The Journal of Emergency Medicine, Vol. 46, No. 3, pp. 383–384, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

Visual Diagnosis in Emergency Medicine

TYPICAL WHIRL SIGN IN SIGMOID VOLVULUS Wai-Zen Shaw, MD,* Chang-Feng Huang, MD,† Tzu-Yao Hung, MD,† and Yu-Hang Yeh, MD† *Department of Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan and †Department of Emergency Medicine, Zhongxing Branch, Taipei City Hospital, Taipei, Taiwan Reprint Address: Yu-Hang Yeh, MD, Department of Emergency Medicine, Zhongxing Branch, Taipei City Hospital, No. 145, Zhengzhou Road, Taipei 10341, Taiwan

abdominal pain, distention, and constipation. Colonic length is one of the most important predisposing factors

CASE REPORT A 70-year-old man without previous medical or surgical history came to our Emergency Department (ED) complaining of a sudden onset of left abdominal pain for hours. The character of pain was constant. He had a similar episode previously but it was of short duration. He denied any vomiting, diarrhea, constipation, or dysuria. On arrival, physical examination revealed diffuse left abdominal tenderness without muscle guarding, and he had hyperactive bowel sounds. Results of laboratory data revealed normal white blood cell count (7800/mL) and mild hypokalemia (2.8 mEq/L). There was neither hematuria nor pyuria in the urinalysis. A plain abdominal x-ray study was notable for an inverted U-shaped colonic gas pattern (Figure 1, arrows) and the absence of rectal gas. In the abdominal computed tomography (CT) scan, we saw an impressive picture of a typical whirl sign, a twisting loop of intestine and its mesentery in a whirllike pattern (Figure 2, arrows) with an enlarged sigmoid. Sigmoid volvulus was diagnosed quickly and the obstruction was successfully relieved after colonoscopy. After resolution of the obstruction, the patient was discharged against medical advice from the ED. DISCUSSION

Figure 1. In this plain abdominal x-ray study, abnormal inverted U-shaped colon gas (arrows) and an absence of rectal gas were noted.

Volvulus is defined as a twisting of intestine and mesentery leading to an obstruction, and its clinical triad is

RECEIVED: 29 December 2012; FINAL SUBMISSION RECEIVED: 13 September 2013; ACCEPTED: 17 September 2013 383


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of sigmoid volvulus; other factors include chronic constipation, systemic and local neurologic disease, adhesions, pregnancy, toxins, megacolon, and metabolic disease (1). Those at highest risk for the development of volvulus include elderly nursing home residents and patients with a traumatic brain injury or mental retardation. Although the diagnosis may be evident from plain radiographs, additional studies such as abdominal CT scan or fluoroscopy are sometimes required to make the diagnosis. Whirl sign revealed in CT scan was first described by Fisher (2). The most sensitive signs of volvulus in x-ray studies are absence of rectal gas, inverted U-shaped colon gas (coffee bean sign), and enlargement of the sigmoid (3). All these findings were seen in our case, as was the typical whirl sign. The mainstay treatment of sigmoid volvulus is to relieve the obstruction (4). In this case, as the typical radiographic signs were seen on the abdominal radiographs and CT scan, he was diagnosed quickly and the obstruction was promptly relieved.


Figure 2. An impressive picture of typical whirl sign, a twisting loop of intestine and its mesentery in a whirl-like pattern (arrows), was seen in the computed tomography scan.

1. Lal SK, Morgenstern R, Vinjirayer EP, Matin A. Sigmoid volvulus an update. Gastrointest Endosc Clin N Am 2006;16:175–87. 2. Fisher JK. Computed tomographic diagnosis of volvulus in intestinal malrotation. Radiology 1981;140:145–6. 3. Levsky JM, Den EI, DuBrow RA, Wolf EL, Rozenblit AM. CT findings of sigmoid volvulus. AJR Am J Roentgenol 2010;194: 136–43. 4. Madiba TE, Thomson SR. The management of sigmoid volvulus. J R Coll Surg Edinb 2000;45:74–80.

Typical whirl sign in sigmoid volvulus.

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