Presentation
Previous subtotal colectomy and small bowel resections with end ileostomy in situ. Severe abdominal pain, tender abdomen with a non-functioning stoma.
Patient Data
Nasogastric tube in situ, adequately sited.
Subtotal colectomy, right iliac fossa ileostomy, and left iliac fossa mucous fistula. The rectum and sigmoid colon are sutured at the left hernial opening. Diverticulosis of the remnant sigmoid. Cholecystectomy clips.
Significantly distended small bowel with a transition point at the proximal small bowel soon after the duodeno-jejunal flexure with a second transition point at the distal small bowel; the two transition points are within 3 cm of each other, which appears to be in keeping with closed-loop obstruction. Nearly the entire remnant small bowel is involved in the closed-loop.
Free fluid at the paracolic gutters, particularly on the right side, and reactive mesenteric lymph nodes. No free gas. Bowel mucosa enhancement was preserved, and there was no pneumatosis or portal venous gas to suggest bowel infarction. Splanchnic vessels are patent.
Simple right renal cysts, the remaining solid abdominal organs are otherwise normal. Prostatic calcification is of doubtful significance. Normal urinary bladder.
Bibasal atelectasis, the imaged lung bases are otherwise clear. Unremarkable bone review.
Conclusion: high-grade closed-loop small bowel obstruction involving nearly the entire remnant small bowel, with a transition point in the right abdomen. There are no current features of ischemic bowel or perforation. Small amount of free fluid is present.
Case Discussion
The key findings in this case would be the presence of two transition points that are in close proximity to each other. Given the fact that nearly the entire remnant small bowel is involved, urgent surgical intervention would be advised to preserve what little small bowel remains for this patient. Additionally, the impression of swirling at the transition point suggests an element of volvulus.
The patient proceeded to emergency surgery where a band adhesion at the transition point as demonstrated on CT was released; in addition, the operative note remarked on a volvulus of the small bowel at the adhesion, corresponding with the swirl sign seen on CT. The small bowel was healthy otherwise and the patient did not require any bowel resection. Gut continuity was restored as part of the same operation, and the patient is recovering well some months post-operatively, though with challenging electrolyte balance given the relatively short length of the remaining small bowel.
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