Elsevier

Legal Medicine

Volume 16, Issue 5, September 2014, Pages 300-302
Legal Medicine

Case Report
A fatal case of adult small bowel volvulus

https://doi.org/10.1016/j.legalmed.2014.05.007Get rights and content

Abstract

A 56-year-old man was hit by a car while riding a bicycle, immediately brought to the hospital, and treated. Four days after the accident, he reported abdominal pain and vomiting in the night, and he died the next day. A forensic autopsy was performed, and almost of the entire small bowel had gangrenous swelling. The mesentery was twisted 180° with clockwise rotation along the vascular axis, and pre-autopsy computed tomography scan showed a whirl sign.

Introduction

Small bowel volvulus is the torsion of the small bowel and its mesentery. It is a well-recognized disease in infants and children, but adult primary small bowel volvulus is rare [1]. The diagnosis is difficult, as the symptoms resemble those of acute abdomen [2]; consequently, it can sometimes be fatal. We report a fatal case of small bowel volvulus that was suspected as being primary, and a pre-autopsy computed tomography (CT) scan showed a “whirl sign.”

Section snippets

Case report

A 56-year-old man was hit by a car while riding a bicycle. He was immediately brought to the hospital and diagnosed with brain contusion, epidural hematoma, subdural hematoma, and fracture of left tibia and fibula. He was ordered to stay in bed for fracture fixation, and conservative management was performed because the brain injury was mild. Four days after the accident, suddenly he unexpectedly reported abdominal pain and vomiting in the night. He was medicated and observed, but developed

Autopsy findings

The victim was 176 cm in height and weighed 63 kg. Rigor mortis was strongly present throughout the body.

On the head and face, many abrasions were noticed. There were some fractures on the right side of the skull and the cranial base. There was a brain contusion in the left temporal lobe with slight epidural and subdural hematoma. No herniation was found in the brain.

In the abdomen, no injury was noted on the surface or subcutaneously. Operation scars were absent, and no adhesion was found in the

Discussion

Bowel volvulus is the result of bowel torsion around the axis of the mesentery. In adults, most volvulus cases occur in the colon, with 70–80% in the sigmoid colon [2]. Small bowel volvulus in adults is rare and is classified in two categories [1], [2]: (a) primary: without any apparent predisposing anatomical abnormalities and (b) secondary: precipitated by underlying anatomical abnormalities, including an anatomical malformations and postoperative adhesions.

In North America and Europe, small

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    Citation Excerpt :

    PMCT scans may be very helpful for the forensic pathologist in such conditions.102,103 Pathological CT findings in small bowel volvulus include distended and u-shaped loops104 converging to ward a point of obstruction, and the whirl sign which is characterized by loops encircling the mesenteric vessels displayed in a whirl-like pattern.104,105 At PMCT, sigmoid volvulus may show the coffee bean sign,104,105 which is created by the apposition of the medial walls and the lateral walls of the dilated loops, and the bird beak sign,105 which indicates a progressive tapering and covering of the proximal and distal loop segments at the point of twisting.

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