An 87-year-old man with Parkinson's disease presented with a 7-day history of progressive abdominal distention and constipation. The physical examination revealed hypoactive bowel sounds and diffuse abdominal tenderness with rebound; there was no fever, abdominal rigidity, or guarding. Computed tomography showed a distended sigmoid colon that was looped in an inverted U (Panel A, arrows). The coronal view revealed dilated loops of colon with a central whirl sign (Panel B, arrow). The whirl results from the rotation of afferent and efferent bowel loops around the point of obstruction, resulting in a tightly twisted mesentery. Colonoscopy revealed the volvulus to be 25 cm from the anal verge; there was no evidence of gangrenous mucosa or masses. The colonoscope was passed through this area and into the dilated colon. Aspiration of gas immediately relieved the abdominal distention. Three days later, the patient returned to his nursing home. His constipation was treated with laxatives, and the volvulus has not recurred after 1 year.
Chen and Chuang NEJM 361 (10): 1009, Figure 1 September 3, 2009
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