European Journal of Radiology 74 (2010) 60–66

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European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Review

Small and large bowel volvulus: Clues to early recognition and complications
Marianne Lepage-Saucier, An Tang ∗ , Jean-Sébastien Billiard,
Jessica Murphy-Lavallée, Luigi Lepanto
Département de radiologie, Hôpital Saint-Luc, Centre Hospitalier Universitaire de Montréal (CHUM),
1058 rue Saint-Denis, Montréal, Québec, Canada H2X 3J4

a r t i c l e i n f o a b s t r a c t

Article history:
Received 27 July 2009
Received in revised form
11 November 2009
Accepted 11 November 2009
This paper was presented at RSNA 2008
meeting as an electronic education exhibit
and was awarded a “Cum Laude Award”. It
was listed as “LL-GI4942: Twist and Shout!
Pictorial Essay: Small and Large Bowel
Volvulus Clues to Early Recognition and
Complications.”
Small and large bowel volvulus are uncommon causes of bowel obstruction with nonspecific clinical
manifestations which may delay the diagnosis and increase morbidity. Therefore, radiologists play an
important role in promptly establishing the diagnosis, recognizing underlying congenital or acquired
risk factors and detecting potentially life-threatening complications. Multidetector CT performed with
intravenous contrast is currently the preferred modality for the evaluation of volvulus, which is best
appreciated when imaging is perpendicular to the axis of bowel rotation, hence the benefit of multiplanar
reformations. In this pictorial essay we review the pathophysiology of the different types of intestinal
volvulus, discuss diagnostic criteria for prompt diagnosis of volvulus and emphasize early recognition of
the complications.
Crown Copyright © 2009 Published by Elsevier Ireland Ltd. All rights reserved.

Keywords:
Midgut volvulus
Cecal volvulus
Sigmoid volvulus

1. Introduction sis. Because of these nonspecific symptoms, awareness of imaging

Volvulus is a pathology affecting both children and adults. Small
bowel volvulus is the cause of only 1–4% of small bowel obstruc-
tions in Western countries, but up to 20–35% of small bowel
obstructions in Africa and Asia [1]. Sigmoid volvulus is the most
frequent type of colonic volvulus, representing 60–75%, in com-
paraison to cecal volvulus that represents 22–33% of all cases [1].
The pathophysiology of small bowel volvulus differs from that
affecting large bowel. Small bowel torsion during volvulus occurs
around the dorsal mesentery [2] (Fig. 1). In contrast, colonic volvu-
lus involves the mobile, intraperitoneal parts of the colon such as
the cecum, transverse colon and sigmoid (Fig. 2).
Congenital risk factors include malrotation (Figs. 3 and 4), fix-
ation anomalies, a long and mobile cecum and dolichosigmoid.
Acquired risk factors include constipation, adhesions, intraperi-
toneal tumors, pregnancy, colonic distension and laxatives [1–4].
The clinical manifestations of volvulus are nonspecific: acute or
recurrent episodes of abdominal pain, bloating, vomiting and sep-
∗ Corresponding author. Tel.: +1 514 890 8000; fax: +1 514 412 7359.
E-mail address: duotango@gmail.com (A. Tang).
findings is important to enable the radiologist to promptly make
the diagnosis.
2. Imaging modalities
The diagnosis of volvulus was traditionally made by abdomi-
nal radiographs and fluoroscopy. Ultrasound can be used for the
investigation of malrotation in the pediatric population.
Multidetector CT performed with intravenous contrast is cur-
rently the preferred modality for the evaluation of acute obstructive
abdominal pathologies [5]. Volvulus is best appreciated when
imaging is perpendicular to the axis of bowel rotation, hence the
benefit of MPR reconstructions.
3. Small bowel volvulus and malrotation
Abdominal radiography is nonspecific for small bowel volvulus,
but may show distension of stomach, duodenum and small bowel
proximal to the transition point with a collapsed appearance or lack
of aeration of the distal bowel loops.
Fluoroscopy may be used in children when malrotation is sus-
pected and can reveal a duodenojejunal junction located on midline

0720-048X/$ – see front matter. Crown Copyright © 2009 Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejrad.2009.11.010
 M. Lepage-Saucier et al. / European Journal of Radiology 74 (2010) 60–66 61

Fig. 3. Forty-five-year-old male with a normal anatomy. Axial contrast-enhanced CT

image shows the normal relationship between the superior mesenteric vein (SMV)
(arrow) located anteriorly and to the right of the superior mesenteric artery (SMA)
(arrowhead).

Fig. 1. In small bowel volvulus, the torsion occurs around the dorsal mesentery
(arrow).

Fig. 4. Seventeen-year-old man with an asymptomatic malrotation. Axial contrast-

enhanced CT shows a SMV (arrow) located on the left side of the SMA (arrowhead).

Fig. 2. Fixed segments are represented in orange, transition segments in yellow and
mobile segments at risk of being involved in volvulus in red (asterisks).

Table 2
Summary of large bowel volvulus signs.

Findings Cecal volvulus Sigmoid volvulus

Table 1
Summary of small bowel volvulus signs. Abdominal “Coffee bean” sign pointing “Coffee bean” pointing
radiograph toward left upper quadrant toward right (or left) upper
Findings Small bowel volvulus quadrant
“Northern exposure” sign
Abdominal Small bowel obstruction pattern
radiography CT Cecal obstruction and Sigmoid obstruction and
CT Volvulus fulcrum centered on dorsal mesentery distension distension
Multiple transition points Transition point centered Transition point centered
Transition points located ≤7 cm from the spine on cecal mesentery on sigmoid mesentery
Swirl extending ≥180◦ including both bowel and “Barber-pole” sign “Barber-pole” sign
vessels around a fixed obstruction point involving ileocolic vessels involving sigmoid vessels
62 M. Lepage-Saucier et al. / European Journal of Radiology 74 (2010) 60–66

Fig. 5. Sixty-five-year-old woman with an asymptomatic malrotation. (a) Transverse US shows the SMA (arrowhead) on right side of the SMV (long arrow). (b) Duplex US
image at the same level confirms the diagnosis.

Fig. 6. Fifty-year-old man with a distal small bowel volvulus caused by an adhesion from a previous partial gastrectomy for gastric cancer. (a) Axial contrast-enhanced CT
image shows distended proximal small bowel loops, free fluid between loops of small bowel (arrowhead) and transition point (long arrow). (b) Axial CT image shows beaking
of the afferent (short arrow) and efferent (long arrow) small bowel loops. (c) Coronal MIP shows whirl sign of the mesenteric vessels (arrow).
 M. Lepage-Saucier et al. / European Journal of Radiology 74 (2010) 60–66 63

or on the right side of the abdomen. A lowered ligament of Treitz
can also be found. If a volvulus is present, the “corkscrew” sign
has been described and if there are peritoneal bands, dilatation of
proximal duodenum may be seen [6,7].
Ultrasound can show small-bowel malrotation (Fig. 5). A whirl
sign can be found in the pediatric population if a volvulus is present,
described as wrapping of the superior mesenteric vein (SMV) and
the mesentery around the superior mesenteric artery (SMA).
The following three signs were validated for the diagnosis of
small bowel volvulus: multiple transition points, transition points
located ≤7 cm from the spine in the antero-posterior plane and a
whirl sign: swirl extending ≥180◦ including both bowel and vessels
around a fixed point of obstruction. The presence of any one of
these three findings at CT revealed volvulus with a sensitivity of
94% and the presence of all three signs had a specificity of 100% [8]
(Fig. 6).
The signs of small bowel volvulus are summarized in Table 1.
4. Cecal volvulus
Three subtypes of cecal volvulus have been described, distin-
guished by the presence of cecal rotation along the longitudinal
axis of the colon, cecal folding to the center of the abdomen, or
combination of both [9].

Fig. 7. Thirty-three-year-old woman with a cecal volvulus who presented with acute abdominal pain. (a) Standing AP radiograph shows distended cecum displaced to the
center of the abdomen and pointing to the left upper quadrant (arrow). (b) Axial contrast-enhanced CT image shows torsion of ileo-cecal vessels (arrowhead) and beaking
of ascending colon (arrow). (c) Subsequent right hemicolectomy specimen revealed edema, ischemia and parietal hemorrhage on 21 cm of cecum and ascending colon.
64 M. Lepage-Saucier et al. / European Journal of Radiology 74 (2010) 60–66

Fig. 9. Seventy-six-year-old woman with a sigmoid volvulus. AP scout shows sig-

moid distension (arrowheads), with inverted “U” pointing toward right upper
Fig. 8. Sixty-four-year-old woman with a cecal volvulus. Thick coronal contrast-
quadrant.
enhanced MIP shows «Barber-Pole» sign. SMA branches (arrowheads) rotate around
the main SMV (long arrow).

Diagnosis is possible with an abdominal radiograph in 70% of

7. Complications, treatment options and prognosis
cases: the cecum is distended, adopting a “coffee bean” shape and
may point toward the left upper quadrant, small bowel may be
The complications are potentially severe and well shown with
distended or fluid-filled due to closed-loop obstruction with the
CT. They influence the prognosis and treatment of all types of volvu-
distal bowel loops collapsed [1,3] (Fig. 7).
lus, therefore emphasizing the importance of early recognition.
CT shows signs of cecal obstruction and distension. The transi-
Potential volvulus complications are related to ischemia and per-
tion point can be well identified with the afferent and efferent loops
foration. The imaging manifestations include: wall edema, poor
collapsed. Torsion of the mesenteric vessels is also seen with what
enhancement, free fluid, parietal hemorrhage, pneumatosis and
is described as the “barber-pole” sign: SMA branches in rotation
peritonitis (Figs. 13–15).
around the main SMV (Fig. 8).

5. Sigmoid volvulus

Radiographic signs seen in sigmoid volvulus include: sigmoid

distension with thinning of haustrations, an inverted “U” that may
point toward the right or left upper quadrant (Fig. 9), a “coffee
bean” or “bent inner tube” configuration of the bowel, distension
of proximal colon and small bowel and a collapsed rectum, or a
“northern exposure sign” that describes a distended sigmoid cepha-
lad to transverse colon. An abrupt reduction in bowel caliber at the
transition point seen as a “beak” or “ace of spades sign” (Fig. 10), a
“corkscrew sign” or wall thickening may be demonstrated at fluo-
roscopy [4].
The signs that are found at CT are similar to those of cecal
volvulus but with an obstruction at the sigmoid level. The tran-
sition point, with the afferent and efferent loops forming a “beak”,
and the vascular torsion can be well demonstrated (Figs. 11
and 12).
The signs of large bowel volvulus are summarized in Table 2.

6. Uncommon types of volvulus

Transverse volvulus represents 2–4% of colonic volvulus and

splenic angle involvement less than 1%. Diagnosis can be made if the
transition point is located on the tranverse colon or splenic flexure Fig. 10. Sixty-one-year-old-man with a sigmoid volvulus. Barium enema shows
[10]. transition point of a sigmoid volvulus (arrow).
 M. Lepage-Saucier et al. / European Journal of Radiology 74 (2010) 60–66
Fig. 11. Sixty-seven-year-old woman with a sigmoid volvulus who presented with
severe abdominal pain. (a) Axial contrast-enhanced CT image with rectal contrast
shows beaking at transition point (arrow). (b) Antero-posterior 3D volume rendering
shows the markedly distended sigmoid volvulus loop (white arrows), the mildly
distended ascending colon (black arrows) and the small bowel loops clumped in the
left flank (arrowheads).
Treatment options vary according to the type of volvulus. If mal-
rotation and Ladd’s band is found in an infant, a preventive surgery
of malrotation can be done, called Ladd’s procedure. Small bowel
volvulus treatment options are surgical only, including surgical
reduction without resection if absence of necrosis and resection
and primary anastomosis. Mortality rate for small bowel volvulus
is about 10–35% [2,8,11].
Treatment is strictly surgical for cecal volvulus. A volvulus
reduction with caecopexy or an ileo-cecal resection and pri-
mary or secondary anastomosis can be done. Recurrence rate
is around 14% and mortality rate varies between 5 and 22%
[12–14].
65
Fig. 12. Seventy-five-year-old woman with recurrent sigmoid volvulus who was
previously treated by decompression colonoscopy. (a) Coronal contrast-enhanced
CT image shows torsion of sigmoid vessels (arrows) in a background of mesenteric
fat (arrowheads). (b) Axial CT image shows the sigmoid proximal (arrow) and distal
to the obstruction (arrowhead).
A sigmoid volvulus can be treated either by coloscopy or surgery.
A decompression coloscopy is indicated for elderly patients,
those with comorbidities and for asymptomatic patients, with
a success rate of about 70–80%. Given the high recurrence rate
(40–50%), coloscopy is usually followed by an elective surgery
during the same hospitalization or on an outpatient basis. Mor-
tality rate is around 14–21% in the absence of necrosis and
53% if necrosis is present [1,4], hence the need for early inter-
vention.
66 M. Lepage-Saucier et al. / European Journal of Radiology 74 (2010) 60–66

8. Conclusion

Intestinal volvulus is a gastrointestinal emergency that can be

seen in a wide population. Malrotation is an important risk fac-
tor for small bowel and cecal volvulus. Because of the nonspecific
clinical manifestations, CT and multiplanar reformations play an
important role in identifying signs of volvulus such as vascular tor-
sion and transition point. Early recognition is critical to prevent
complications.

Conflict of interest

We confirm that the authors or authors’ institution have no con-

flict of interest, personal relationship or commercial involvement
that inappropriately influenced our judgement in the preparation
of this manuscript.

Acknowledgement
Fig. 13. Fifty-two-year-old man with a small bowel volvulus. Axial contrast-
enhanced CT image shows small bowel wall edema (arrowheads).
We acknowledge Mrs Mireille Bricault for producing the illus-
trations and Mr Éric Fournier for the 3D reconstructions.
Contribution: The manuscript provides a one-stop shop review
article for radiologists interested in the topic of midgut, cecal or sig-
moid volvulus. We summarized the pathophysiology, risk factors,
imaging findings, potential complications, treatment and progno-
sis of each entity. A thorough pictorial essay including diagrams,
radiographs, ultrasound, doppler, CT and surgical specimen was
included for educational purpose. We emphasized key imaging fea-
tures revealed by MDCT and multiplanar reformations to promptly
recognize the diagnosis and potentially life-threatening complica-
tions.

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Fig. 15. Twenty-four-year-old woman with a cecal and ascending colon volvulus
who developed post-operative hemodynamic instability. Axial contrast-enhanced
CT image shows pneumatosis (arrowheads).