Downloaded from emj.bmj.com on October 19, 2014 - Published by group.bmj.com
Review
IMAGES IN EMERGENCY MEDICINE
Emergency CT helps unravel an unusual problem! A patient presented to the emergency department with a 2 h history of severe upper abdominal pain and vomiting. The only past medical history of note was a diagnosis of irritable bowel syndrome. The patient was distressed and vital signs were BP 124/80, T 36.8, P 77, RR 16 and oxygen saturations 99% on room air. Clinical examination revealed tenderness in the left abdomen but no guarding. Laboratory investigations were an Hb level of 12.2, WBC 5.4, neutrophils 34.5%, platelets 267, amylase 55 IU, Na 138, K 4.4, Ca 2.3, urea 2.6 and CRP 1.7. Titrated opiate analgesia was administered and an abdominal x-ray was performed, which showed a distended gas-filled viscus in the upper abdomen (figure 1). An emergency CT of the abdomen was requested (figure 2). CT revealed ‘whirling’ of the transverse colon in the left upper quadrant. The patient was referred to the surgical team for definitive care. At laparotomy, bowel ischaemia was noted and an extended right hemicolectomy with fashioning of an end ileostomy was performed. The patient made a full recovery after being discharged from hospital 5 days later.
Figure 2 CT of the abdomen showing ‘whirl sign’ (see the above arrow) of transverse colonic volvulus.
DISCUSSION Spontaneous volvulus of the transverse colon is rare and diagnosis can be challenging. Significant morbidity and mortality from
bowel ischaemia and peritonitis can result. Once diagnosed, transverse colonic volvulus constitutes a surgical emergency. The ‘whirl sign’ is a well-reported radiological sign on CT of intestinal volvulus.1–3 Rotation of afferent and efferent bowel loops around a fixed point of obstruction results in a tightly twisted mesentery and associated intestinal ischaemia. This case illustrates the importance of early CT, which helped to facilitate successful management of an unusual potentially lifethreatening emergency. Olu Fayomi Correspondence to Dr Olu Fayomi, Department of Emergency Medicine, The Ipswich Hospital, Ipswich, UK: [email protected] Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Fayomi O. Emerg Med J 2014;31:938. Accepted 4 November 2013 Published Online First 9 January 2014 Emerg Med J 2014;31:938. doi:10.1136/emermed-2013-203359
REFERENCES 1
Figure 1 Abdominal x-ray showing gas-filled viscus. 938
2 3
Fisher JK. Computed tomographic diagnosis of volvulus in intestinal malrotation. Radiology 1981;140:145–146. Chen P-H, Chuang C-H. Sigmoid volvulus. N Engl J Med 2009;361:1009. Sana L. Spontaneous transverse colon volvulus. Pan Afr Med J 2013;14:160.
Zhong S, et al. Emerg Med J 2014;31:930–938. doi:10.1136/emermed-2012-202282
Downloaded from emj.bmj.com on October 19, 2014 - Published by group.bmj.com
Emergency CT helps unravel an unusual problem! Olu Fayomi Emerg Med J 2014 31: 938 originally published online January 9, 2014
doi: 10.1136/emermed-2013-203359
Updated information and services can be found at: http://emj.bmj.com/content/31/11/938.full.html
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References
This article cites 1 articles http://emj.bmj.com/content/31/11/938.full.html#ref-list-1
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Review
IMAGES IN EMERGENCY MEDICINE
Emergency CT helps unravel an unusual problem! A patient presented to the emergency department with a 2 h history of severe upper abdominal pain and vomiting. The only past medical history of note was a diagnosis of irritable bowel syndrome. The patient was distressed and vital signs were BP 124/80, T 36.8, P 77, RR 16 and oxygen saturations 99% on room air. Clinical examination revealed tenderness in the left abdomen but no guarding. Laboratory investigations were an Hb level of 12.2, WBC 5.4, neutrophils 34.5%, platelets 267, amylase 55 IU, Na 138, K 4.4, Ca 2.3, urea 2.6 and CRP 1.7. Titrated opiate analgesia was administered and an abdominal x-ray was performed, which showed a distended gas-filled viscus in the upper abdomen (figure 1). An emergency CT of the abdomen was requested (figure 2). CT revealed ‘whirling’ of the transverse colon in the left upper quadrant. The patient was referred to the surgical team for definitive care. At laparotomy, bowel ischaemia was noted and an extended right hemicolectomy with fashioning of an end ileostomy was performed. The patient made a full recovery after being discharged from hospital 5 days later.
Figure 2 CT of the abdomen showing ‘whirl sign’ (see the above arrow) of transverse colonic volvulus.
DISCUSSION Spontaneous volvulus of the transverse colon is rare and diagnosis can be challenging. Significant morbidity and mortality from
bowel ischaemia and peritonitis can result. Once diagnosed, transverse colonic volvulus constitutes a surgical emergency. The ‘whirl sign’ is a well-reported radiological sign on CT of intestinal volvulus.1–3 Rotation of afferent and efferent bowel loops around a fixed point of obstruction results in a tightly twisted mesentery and associated intestinal ischaemia. This case illustrates the importance of early CT, which helped to facilitate successful management of an unusual potentially lifethreatening emergency. Olu Fayomi Correspondence to Dr Olu Fayomi, Department of Emergency Medicine, The Ipswich Hospital, Ipswich, UK: [email protected] Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Fayomi O. Emerg Med J 2014;31:938. Accepted 4 November 2013 Published Online First 9 January 2014 Emerg Med J 2014;31:938. doi:10.1136/emermed-2013-203359
REFERENCES 1
Figure 1 Abdominal x-ray showing gas-filled viscus. 938
2 3
Fisher JK. Computed tomographic diagnosis of volvulus in intestinal malrotation. Radiology 1981;140:145–146. Chen P-H, Chuang C-H. Sigmoid volvulus. N Engl J Med 2009;361:1009. Sana L. Spontaneous transverse colon volvulus. Pan Afr Med J 2013;14:160.
Zhong S, et al. Emerg Med J 2014;31:930–938. doi:10.1136/emermed-2012-202282
Downloaded from emj.bmj.com on October 19, 2014 - Published by group.bmj.com
Emergency CT helps unravel an unusual problem! Olu Fayomi Emerg Med J 2014 31: 938 originally published online January 9, 2014
doi: 10.1136/emermed-2013-203359
Updated information and services can be found at: http://emj.bmj.com/content/31/11/938.full.html
These include:
References
This article cites 1 articles http://emj.bmj.com/content/31/11/938.full.html#ref-list-1
Email alerting service
Topic Collections
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Pain (neurology) (934 articles) Ethics (364 articles) Pain (anaesthesia) (169 articles)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions
To order reprints go to: http://journals.bmj.com/cgi/reprintform
To subscribe to BMJ go to: http://group.bmj.com/subscribe/
