dynamic fluoroscopic images from single contrast UGI show that initially contrast did not cross midline and was only apparent in the first and second segment of the duodenum.

Fig. 3.

Subsequent single contrast UGI images show the contrast crossing midline and the duodenojejunal junction in proper location, in the left upper abdominal quadrant. Multiple duodenal and jejunal diverticula are also seen.

Fig. 4.

CT Abdomen/Pelvis, post UGI, shows interval decreased gastric distention. The proximal jejunal loops are now located within the left upper quadrant. Swirling of the mesenteric root was no longer present.

Fig. 5.

Upright frontal abdominal radiograph shows contrast filled loops of bowel in proper orientation.

Fig. 6.

Intraoperative photos show resection of a portion of the jejunum (approximately 45 cm) that contained multiple diverticula of varying sizes.

Discussion

Our patient with multiple diverticula of varying sizes, that measured up to 6.4 cm and a diagnosed volvulus would be considered a secondary volvulus. In the clinical setting both primary and secondary midgut volvulus present with non-specific symptoms of abdominal pain, distension, and emesis. Untreated can progress to hematochezia, pain out of proportion to exam, and systemic inflammatory response [1,3,5]. Our patient's presentation of acute onset severe abdominal pain, nausea, vomiting, shortness of breath, and diarrhea is in line with an early and non-specific presentation of small bowel obstruction. When presenting with small bowel obstruction, an estimated 3%-6% of patients, are diagnosed with midgut volvulus in western populations [3]. While a thorough history and physical exam are helpful; imaging is often necessary to make the specific diagnosis of volvulus. UGI with small bowel follow-through exam is essential in the diagnosis of volvulus and detection of anatomic abnormalities such as malrotation. Plain abdominal films, Ultrasound for pediatric patients, CT, and Magnetic Resonance Imaging may be used in conjunction to confirm and assist in diagnosis of volvulus and detect anatomic abnormalities such as malrotation [1]. In addition to volvulus, imaging for our patient revealed small bowel diverticula, particularly in duodenal and jejunal regions. Small bowel diverticula are rare, occurring in as little as 1% of the population with most cases being asymptomatic [6,7]. Of the 10%-15% of patients who develop complications of small bowel diverticula, volvulus is one of many less common complications [6]. Intraperitoneal infections related to perforation or abscess appear to be more common complications [6,7]. This patient's mechanism of volvulus, the effect of the mass of a large diverticulum is a likely cause. Mass effect is known to contribute to restriction of blood flow by way of abnormal rotation in other organ systems. Most notable and well-studied is that of ovarian torsion. An ovarian mass >5 cm is a known risk factor for torsion as this mass acts as a counterweight by which rotation may occur around a fixed axis [8]. It is proposed that this motion can occur through physical activity or sudden movements [9]. By the same mechanism rotation back to an unrestricted position can occur causing relapsing and remitting symptoms [9]. It is proposed that similar forces were at work during this report of volvulus which occurred while golfing and later resolved during UGI. Small bowel obstruction can occur from small bowel volvulus. Although prior report of spontaneous resolution of primary small bowel volvulus after oral adminastrition of CT dye has been documented [2]; this is the first known report radiographically documenting resolution of a secondary small bowel volvulus after the ingestion of oral contrast during UGI. The volvulus was likely secondary to large jejunal diverticula that were prophylactically resected. This case can be used for further investigation into the therapeutic role of oral contrast and physical manipulation/repositioning in the management of secondary small bowel volvulus.

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