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CT angiographic demonstration of a mesenteric vessel "whirlpool" in intestinal malrotation and midgut volvulus: a case report.

Bozlar U, Ugurel MS, Ustunsoz B, Coskun U - Korean J Radiol (2008 Sep-Oct)

Bottom Line: Although the color Doppler ultrasonography diagnosis of intestinal malrotation with midgut volvulus, based on the typical "whirlpool" appearance of the mesenteric vascular structures is well-defined in the peer-reviewed literature, the combination of both the angiographic illustration of these findings and the contemporary state-of-the-art imaging techniques is lacking.We report the digital subtraction angiography and multidetector computed tomography angiography findings of a 37-year-old male with intestinal malrotation.

View Article: PubMed Central - PubMed

Affiliation: Gulhane Military Medical Academy, Department of Radiology, Ankara, Turkey. ubozlar@yahoo.com

ABSTRACT
Although the color Doppler ultrasonography diagnosis of intestinal malrotation with midgut volvulus, based on the typical "whirlpool" appearance of the mesenteric vascular structures is well-defined in the peer-reviewed literature, the combination of both the angiographic illustration of these findings and the contemporary state-of-the-art imaging techniques is lacking. We report the digital subtraction angiography and multidetector computed tomography angiography findings of a 37-year-old male with intestinal malrotation.

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Intestinal malrotation and midgut volvulus.A-F. Oblique digital subtraction angiogram (A) of patient depicting "barber's pole" sign (arrows) due to rotations of superior mesenteric artery and its branches. Axial CT (B, C) and 3D-MDCT angiography (D, E) images in arterial phase (B, D) and venous phase(C, E) depicting rotational abnormality of mesenteric arterial root and its branches (arrowheads, whirl sign) along with tortuous dilated superior mesenteric vein (arrows) which also contributes to "whirlpool" configuration. Note "clockwise" rotation (superior to inferior), as viewed from caudal aspect, of both arterial branches and mesenteric vein (at least partially on each other). Image from upper gastrointestinal series with barium (F), immediately after CT-angiography examination demonstrating "corkscrew" configuration (arrows) of proximal small bowel as it twists around superior mesenteric artery. Note that excreted renal pelvocalyceal contrast remaining from CT examination complicates this image.
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Figure 1: Intestinal malrotation and midgut volvulus.A-F. Oblique digital subtraction angiogram (A) of patient depicting "barber's pole" sign (arrows) due to rotations of superior mesenteric artery and its branches. Axial CT (B, C) and 3D-MDCT angiography (D, E) images in arterial phase (B, D) and venous phase(C, E) depicting rotational abnormality of mesenteric arterial root and its branches (arrowheads, whirl sign) along with tortuous dilated superior mesenteric vein (arrows) which also contributes to "whirlpool" configuration. Note "clockwise" rotation (superior to inferior), as viewed from caudal aspect, of both arterial branches and mesenteric vein (at least partially on each other). Image from upper gastrointestinal series with barium (F), immediately after CT-angiography examination demonstrating "corkscrew" configuration (arrows) of proximal small bowel as it twists around superior mesenteric artery. Note that excreted renal pelvocalyceal contrast remaining from CT examination complicates this image.

Mentions: A 37-year-old man was seen for complaints of intermittent abdominal pain, which usually occurred after meals. The initial US and CDUS screening revealed counterclockwise superior mesenteric vein twisting around the superior mesenteric artery (SMA). However, the etiology underlying this appearance was not recognized and the patient was referred for an angiography due to the suspicion of a congenital vascular anomaly or variation as a reason to explain his post-prandial abdominal pain. In the catheter angiography study, the SMA was found to be twisted (Fig. 1A). Subsequent to this study, the patient was taken into suites for upper GI series and CT examinations, with the suspicion of intestinal malrotation. Although the angiography was fairly diagnostic, a MDCT was performed to document the state of the superior mesenteric vein and the vascularity of the subtended bowel. A CT angiography was performed with a 16-detector row computed tomography (Philips Medical System, MX8000IDT, Haifa, Israel) with the following parameters; kV: 100, mAs: 158, collimation: 16 × 0.75 mm, slice thickness: 1 mm, slice increments: 0.5 mm, and pitch: 0.9. One hundred twenty milliliters of Iohexol 300 mgI/ml (Omnipaque, Amersham Health, Cork, Ireland) was administered via the antecubital vein at a flow rate of 4 mL/sec. In addition, the automated bolus tracking method was used for imaging in the arterial phase. Moreover, portal venous scans were obtained with a 60-second delay after the initial injection. The arterial phase axial CT images showed that the superior mesenteric vein and artery had an inverse relationship. The three-dimensional reformatted images from the CT angiography demonstrated the mesenteric vessels to be rotating with an eventual tortuous and dilated superior mesenteric vein (Figs. 1B-E). Otherwise, the CT imaging results were normal, except for the absence of the uncinate process of the pancreas. This was likely related with the well-known generalized problem of counterclockwise rotation in malrotation patients, which is the uncinate process formed from the ventral pancreatic bud after its rotational migration around the duodenum and fusion with the dorsal pancreas. The small bowel series revealed that the duodenojejunal junction was on the right side of the midaxis and inferior to the duodenal bulb. The proximal jejunum was also observed to be rotated around its axis (corkscrew sign) (Fig. 1F). As a result of this diagnosis, the patient was offered surgical correction of the volvulus and release of predisposing fibrous bands or adhesions that might have developed in the long run secondary to the congenital malrotation (Ladd's procedure). However, the patient did not consent to surgery and was lost to follow-up.


CT angiographic demonstration of a mesenteric vessel "whirlpool" in intestinal malrotation and midgut volvulus: a case report.

Bozlar U, Ugurel MS, Ustunsoz B, Coskun U - Korean J Radiol (2008 Sep-Oct)

Intestinal malrotation and midgut volvulus.A-F. Oblique digital subtraction angiogram (A) of patient depicting "barber's pole" sign (arrows) due to rotations of superior mesenteric artery and its branches. Axial CT (B, C) and 3D-MDCT angiography (D, E) images in arterial phase (B, D) and venous phase(C, E) depicting rotational abnormality of mesenteric arterial root and its branches (arrowheads, whirl sign) along with tortuous dilated superior mesenteric vein (arrows) which also contributes to "whirlpool" configuration. Note "clockwise" rotation (superior to inferior), as viewed from caudal aspect, of both arterial branches and mesenteric vein (at least partially on each other). Image from upper gastrointestinal series with barium (F), immediately after CT-angiography examination demonstrating "corkscrew" configuration (arrows) of proximal small bowel as it twists around superior mesenteric artery. Note that excreted renal pelvocalyceal contrast remaining from CT examination complicates this image.
© Copyright Policy - open-access
Related In: Results  -  Collection

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Show All Figures
getmorefigures.php?uid=PMC2627208&req=5

Figure 1: Intestinal malrotation and midgut volvulus.A-F. Oblique digital subtraction angiogram (A) of patient depicting "barber's pole" sign (arrows) due to rotations of superior mesenteric artery and its branches. Axial CT (B, C) and 3D-MDCT angiography (D, E) images in arterial phase (B, D) and venous phase(C, E) depicting rotational abnormality of mesenteric arterial root and its branches (arrowheads, whirl sign) along with tortuous dilated superior mesenteric vein (arrows) which also contributes to "whirlpool" configuration. Note "clockwise" rotation (superior to inferior), as viewed from caudal aspect, of both arterial branches and mesenteric vein (at least partially on each other). Image from upper gastrointestinal series with barium (F), immediately after CT-angiography examination demonstrating "corkscrew" configuration (arrows) of proximal small bowel as it twists around superior mesenteric artery. Note that excreted renal pelvocalyceal contrast remaining from CT examination complicates this image.
Mentions: A 37-year-old man was seen for complaints of intermittent abdominal pain, which usually occurred after meals. The initial US and CDUS screening revealed counterclockwise superior mesenteric vein twisting around the superior mesenteric artery (SMA). However, the etiology underlying this appearance was not recognized and the patient was referred for an angiography due to the suspicion of a congenital vascular anomaly or variation as a reason to explain his post-prandial abdominal pain. In the catheter angiography study, the SMA was found to be twisted (Fig. 1A). Subsequent to this study, the patient was taken into suites for upper GI series and CT examinations, with the suspicion of intestinal malrotation. Although the angiography was fairly diagnostic, a MDCT was performed to document the state of the superior mesenteric vein and the vascularity of the subtended bowel. A CT angiography was performed with a 16-detector row computed tomography (Philips Medical System, MX8000IDT, Haifa, Israel) with the following parameters; kV: 100, mAs: 158, collimation: 16 × 0.75 mm, slice thickness: 1 mm, slice increments: 0.5 mm, and pitch: 0.9. One hundred twenty milliliters of Iohexol 300 mgI/ml (Omnipaque, Amersham Health, Cork, Ireland) was administered via the antecubital vein at a flow rate of 4 mL/sec. In addition, the automated bolus tracking method was used for imaging in the arterial phase. Moreover, portal venous scans were obtained with a 60-second delay after the initial injection. The arterial phase axial CT images showed that the superior mesenteric vein and artery had an inverse relationship. The three-dimensional reformatted images from the CT angiography demonstrated the mesenteric vessels to be rotating with an eventual tortuous and dilated superior mesenteric vein (Figs. 1B-E). Otherwise, the CT imaging results were normal, except for the absence of the uncinate process of the pancreas. This was likely related with the well-known generalized problem of counterclockwise rotation in malrotation patients, which is the uncinate process formed from the ventral pancreatic bud after its rotational migration around the duodenum and fusion with the dorsal pancreas. The small bowel series revealed that the duodenojejunal junction was on the right side of the midaxis and inferior to the duodenal bulb. The proximal jejunum was also observed to be rotated around its axis (corkscrew sign) (Fig. 1F). As a result of this diagnosis, the patient was offered surgical correction of the volvulus and release of predisposing fibrous bands or adhesions that might have developed in the long run secondary to the congenital malrotation (Ladd's procedure). However, the patient did not consent to surgery and was lost to follow-up.

Bottom Line: Although the color Doppler ultrasonography diagnosis of intestinal malrotation with midgut volvulus, based on the typical "whirlpool" appearance of the mesenteric vascular structures is well-defined in the peer-reviewed literature, the combination of both the angiographic illustration of these findings and the contemporary state-of-the-art imaging techniques is lacking.We report the digital subtraction angiography and multidetector computed tomography angiography findings of a 37-year-old male with intestinal malrotation.

View Article: PubMed Central - PubMed

Affiliation: Gulhane Military Medical Academy, Department of Radiology, Ankara, Turkey. ubozlar@yahoo.com

ABSTRACT
Although the color Doppler ultrasonography diagnosis of intestinal malrotation with midgut volvulus, based on the typical "whirlpool" appearance of the mesenteric vascular structures is well-defined in the peer-reviewed literature, the combination of both the angiographic illustration of these findings and the contemporary state-of-the-art imaging techniques is lacking. We report the digital subtraction angiography and multidetector computed tomography angiography findings of a 37-year-old male with intestinal malrotation.

Show MeSH
Related in: MedlinePlus