Barber-Pole Sign in CT Angiography, Adult Presentation of Midgut Malrotation: A Case Report

Abstract

Adult midgut volvulus is a challenging diagnosis because of its low incidence and nonspecific symptoms. Diagnostic delay and long-term complaints are frequent in this clinical scenario. We reported a patient referred to our diagnostic imaging unit with intermittent abdominal pain, bloating and episodic vomiting for several years. He underwent barium gastrointestinal transit and abdominal ultrasound, which revealed severe gastric dilatation, food retention and slow transit until a depressed duodenojejunal flexure, with malrotation of the midgut and jejunal loops being located in the right upper quadrant. Computed tomography angiography was performed, showing rotation of the small intestine around the mesentery root, suggestive of midgut malrotation. In addition, an abnormal twisted disposition of superior mesenteric artery with corkscrew appearance was seen, shaping the pole-barber sign which was evident in volume rendering three-dimensional reconstructions. The patient underwent scheduled surgical treatment without any complication and had good outcome after hospital discharge and follow-up. Computed tomography plays an important role in evaluation of adult midgut volvulus. In addition, angiographic reconstructions can help us to assess the anatomic disposition of mesenteric vascular supply. Both of these assessments are useful in preoperative management.

An unusual presentation of congenital intestinal malrotation in a nonagenarian

“…Diagnosis of pathologies such as appendicitis are difficult to detect in patient’s with malrotation and represent a clinical dilemma [11] . Of the imaging modalities, conventional X-rays yield low utility with positive cases usually showing abnormal fluid and air levels with abnormal jejunal loops and an absent colon on the right side of the abdomen [4] . CT imaging currently stands as the gold standard imaging modality available for diagnosing malrotation and if possible, with PO contrast [12] .…”

“…A large portion (40%) of affected patients are diagnosed within the first week of life with the vast majority (75–85%) following within the first year [3] . Very few cases in children remain quiescent, therefore incidence rates in adults become increasingly small and one estimate shows an occurrence of 0.16% within the adult population [4] . Intestinal malrotation occurs when the colon and small intestine fail to properly rotate into their normal anatomic positions when the intestines return into the abdominal cavity in utero.…”

A rare acute presentation of intestinal malrotation in the elderly

“…1,2 The "whirlpool sign" first described by Fisher on CT scan and by Pracros et al on USS demonstrated by clockwise encirclement of the SMA by coils of small bowel with mesentery and the superior mesenteric vein (SMV) is seen on doppler USS even though it may be associated with technical difficulties in adults. [20][21][22] Abdominal CT scan can demonstrate SMV in anomalous location posterior and left of the SMA even though patients with malrotation may have a normal SMA-SMV orientation, and an abnormality of SMA-SMV relationship may be due to a normal variant and not necessarily intestinal malrotation. 7,23 Also, midgut and duodenum may be noted not to cross the spine.…”

Small Bowel Volvulus due to Mesenteric Lymphatic Malformation: MDCT Demonstration of Counterclockwise Barber Pole Sign

“…Lymphatic malformations are a frequently encountered pediatric disease, representing 6% of benign tumors in children 1,2 In pediatric patients, lymphatic malformations are often located in the cervico-facial region and in the axilla. Intra-abdominal localization is less frequent, with a reported incidence of <5 % of the total.…”

“…Although the malformation is mostly asymptomatic, some may lead to complications, such as secondary infection, rupture, hemorrhage, volvulus, or intestinal obstruction, particularly when the lesion increases in size and volume. 1 As a cause of small bowel volvulus, the mesenteric lymphatic malformations constitute a relatively uncommon entity. 4,5 When small bowel volvulus is encountered, it is a surgical emergency and needs prompt diagnosis and management.…”