Unusual Presentations of Midgut Volvulus with the Whirlpool Sign

Objective: The purpose of this series was to emphasize the varied presentations of midgut volvulus from neonatal life to well into adulthood and to evaluate the role of the whirlpool sign on sonography in diagnosing this condition.

Methods: A retrospective search of all midgut volvulus cases diagnosed in the radiology department of a 1500-bed general hospital between February 2002 and July 2005 was done. Eight patients with surgically confirmed midgut volvulus were found, all of whom had undergone sonography as the initial screening investigation.

Results: Eight patients, with ages ranging from 9 days to 32 years (mean age, 11.8 years), had undergone sonography for varied conditions, including bilious and nonbilious vomiting, vague abdominal pain, epigastric lumps, weight loss, features mimicking appendicitis, and pancreatitis. In all patients, the diagnosis of midgut volvulus was made on the basis of the clockwise whirlpool sign on sonography. Subsequently, 4 patients underwent upper gastrointestinal series, and contrast-enhanced computed tomography was done in 6 cases. Surgical confirmation of the diagnosis was obtained in all cases. Two patients were taken for surgery on the basis of only sonographic findings.

Conclusions: Midgut volvulus can also appear much beyond the neonatal age group with a variety of clinical presentations, making the clinical diagnosis in such patients very difficult, if not impossible. Identification of the clockwise whirlpool sign on sonography is an accurate way of diagnosing this condition, which can preclude the need for further investigations and can allow prompt surgical intervention.