98 Visite/Pictorial Essay

The Coffee Bean Sign: Diagnosing Sigmoid Volvulus in an 8-Year-Old Child


T. M. Theilen, H. C. Fiegel, S. Gfrörer, U. Rolle


 Department of Pediatric Surgery and Pediatric Urology, University Hospital Frankfurt, Frankfurt, Germany

Key words ▶ coffee bean sign ● ▶ kidney bean sign ● ▶ inverted U-sign ● ▶ sigmoid volvulus ● ▶ large bowel obstruction ● ▶ chronic constipation ●


Schlüsselwörter ▶ Coffee Bean Sign ● ▶ Kidney Bean Sign ● ▶ Inverted U-Sign ● ▶ Sigmoid Volvulus ● ▶ Dickdarm Obstruktion ● ▶ chronische Obstipation ●

Sigmoid volvulus is a rare cause of acute large bowel obstruction among the pediatric age group [4]. The diagnosis of a sigmoid volvulus warrants immediate intervention to rescue bowel perfusion. However, making the diagnosis of a sigmoid volvulus especially in children with underlying neurologic conditions can be challenging. A plain abdominal radiograph can help to make the diagnosis when a coffee bean sign, highly indicative for sigmoid volvulus, is shown. The coffee bean sign depicts the dilated and twisted sigmoid ­colon as an air filled bowel loop mostly in the upper quadrants of the abdomen [3]. Here we report a case of an 8-year-old mentally and physically disabled boy with agenesis of the corpus callosum and epilepsy suffering from acute sigmoid volvulus. A plain abdominal radio­ graphy revealed the coffee bean sign.

Case report

▼ Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1395617 Published online: February 4, 2015 Klin Padiatr 2015; 227: 98–99 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0300-8630 Correspondence Dr. Till Martin Theilen Department Pediatric Surgery University Hospital Frankfurt Theodor-Stern-Kai 7 60590 Frankfurt Germany Tel.:  + 49/1577/6401 271 Fax:  + 49/69/6301 7936 [email protected]

An 8-year-old, disabled boy with recurrent bilious vomiting and an extended abdomen presented to our emergency unit. A fairly sudden onset of symptoms began 8 h prior to presentation. For a week before the onset of symptoms he suffered from severe gastroenteritis with high fever, diarrhea and excessive fluid loss. He has had a longstanding history of chronic constipation with frequent episodes of decompensation leading to numerous previous visits to our clinic. Rectal irrigation and oral intake of glycol lead to relieve of symptoms in these cases. In his previous history, he underwent left sided open renal pyeloplasty for ureteropelvic junction obstruction. The physical examination showed a markedly distended, non-tender abdomen with mild reaction to pain in the right lower quadrant and few soft bowel sounds. He was in mild distress and pain. Digital rectal examination showed an

Theilen TM et al. The Coffee Bean Sign:.  Klin Padiatr 2015; 227: 98–99

empty vault with consecutive blood tinged mucoid discharge. Initial rectal irrigation led to a mild relief with passing of gas and small amounts of stool. Upon presentation he had a leukocytosis of 21.15/nl with a neutrophilia of 85.6 %. Venous blood gas analysis indicated a metabolic acidosis (pH of 7.192, pCO2 39.8 mmHg, HCO3− 14.1 mmol/L, base excess −13.0 mmol/L). The C-reactive protein and electrolytes were normal. Fluid resuscitation and repeated rectal irrigation was assessed. Due to insufficient rectal irrigation a plain abdominal radiograph was taken to rule out mechanical ­ obstruction. It did not reveal free abdominal air or air-fluid levels but large faecoliths in the left descending colon. However, it also showed the coffee bean sign leading to the immediate decision to take the patient to the operating ▶  Fig. 1). Upon laparotomy widely disroom ( ● tended large bowel developed showing defined infarction of the descending and sigmoid colon ▶  Fig. 2). Of note, due to a volvulated mesentery ( ● no adhesions were seen. Resection of the necrotic bowel and primary descendo-rectal anastomosis was carried out.


Patients with agenesis of the corpus callosum typically show mental retardation, low muscle tone and low perception of pain [7]. Judging symptoms of an acute abdomen in these children can therefore be quite troublesome. In retrospect, the radiographic sign of the coffee bean lead to prompt surgical intervention in the case presented. Without the radiographic finding, the diagnosis of a large bowel volvulus could have easily been missed. The patient was known to suffer from chronic constipation with recurrent hospital visits. Rectal irrigation had always led to prompt relive of symptoms. At the present visit a (sub-) ileus due to fecal impactation rebounding after an episode of diarrhea with an

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Das Coffee Bean Zeichen: Diagnosestellung eines Volvulus des Colon sigmoideum eines 8-jährigen Kindes

Fig. 1  Plain abdominal radiograph of the patient in left-sided position showing the coffee bean sign. Solid arrows indicate the dilated, air-filled, and twisted colon loop in the upper abdomen. Dashed arrows indicate the radiographic line formed by the 2 adjacent bowel walls illustrating the crease of a coffee bean.

sometimes not easy to make. Symptoms of acute constipation and sigmoid volvulus can show a smooth transition [9]. As a matter of principle, chronic constipation is one of the main risk factors for sigmoid volvulus [5, 6]. In suspected pathology other then constipation a plain abdominal radiograph can assist in making the correct diagnosis. As in the case presented, the radiographic finding of a coffee bean sign was highly indicative for a large bowel volvulus. However, the sensitivity of the coffee bean sign for sigmoid volvulus in children is reported to be only 16–29 % in review of pediatric cases in the literature [4, 8]. The coffee bean sign is a well-described radiographic finding. Synonym terms consist of kidney bean or inverted U-sign. The coffee or kidney bean correlates to a U-shaped, gas-filled large bowel loop twisted on its mesentery base. The illustration of a coffee bean is the result of a radiographic line formed by the 2 adjacent bowel walls of the U-shaped loop resembling the crease ▶  Fig. 1). In addition, the loop can typically be of a coffee bean ( ● distinguished from neighboring bowel by the absence of haustra [2, 3]. Despite the lower rate of sensitivity of the coffee bean sign in children a plain abdominal radiograph should especially be considered in patients with underlying medical and neurologic conditions altering physical findings. Thorough examination and early diagnosis is warranted since delayed diagnosis of sigmoid volvulus in children is associated with high mortality (21–29 %) [1, 8]. In navigating through differential diagnoses for large ­bowel obstruction the coffee bean sign can lead the way.

Conflict of interest: The authors have no conflict of interest to disclose. References

Fig. 2  Upon laparotomy the dilated, air-filled, and twisted colon loop showed defined infarction.

excessive loss of body fluids seemed eminent. This time, however, rectal irrigation was uneventful. A plain abdominal radiograph was taken to rule out mechanical obstruction. Constipation was confirmed but in addition the ­coffee bean sign defining a ▶  Fig. 1). The patient was taken sigmoid volvulus was apparent ( ● to the operating room where the diagnosis of sigmoid volvulus ▶  Fig. 2). was confirmed ( ● Differentiating symptoms of an acute episode of constipation with abdominal distension, abdominal pain, vomiting, and compromised general state of health from other urgent causes is

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Theilen TM et al. The Coffee Bean Sign:.  Klin Padiatr 2015; 227: 98–99

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The coffee bean sign: diagnosing sigmoid volvulus in an 8-year-old child.

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