Q J Med 2014; 107:779 doi:10.1093/qjmed/hcu038

Advance Access Publication 18 February 2014

Clinical picture Whirl sign

Patient consent: Obtained. Photographs and text from: W.T. Lin, Department of Orthopaedics, Chi Mei Medical Center, Tainan,

Figure 1. Contrast-enhanced CT of abdomen showed whirl sign (arrow) at right mesentery.

Taiwan and Department of Physical Therapy, Shu Zen College of Medicine and Management; C.M. Chao, Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan and Department of Nursing, Min-Hwei College of Health Care Management, Tainan, Taiwan. email: [email protected] Conflict of interest: None declared.

References 1. Epelman M. The whirlpool sign. Radiology 2006; 240:910–1. 2. Duda JB, Bhatt S, Dogra VS. Utility of CT whirl sign in guiding management of small-bowel obstruction. AJR Am J Roentgenol 2008; 191:743–7. 3. Frank AJ, Goffner LB, Fruauff AA, Losada RA. Cecal volvulus: the CT whirl sign. Abdom Imaging 1993; 18:288–9.

! The Author 2014. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: [email protected]

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A 52-year-old man presented with abdominal pain for 1 day at emergency department. He had the medical history of chronic hepatitis B. The patient reported no trauma, nausea, vomiting, constipation and diarrhea. His vital signs were body temperature 36.68C, pulse rate 74 beats/min, respiratory rate 18/min and blood pressure 132/82 mm Hg. Physical examinations were unremarkable except the examinations of the abdomen indicated distension and pain upon palpitation over epigastric area. Laboratory data revealed that the white blood cell count of 13 400/mm3 and lipase of 149 IU/l (normal reference: 73 393 IU/l). Contrast-enhanced computed tomography (CT) of abdomen showed whirl sign at right mesentery, which indicated volvulus (Figure 1). Emergent exploratory laparotomy confirmed the presence of small bowel volvulus and reduction of volvulus was performed. The postoperation course was smooth and he was discharged uneventfully finally. CT ‘whirl sign’ is demonstrated by the enhanced mesenteric vessel when the bowel rotates around its own mesentery.1,2 It can develop in several clinical conditions, including malrotation with midgut volvulus, cecal volvulus and close loop obstruction.1–3 The sensitivity and specificity of CT whirl sign for diagnosing small bowel obstruction were 60% and 94%, respectively.2 Moreover, the odds ratio for the whirl sign in predicting the presence of small bowel obstruction necessitating surgery was 25.3 (95% CI, 10.3–62.3).2 As our case, ‘whirl sign’ in CT can provide useful information for diagnosing volvulus and suggest surgical intervention.

Whirl sign.

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