Legal Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Case Report
A fatal case of adult small bowel volvulus Mutsumi Hayakawa ⇑, Yohsuke Makino, Daisuke Yajima, Go Inokuchi, Ayumi Motomura, Fumiko Chiba, Suguru Torimitsu, Namiko Ishii, Hisako Saitoh, Hirotaro Iwase Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba, Japan
a r t i c l e
i n f o
Article history: Received 21 April 2014 Accepted 17 May 2014 Available online xxxx Keywords: Small bowel volvulus Computed tomography Whirl sign
a b s t r a c t A 56-year-old man was hit by a car while riding a bicycle, immediately brought to the hospital, and treated. Four days after the accident, he reported abdominal pain and vomiting in the night, and he died the next day. A forensic autopsy was performed, and almost of the entire small bowel had gangrenous swelling. The mesentery was twisted 180° with clockwise rotation along the vascular axis, and pre-autopsy computed tomography scan showed a whirl sign. Ó 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Small bowel volvulus is the torsion of the small bowel and its mesentery. It is a well-recognized disease in infants and children, but adult primary small bowel volvulus is rare [1]. The diagnosis is difficult, as the symptoms resemble those of acute abdomen [2]; consequently, it can sometimes be fatal. We report a fatal case of small bowel volvulus that was suspected as being primary, and a pre-autopsy computed tomography (CT) scan showed a ‘‘whirl sign.’’ 2. Case report A 56-year-old man was hit by a car while riding a bicycle. He was immediately brought to the hospital and diagnosed with brain contusion, epidural hematoma, subdural hematoma, and fracture of left tibia and fibula. He was ordered to stay in bed for fracture fixation, and conservative management was performed because the brain injury was mild. Four days after the accident, suddenly he unexpectedly reported abdominal pain and vomiting in the night. He was medicated and observed, but developed cardiopulmonary arrest the next day and could not be resuscitated. A forensic autopsy was performed 2 days after his death, because the relationship between the accident and his death needed to be cleared. 3. Autopsy findings The victim was 176 cm in height and weighed 63 kg. Rigor mortis was strongly present throughout the body. ⇑ Corresponding author. Tel.: +81 43 222 7171; fax: +81 43 226 2005. E-mail address: [email protected] (M. Hayakawa).
On the head and face, many abrasions were noticed. There were some fractures on the right side of the skull and the cranial base. There was a brain contusion in the left temporal lobe with slight epidural and subdural hematoma. No herniation was found in the brain. In the abdomen, no injury was noted on the surface or subcutaneously. Operation scars were absent, and no adhesion was found in the abdominal cavity. The mesentery was twisted 180° clockwise along the vascular axis (Fig. 1), and another sausage-like torsion was found near the ileocecum (Fig. 2). Most of the small bowel was swelling and discolored to dark purple. No other macroor microscopic disease was found in the abdominal organs. According to the medical records, he was not on a prescription for any drug accelerating bowel peristalsis. In the lower limbs, there were two perforations for fracture fixation in the heel. Single fractures were present in both the left tibia and fibula, surrounded by crushed muscle and widespread bleeding. The CT revealed twisting of the mesentery around the arterial axis and showed a whirl sign (Fig. 3).
4. Discussion Bowel volvulus is the result of bowel torsion around the axis of the mesentery. In adults, most volvulus cases occur in the colon, with 70–80% in the sigmoid colon [2]. Small bowel volvulus in adults is rare and is classified in two categories [1,2]: (a) primary: without any apparent predisposing anatomical abnormalities and (b) secondary: precipitated by underlying anatomical abnormalities, including an anatomical malformations and postoperative adhesions.
http://dx.doi.org/10.1016/j.legalmed.2014.05.007 1344-6223/Ó 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Hayakawa M et al. A fatal case of adult small bowel volvulus. Leg Med (2014), http://dx.doi.org/10.1016/ j.legalmed.2014.05.007
2
M. Hayakawa et al. / Legal Medicine xxx (2014) xxx–xxx
Fig. 1. Rotation of the mesentery along the vascular axis with dark purple discoloration of the bowel. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
Fig. 2. Another torsion near the ileocecum showing a sausage-like pattern.
In North America and Europe, small bowel volvulus is reported in 1.7% of all intestinal obstructions [2]. On the other hand, in African, Asian, and Middle Eastern countries, it is comparatively common. In Japan, statistical analysis of 47 cases was reported in 2008 [3]. Including the present case and an additional 25 reported cases, there are now 73 total reported cases in Japan. The cause of primary small bowel volvulus is sometimes pointed sudden accelerated bowel peristalsis. In previous reports, small bowel volvulus occurred after religious practice such as Ramadan [2] or drinking a special beer containing a high concentration of serotonin in Uganda [4]. In the Japanese literature, in some cases it occurred after eating nuts too quickly or intense sexual acts. It has also been reported to be related to diabetes mellitus [5]. There are no specific symptoms of small bowel volvulus, and the symptoms are similar to those of common acute abdomen, including abdominal pain, vomiting, and abdominal distension.
This can cause a delayed diagnosis and can be fatal. The mortality of small bowel volvulus varies 9–35%, but increases 20–100% with a gangrenous bowel [2]. CT scans are useful diagnosing small bowel volvulus. In many cases, it reveals torsion of the small intestine around the mesenteric vascular axis called the whirl sign [1,3,5–9], which shows a sensitivity of 60% and specificity of 94% [6]. In recent study the whirl sign may not be apparent if the axis of rotation is not perpendicular to the transverse scanning [9]. In the present case, the small bowel was not examined while the victim was alive. The volvulus was identified only on autopsy and the pre-autopsy CT scan, which showed the whirl sign. The relationship between the accident and his death was doubted at first and was eventually denied because of the following reasons. In this accident, no abdominal injury was found; furthermore, even if a blow occurred without bruising either subcutaneously or on the abdomen, there was no report of
Please cite this article in press as: Hayakawa M et al. A fatal case of adult small bowel volvulus. Leg Med (2014), http://dx.doi.org/10.1016/ j.legalmed.2014.05.007
M. Hayakawa et al. / Legal Medicine xxx (2014) xxx–xxx
3
The symptoms first occurred 4 days after the accident while the patient was staying in bed 3. For fracture fixation. 4. No medications that accelerated bowel peristalsis were administered. In the present case, the traffic accident was not connected to the victim’s small bowel volvulus; furthermore, it was considered primary in nature as there was no evidence of a previous operation and no adhesions in the abdominal cavity. References
Fig. 3. Abdominal computed tomography scan showing the whirl sign with twisting of the mesentery around the arterial axis (arrow).
1. Small bowel volvulus after the abdominal blow. 2. It is inconceivable that small bowel volvulus occurred just after the accident with no symptoms for 4 days.
[1] Huang JC, Shin JS, Huang YT, Chao CJ, Ho SC, Wu MJ, et al. Small bowel volvulus among adults. J Gastroenterol Hepatol 2005;20:1906–12. [2] Roggo A, Ottinger LW. Acute small bowel volvulus in adults. A sporadic form of strangulating intestinal obstruction. Ann Surg 1992;216:135–41. [3] Maki A, Fujiki T, Matsuo K, Tanaka S, Ikeda S, Yamashita Y. A case of primary volvulus of the small intestine in an adult. J Jpn Surg Assoc 2008;69:567–71 (In Japanese). [4] De Souza LJ. Volvulus of the small bowel. Br Med J 1976;1:1055–6. [5] Ruis-Tovar J, Morales V, Sanjuanbenito A, Lobo A, Martinez-Molina E. Volvulus of the small bowel in adults. Am Surg 2009;75(12):1179–82. [6] Huang YM, Wu CC. Whirl sign in small bowel volvulus. BMJ Case Rep 2012;13:2012 (pii: bcr2012006688). [7] Birnbaum DJ, Grègoire E, Campan P, Hardwigsen J, Le Treut YP. Primary small bowel volvulus in adult. J Emerg Med 2013;44(4):e329–30. [8] Snyder JA, Lum C, Davidson MD. Elderly patient with small bowel volvulus. J Am Osteopath Assoc 2010;110(11):678–9. [9] Ho YC. ‘‘Venous Cut-off Sign’’ as an adjunct to the ‘‘Whirl Sign’’ in recognizing acute small bowel volvulus via CT scan. J Gastrointest Surg 2012;16:2005–6.
Please cite this article in press as: Hayakawa M et al. A fatal case of adult small bowel volvulus. Leg Med (2014), http://dx.doi.org/10.1016/ j.legalmed.2014.05.007
Contents lists available at ScienceDirect
Legal Medicine journal homepage: www.elsevier.com/locate/legalmed
Case Report
A fatal case of adult small bowel volvulus Mutsumi Hayakawa ⇑, Yohsuke Makino, Daisuke Yajima, Go Inokuchi, Ayumi Motomura, Fumiko Chiba, Suguru Torimitsu, Namiko Ishii, Hisako Saitoh, Hirotaro Iwase Department of Legal Medicine, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba City, Chiba, Japan
a r t i c l e
i n f o
Article history: Received 21 April 2014 Accepted 17 May 2014 Available online xxxx Keywords: Small bowel volvulus Computed tomography Whirl sign
a b s t r a c t A 56-year-old man was hit by a car while riding a bicycle, immediately brought to the hospital, and treated. Four days after the accident, he reported abdominal pain and vomiting in the night, and he died the next day. A forensic autopsy was performed, and almost of the entire small bowel had gangrenous swelling. The mesentery was twisted 180° with clockwise rotation along the vascular axis, and pre-autopsy computed tomography scan showed a whirl sign. Ó 2014 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Small bowel volvulus is the torsion of the small bowel and its mesentery. It is a well-recognized disease in infants and children, but adult primary small bowel volvulus is rare [1]. The diagnosis is difficult, as the symptoms resemble those of acute abdomen [2]; consequently, it can sometimes be fatal. We report a fatal case of small bowel volvulus that was suspected as being primary, and a pre-autopsy computed tomography (CT) scan showed a ‘‘whirl sign.’’ 2. Case report A 56-year-old man was hit by a car while riding a bicycle. He was immediately brought to the hospital and diagnosed with brain contusion, epidural hematoma, subdural hematoma, and fracture of left tibia and fibula. He was ordered to stay in bed for fracture fixation, and conservative management was performed because the brain injury was mild. Four days after the accident, suddenly he unexpectedly reported abdominal pain and vomiting in the night. He was medicated and observed, but developed cardiopulmonary arrest the next day and could not be resuscitated. A forensic autopsy was performed 2 days after his death, because the relationship between the accident and his death needed to be cleared. 3. Autopsy findings The victim was 176 cm in height and weighed 63 kg. Rigor mortis was strongly present throughout the body. ⇑ Corresponding author. Tel.: +81 43 222 7171; fax: +81 43 226 2005. E-mail address: [email protected] (M. Hayakawa).
On the head and face, many abrasions were noticed. There were some fractures on the right side of the skull and the cranial base. There was a brain contusion in the left temporal lobe with slight epidural and subdural hematoma. No herniation was found in the brain. In the abdomen, no injury was noted on the surface or subcutaneously. Operation scars were absent, and no adhesion was found in the abdominal cavity. The mesentery was twisted 180° clockwise along the vascular axis (Fig. 1), and another sausage-like torsion was found near the ileocecum (Fig. 2). Most of the small bowel was swelling and discolored to dark purple. No other macroor microscopic disease was found in the abdominal organs. According to the medical records, he was not on a prescription for any drug accelerating bowel peristalsis. In the lower limbs, there were two perforations for fracture fixation in the heel. Single fractures were present in both the left tibia and fibula, surrounded by crushed muscle and widespread bleeding. The CT revealed twisting of the mesentery around the arterial axis and showed a whirl sign (Fig. 3).
4. Discussion Bowel volvulus is the result of bowel torsion around the axis of the mesentery. In adults, most volvulus cases occur in the colon, with 70–80% in the sigmoid colon [2]. Small bowel volvulus in adults is rare and is classified in two categories [1,2]: (a) primary: without any apparent predisposing anatomical abnormalities and (b) secondary: precipitated by underlying anatomical abnormalities, including an anatomical malformations and postoperative adhesions.
http://dx.doi.org/10.1016/j.legalmed.2014.05.007 1344-6223/Ó 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Hayakawa M et al. A fatal case of adult small bowel volvulus. Leg Med (2014), http://dx.doi.org/10.1016/ j.legalmed.2014.05.007
2
M. Hayakawa et al. / Legal Medicine xxx (2014) xxx–xxx
Fig. 1. Rotation of the mesentery along the vascular axis with dark purple discoloration of the bowel. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
Fig. 2. Another torsion near the ileocecum showing a sausage-like pattern.
In North America and Europe, small bowel volvulus is reported in 1.7% of all intestinal obstructions [2]. On the other hand, in African, Asian, and Middle Eastern countries, it is comparatively common. In Japan, statistical analysis of 47 cases was reported in 2008 [3]. Including the present case and an additional 25 reported cases, there are now 73 total reported cases in Japan. The cause of primary small bowel volvulus is sometimes pointed sudden accelerated bowel peristalsis. In previous reports, small bowel volvulus occurred after religious practice such as Ramadan [2] or drinking a special beer containing a high concentration of serotonin in Uganda [4]. In the Japanese literature, in some cases it occurred after eating nuts too quickly or intense sexual acts. It has also been reported to be related to diabetes mellitus [5]. There are no specific symptoms of small bowel volvulus, and the symptoms are similar to those of common acute abdomen, including abdominal pain, vomiting, and abdominal distension.
This can cause a delayed diagnosis and can be fatal. The mortality of small bowel volvulus varies 9–35%, but increases 20–100% with a gangrenous bowel [2]. CT scans are useful diagnosing small bowel volvulus. In many cases, it reveals torsion of the small intestine around the mesenteric vascular axis called the whirl sign [1,3,5–9], which shows a sensitivity of 60% and specificity of 94% [6]. In recent study the whirl sign may not be apparent if the axis of rotation is not perpendicular to the transverse scanning [9]. In the present case, the small bowel was not examined while the victim was alive. The volvulus was identified only on autopsy and the pre-autopsy CT scan, which showed the whirl sign. The relationship between the accident and his death was doubted at first and was eventually denied because of the following reasons. In this accident, no abdominal injury was found; furthermore, even if a blow occurred without bruising either subcutaneously or on the abdomen, there was no report of
Please cite this article in press as: Hayakawa M et al. A fatal case of adult small bowel volvulus. Leg Med (2014), http://dx.doi.org/10.1016/ j.legalmed.2014.05.007
M. Hayakawa et al. / Legal Medicine xxx (2014) xxx–xxx
3
The symptoms first occurred 4 days after the accident while the patient was staying in bed 3. For fracture fixation. 4. No medications that accelerated bowel peristalsis were administered. In the present case, the traffic accident was not connected to the victim’s small bowel volvulus; furthermore, it was considered primary in nature as there was no evidence of a previous operation and no adhesions in the abdominal cavity. References
Fig. 3. Abdominal computed tomography scan showing the whirl sign with twisting of the mesentery around the arterial axis (arrow).
1. Small bowel volvulus after the abdominal blow. 2. It is inconceivable that small bowel volvulus occurred just after the accident with no symptoms for 4 days.
[1] Huang JC, Shin JS, Huang YT, Chao CJ, Ho SC, Wu MJ, et al. Small bowel volvulus among adults. J Gastroenterol Hepatol 2005;20:1906–12. [2] Roggo A, Ottinger LW. Acute small bowel volvulus in adults. A sporadic form of strangulating intestinal obstruction. Ann Surg 1992;216:135–41. [3] Maki A, Fujiki T, Matsuo K, Tanaka S, Ikeda S, Yamashita Y. A case of primary volvulus of the small intestine in an adult. J Jpn Surg Assoc 2008;69:567–71 (In Japanese). [4] De Souza LJ. Volvulus of the small bowel. Br Med J 1976;1:1055–6. [5] Ruis-Tovar J, Morales V, Sanjuanbenito A, Lobo A, Martinez-Molina E. Volvulus of the small bowel in adults. Am Surg 2009;75(12):1179–82. [6] Huang YM, Wu CC. Whirl sign in small bowel volvulus. BMJ Case Rep 2012;13:2012 (pii: bcr2012006688). [7] Birnbaum DJ, Grègoire E, Campan P, Hardwigsen J, Le Treut YP. Primary small bowel volvulus in adult. J Emerg Med 2013;44(4):e329–30. [8] Snyder JA, Lum C, Davidson MD. Elderly patient with small bowel volvulus. J Am Osteopath Assoc 2010;110(11):678–9. [9] Ho YC. ‘‘Venous Cut-off Sign’’ as an adjunct to the ‘‘Whirl Sign’’ in recognizing acute small bowel volvulus via CT scan. J Gastrointest Surg 2012;16:2005–6.
Please cite this article in press as: Hayakawa M et al. A fatal case of adult small bowel volvulus. Leg Med (2014), http://dx.doi.org/10.1016/ j.legalmed.2014.05.007
