Caught in the Whirl: A Case Report of Midgut Volvulus in an Elderly Patient

Adult midgut volvulus is an uncommon but potentially life-threatening condition that often presents with nonspecific and intermittent symptoms, making diagnosis challenging. This case highlights the importance of maintaining a high index of suspicion in older patients with postprandial abdominal pain and physiologic abnormalities, even in the setting of a relatively benign abdominal exam. Early diagnosis is paramount to prevent complications such as bowel necrosis and short intestinal syndrome, especially given that mortality rates approach 5%. Advanced imaging plays a critical role, particularly CT imaging. Characteristic findings include a “whirlpool” sign, or a swirled appearance of the mesentery and superior mesenteric vein (SMV) around the superior mesenteric artery (SMA), malrotated bowel configuration, transposition of the SMA/SMV, bowel obstruction, and pneumoperitoneum. The direction of the whirlpool swirl tends to be clockwise on ultrasound and counter-clockwise on CT. 3 , 13 A systematic review of adult malrotation cases demonstrated that CT tends to be the most frequently used imaging modality in diagnosis, and the whirlpool sign was observed in roughly one third of cases. The most common imaging finding was abnormalities of the superior mesenteric axis. 14 CTA of the abdomen and pelvis is the preferred imaging modality when bowel ischemia is suspected 12 because it allows detailed evaluation of the mesenteric vasculature while still adequately assessing bowel pathology such as volvulus, which may present with overlapping clinical features. The sensitivity and specificity of the whirlpool sign on CTA in adults is 64–100% and 98–100%, respectively. When multiple CT predictors are present, such as multiple transition points, location, and whirlpool sign, specificity approaches 100%. 15 , 16 CT is generally highly accurate for diagnosing small bowel obstruction and its causes, including volvulus. This case highlights an uncommon presentation of midgut volvulus in an adult without typical predisposing risk factors such as extensive abdominal adhesions. The patient presented with non-specific symptoms, including postprandial abdominal pain, bloating, and nausea. Physical exam was notable for tachycardia, but was otherwise relatively benign, with minimal abdominal distension or tenderness. Thus, imaging was critical for timely diagnosis and guiding definitive management. An additional complexity in this case was the presence of apparent pneumoperitoneum on imaging without an identifiable perforation at the time of surgery, despite running the bowel and performing an esophagogastroduodenoscopy and sigmoidoscopy. One possibility is the subdiaphragmatic lucency seen on the upright chest x-ray may have represented interposed bowel, as seen in Chilaiditi syndrome, rather than true free intraperitoneal air. Alternatively, transient or micro perforation, potentially related to diverticular disease, as suggested by the surgical team, may have sealed prior to operative exploration. These possibilities highlight the limitations of imaging in definitively distinguishing true pneumoperitoneum from mimics. The patient’s post-operative course was uncomplicated, and he was discharged home in stable condition. He has continued to do well with no complications noted at follow-up visits. This patient’s case contributes to the literature on adult midgut volvulus due to malrotation, which is a rare but serious diagnosis. It also highlights the critical importance of imaging in diagnosis and management. Due to its high sensitivity for vascular compromise and characteristic signs, CTA is the preferred imaging modality for suspected volvulus in adults. However, adjunctive imaging such as upright abdominal or chest x-rays, which are useful for identifying free air, and abdominal ultrasound may be helpful in expediting the diagnosis and guiding early management, especially in unstable patients or resource-limited settings. This case underscores several key principles: first, that normal laboratory values, including lactate, do not exclude early bowel ischemia; second, that a high index of suspicion should be maintained in elderly patients with postprandial abdominal pain and abnormal vital signs even when the abdominal exam appears reassuring, since the clinical history may suggest pain out of proportion to exam; and third, that timely CTA can facilitate rapid diagnosis and surgical management. Ultimately, early recognition and intervention are essential to prevent progression to bowel necrosis and other serious complications.