The Journal of Emergency Medicine, Vol. 47, No. 3, pp. 318–319, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2013.11.100

Visual Diagnosis in Emergency Medicine

THE COFFEE BEAN SIGN Tatsuya Fujikawa, MD, PHD and Masahiro Hoshimoto, MD, PHD Department of Internal Medicine, Seikeikai Hospital, Koryo-nakamachi, Sakai, Osaka, Japan Reprint Address: Tatsuya Fujikawa, MD, PHD, Department of Internal Medicine, Seikeikai Hospital, 4-2-10 Koryo-nakamachi, Sakai, Osaka 590-0024, Japan

CASE REPORT A 24-year-old woman with chronic constipation presented with progressive abdominal pain, distension, and vomiting for the past 3 h. Abdominal examination revealed hypoactive bowel sounds and lower abdominal tenderness without rebound. Fever, abdominal guarding, or rigidity was not detected. Laboratory results revealed leukocytosis (white cell count, 27,800/mL). A plain radiograph and subsequent abdominal computed tomography revealed gross dilatation of the sigmoid colon, with characteristic features of sigmoid volvulus, including the coffee bean (Figure 1, arrows) and whirl signs (Figure 2, arrows). Subsequent colonoscopy under x-ray guidance was performed. The colonoscope was passed through the twisted lumen into the dilatated colon, and detorsion of the volvulus was successfully achieved. Tumors or intestinal ischemia were not observed near the volvulus. Abdominal distention was relieved immediately after detorsion. The following day, oral food intake was resumed after confirming the absence of abnormal symptoms and normal intestinal peristalsis. Since discharge, the volvulus has not recurred and defecation has been normal.

Figure 1. A plain radiograph of the abdomen showing a distended sigmoid colon with the coffee bean sign (arrows).

RECEIVED: 24 May 2013; ACCEPTED: 17 November 2013 318

The Coffee Bean Sign

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DISCUSSION The colon, most commonly the sigmoid colon, twists on its own mesenteric axis in volvulus, causing partial or complete obstruction of the large bowel, abdominal bloating, pain, vomiting, constipation, and peritonitis (1,2). Sigmoid volvulus may be caused by chronic constipation, anatomic variation, neurologic disease, or megacolon (2). Conservative treatments such as endoscopic decompression and detorsion are considered as first-line treatments (3). However, surgery may be required for bowel ischemia, failed endoscopic treatment, and recurrent volvulus (2,3). Physicians should be aware of the above-mentioned signs of sigmoid volvulus that indicate acute abdominal obstruction, and consider emergency surgery.

REFERENCES

Figure 2. Coronal computed tomography of the abdomen showing spiraled loops of bowel and mesentery with the whirl sign (arrows).

1. Jones DJ. ABC of colorectal diseases. Large bowel volvulus. BMJ 1992;305:358–60. 2. Lee YS, Lee WJ. Coffee-bean sign. CMAJ 2008;178:1657. 3. Albaba M, Takahashi PY. 83-year-old woman with abdominal distention and constipation. Mayo Clin Proc 2009;84: 1126–9.

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