Swirl Sign — Intestinal Volvulus after Roux-en-Y Gastric Bypass

A 56-year-old man presented after a day and a half of midabdominal pain, nausea, and bilious emesis. The patient had undergone Roux-en-Y gastric bypass 7 years earlier. During the physical examination, tachycardia and tachypnea were noted. The abdominal examination showed a distended, tympanic abdomen with severe generalized abdominal tenderness, involuntary guarding, and rebound tenderness consistent with peritonitis. Radiography (Panel A) and computed tomography (CT) (Panel B) showed dilated loops of small bowel distal to the jejunojejunostomy staple line with proximal decompression. Swirling of the bowel and mesenteric vessels was noted on CT as they herniated through the jejunojejunostomy mesenteric defect. Exploratory laparoscopy showed an internal hernia of the small bowel. The herniation was reduced and the defect closed. Small-bowel obstructions associated with internal hernias after gastric bypass can progress to bowel necrosis and death. The patient's postoperative course was uncomplicated, and he was discharged home on postoperative day 2.

一名56岁男性患者因中腹部疼痛、恶心和呕吐胆汁一天半就诊。患者7天前曾接受胃肠道Roux-en-Y手术。体格检查发现患者心动过速及呼吸频数。腹部检查发现腹胀，叩诊鼓音，且有严重的广泛性压痛、肌卫及反跳痛，符合腹膜炎表现。X光（图A）及CT（图B）显示空肠空肠吻合口远端小肠扩张肠襻，近端肠襻则没有扩张。小肠及肠系膜血管经空肠空肠吻合口肠系膜缺损处疝出，CT上表现为旋转征。腹腔镜探查发现存在小肠内疝，遂将疝内容物复位并修补缺损。胃肠道旁路手术后内疝伴随的小肠梗阻可发展为小肠坏死甚至死亡。患者术后病程恢复良好，术后第2天出院。