A midgut volvulus is a complication of malrotated bowel and results in a proximal bowel obstruction and ischaemia.

Epidemiology A midgut volvulus of malrotated bowel can potentially occur at any age but in approximately 75% of cases is within a month of birth 4,6, most within the first week 3, and 90% within 1 year 6. Clinical presentation Typically the neonate is entirely normal for a period before suddenly presenting with bilious vomiting. If the volvulus does not spontaneously reduce, then the venous obstruction created by the superior mesenteric vein wrapped around the superior mesenteric artery results in venous obstruction and gradual onset of ischaemia and eventual necrosis. As this occurs, the abdomen becomes swollen as fluid accumulates in the lumen of the bowel, and becomes tender. Eventually peritonitis and shock become established. Radiographic features
Plain film

Unfortunately plain films are non-contributory appearing either normal early on, or having appearances of a bowel obstruction or even pneumoperitoneum later in the course of the disease. Occasionally complete obstruction can lead to distension of the duodenal bulb and stomach leading to a double bubble sign 7.
Contrast study

A paediatric upper gastrointestinal contrast study is the examination of choice when the diagnosis is suspected. Not only is it able to identify the volvulus, but even in instances where spontaneous reduction has occurred, the underlying malrotation will be evident. In the setting of volvulus findings include:

corkscrew sign tapering of beaking of the bowel in complete obstruction 3 malrotated bowel configuration

Contrast enemas have also been used historically. The theory being that in malrotation the large bowel will also be malrotated. Unfortunately in 20 - 30% of cases the caecum is normally located. The converse is also true, with position of the caecum in normal individuals being variable 3.
Ultrasound

Ultrasound findings include 1-5:

CT

clockwise whirlpool sign abnormal superior mesenteric vessels o inverted SMA/SMV relationship o solitary hyperdynamic pulsating SMA o truncated SMA o inapparent SMV abnormal bowel o dilated duodenum proximal to obstruction o thickened wall of small bowel distal to obstruction o dilated fluid filled loops of small bowel free intra-abdominal fluid

CT is often carried out in older patients, in which presentation is non-specific. Findings include :

whirlpool sign of twisted mesentary malrotated bowel configuration inverted SMA/SMV relationship bowel obstruction free fluid / free gas in advanced cases

Associations 8

gastroschisis omphalocele diaphragmatic hernia duodenal or jejunal atresia

Treatment and prognosis Urgent surgical repair (Ladd procedure) is required to prevent ischaemia or to resect infarcted bowel loops. If resection is performed stomas are usually created. Additionally the Ladd bands are divided and the mesenteric pedicle widened. In some instances pexy of the duodenum and caecum may be performed although it is unclear if this is of benefit in preventing recurrence 6. It should be noted that normal anatomical positioning is not achieved; the duodenum and small bowel remain on the right, and the caecum and colon are on the left side of the abdomen 6. Prognosis is dependent on the state of the small bowel and presence of systemic shock. In cases where no ischaemia of the bowel is present, and the child is otherwise well, prognosis is extremely good. Overall a mortality of 3 - 9% is reported 6. Small bowel obstruction for adhesions is seen a distant complication in 5 - 10% of cases. Differential diagnosis

Vomiting in infancy has numerous causes and needs to be distinguished from normal possetting. Differential of a proximal obstruction includes 3,6,7:

pyloric stenosis : vomiting with be non-bilious and projectile congenital obstruction o duodenal web o duodenal atresia o intestinal atresia o annular pancreas meconium ileus intussusception external compression of the dudenum o choledochal cyst o mesenteric duplication cyst o intramural duodenal haematoma o preduodenal portal vein o retroperitoneal tumour o superior mesenteric artery syndrome

with whirlpool sign

with corkscrew sign

with whirlpool sign

with whirlpool sign

The term cecal volvulus is a misnomer because, in most patients with cecal volvulus, the torsion is located in the ascending colon above the ileocecal valve. In general, a partial malrotation is necessary for cecal volvulus to occur, because the cecum and parts of the ascending colon are involved. Early diagnosis is essential to reduce the high mortality rate reported with this condition, which is essentially a closed-loop obstruction that may lead to vascular compromise with consequent gangrene and perforation.[1] The diagnosis is mostly based on plain abdominal radiographic findings aided by those of single-contrast barium enema examination (see the following images). Computed tomography (CT) scanning is useful in identifying signs of ischemia, which include mural thickening, infiltration of the mesenteric fat, and pneumatosis intestinalis. Treatment is surgical, but reduction of the volvulus has been reported after barium enema examination. Colonoscopy may be considered for the purpose of decompression.[2, 3, 4, 5, 6]

Plain supine abdominal radiograph from an 81-year-old man presenting with abdominal pain and vomiting. The radiograph shows a markedly distended loop of bowel 15-cm in diameter with its axis running from the right lower quadrant to the mid abdomen. This loop of bowel represent a twisted cecum with the caput cecum directed medially (arrows). The haustra within the cecum (C) are effaced. Note the proximal dilated loop of small bowel. The distal colon shows little if any air. At surgery a cecal volvulus was confirmed.

Right oblique image from a barium enema examination in from a 53-year-old woman who presented with clinical features of intestinal obstruction. This image shows a bird-beak appearance (arrow). At surgery, a cecal volvulus was confirmed.

Wolfer et al described defective peritoneal fixation of the ascending colon and cecum in 10% of the population.[7] This fixation permits abnormal mobility of the ascending colon and cecum, making displacement of the right colon into any part of the abdominal cavity possible. Depending on the length of the mobile ascending colon, a variety of obstructive bowel patterns may result. Many authors have described an association with adhesions, membranes, and bands, which may provide a nodal point around which the mobile ascending colon may twist. Although these conditions are frequently present, they are not essential for a volvulus to occur. Many studies of cecal volvulus have focused on the possibility of volvulus of the right colon occurring in association with obstructive lesions, usually in the left colon.[8] The most common distal colonic lesions associated with cecal volvulus are colonic carcinoma and diverticulitis.
Types of cecal volvulus

Two types of cecal volvulus are described: axial torsion type and the cecal bascule type. In practice, differentiation between the 2 types is not clinically important, because the clinical presentation and treatment is the same. However, the radiographic appearances are different, and recognition of these differences is important for diagnosis. Axial torsion, the most common form of volvulus, occurs with the development of a twist of 180-360o; along the longitudinal axis of the ascending colon. This form has a high mortality rate, because the obstructive process is associated with vascular compromise, which can lead to gangrene and perforation, often on the antimesenteric border, where the ischemic changes may be most pronounced. In the cecal bascule type of volvulus, the cecum folds anteromedial to the ascending colon, with the production of a flap-valve occlusion at the site of flexion. This form of torsion occurs in a transverse plane and is associated with marked distention of the cecum, which is often displaced into the center of the abdomen. As many as one third of the patients with cecal volvulus have this variety, and reduction of cecal bascule after barium enema examination is reported. With a cecal bascule, the ileum may passively twist with the cecum and not be obstructed. A constant feature of cecal bascule is the presence of a constricting band across the ascending colon; this may be found at laparotomy.[9]
Anatomy

Occasionally, diaphragmatic interposition of the right colon (Chilaiditi syndrome) occurs. This is related to redundancy of bowel rather than defective fixation. The right side of the colon may have a defective fixation and abnormal mobility; therefore, it may be located anywhere in the abdomen, including beneath the right hemidiaphragm. This motility may allow the right side of the colon and cecum to herniate into the inguinal and femoral canals. Most of these abnormalities of fixation can be diagnosed radiologically. The most important complication of the abnormalities of fixation is a volvulus of the right side of the colon and/or cecum.

Preferred examination

The preferred examinations are plain abdominal radiography, barium enema examination (usually with a single contrast agent), and CT scanning.[2, 10]
Limitations of techniques

Bowel gas patterns on a plain abdominal radiograph may not be characteristic, because the right colon and/or cecum may be displaced to any part of the abdominal cavity. A redundant looplike cecal volvulus may be confused with a sigmoid volvulus. In the presence of a closed-loop obstruction of the colon, evaluation of the 2 sites of obstruction may not be possible with barium enema examination.
Differential diagnosis and other problems to be considered

Sigmoid volvulus is part of the differential diagnosis. Other conditions to be considered are a distended stomach from high gastrointestinal obstruction or gastroparesis, other forms of large bowel obstruction, and a giant sigmoid diverticulum.
Radiologic interventions

An attempt should always be made to reduce the volvulus with barium enema examination, unless contraindications are present (see Special concerns, below). Reduction with barium enema examination is particularly successful in the rare cecal volvulus that occurs in the postpartum patient. The volvulus may reduce during evacuation of the contrast agent. However, surgery is required in many patients and is urgent after reduction in those with gross abdominal tenderness or in those in whom leukocytosis suggests ischemia. The postoperative abdomen, especially after closed segmental resection of the descending colon, presumably with stenosis, is a precipitating cause of cecal volvulus. After colonic resection and anastomosis, evaluation of the colon with a barium enema is undesirable, no matter how carefully the procedure is performed. Evaluation with water-soluble contrast material has been used to evaluate the postoperative colon. The safety of this procedure in the postoperative abdomen cannot yet be determined because experience is limited.
Special concerns

The contraindications for a barium enema are signs and symptoms of peritonitis, rectal bleeding, radiographic signs of gas in the bowel wall, and pneumoperitoneum. Overdistention of the cecum with air and/or barium during a barium enema examination may result in cecal perforation. Delay in surgical treatment in the presence of increasing cecal distention can also result in cecal perforation.

Radiography
The plain abdominal radiograph is usually the key to the diagnosis of cecal volvulus. In axial torsion, the image may show a markedly distended loop of large bowel with its long axis extending from the right lower quadrant to the epigastrium or left upper quadrant, the most

common site to which the cecum is displaced (see the image below). Depending on the initial bowel position and the length of mobile right colon, the distended cecum may be seen anywhere in the abdomen.

Plain supine abdominal radiograph from an 81-year-old man presenting with abdominal pain and vomiting. The radiograph shows a markedly distended loop of bowel 15-cm in diameter with its axis running from the right lower quadrant to the mid abdomen. This loop of bowel represent a twisted cecum with the caput cecum directed medially (arrows). The haustra within the cecum (C) are effaced. Note the proximal dilated loop of small bowel. The distal colon shows little if any air. At surgery a cecal volvulus was confirmed.

Despite the varying positions of the distended cecum, the plain radiographic features of a cecal volvulus are characteristic, and the caput cecum can typically be identified (see the first image below). The colonic haustral pattern is generally maintained, although some effacement may be present if superimposed ischemia is present. When shorter segments of the colon and cecum are involved, the distended cecum may be found in the normal location (see the second image below).

A 53-year-old woman presented with clinical features of intestinal obstruction. This plain supine radiograph was performed on the day of admission. It shows a large air-filled viscus (15 cm in diameter), with the axis running from the mid abdomen to the left hypochondrium. No haustra are seen in the air-filled viscus (short arrow). Note that the right iliac fossa is empty (long arrow), but formed feces intermingled with air are noted in part of the ascending colon. The air can be traced up to the rectum. At this stage, no firm radiologic diagnosis was entertained, although the working clinical diagnosis was partial bowel obstruction.

This plain supine radiograph was obtained 24 hours after the radiograph in the previous image (from a 53-year-old woman who presented with clinical features of intestinal obstruction). The position of the air filled viscus has changed and suggests that the air-filled viscus is mobile. The viscus now looks much more like a cecum. The caput cecum is directed toward the right iliac fossa. The twist is outlined by air (arrows).

In most patients, obstruction is almost complete; thus, the distal colon is usually empty and the small bowel is frequently distended. Occasionally, a long-axis torsion may be associated with signs of incomplete obstruction. Rarely, small-bowel loops are identified to the right of the distended cecum and ascending colon. The ileocecal valve may possibly be identified, and on occasion, the point of torsion may be outlined by gas, as an area of conelike narrowing. In the cecal bascule form of volvulus, the distended air-filled cecum is located more centrally. With this variant, the ileum can passively twist with the cecum, and small bowel is not obstructed. If the appendix is filled with gas and in an unusual location attached to a distended cecum, the diagnosis can be made readily. Single contrast barium enema examination is generally adequate for the evaluation of cecal volvulus. A double-contrast barium enema study does not confer any significant advantage, because no fine detail is necessary to make the diagnosis. The administration of glucagon is often necessary, because patients may have considerable colonic spasm and find it difficult to retain the contrast agent. The barium enema study shows a nondilated distal colon to the point of twist (see the following images). If the obstruction is not complete, some barium may trickle past the site of obstruction, and the twist may be visualized in more detail. If the twist occurs along the transverse axis, the obstruction appears relatively smooth, and no spiral twist is usually seen. In a cecal bascule, a rounded termination of the barium column may be seen. This, when seen near a distended gas-filled viscus, should alert the radiologist to the diagnosis of a volvulus.

This unprepared barium enema examination was obtained 12 hours after the first supine plain radiograph from a 53-year-old woman who presented with clinical features of intestinal obstruction. The image shows a nondilated colon. The barium-filled colon can be traced back to the right iliac fossa where there is a bird-beak cutoff (solid arrow). The dilated cecum lies in the epigastrium where there is an air fluid level (open arrow). Note that the barium has not entered the cecum.

Right oblique image from a barium enema examination in from a 53-year-old woman who presented with clinical features of intestinal obstruction. This image shows a bird-beak appearance (arrow). At surgery, a cecal volvulus was confirmed.

Left: Plain abdominal radiograph from a 48-year-old woman showing a massively distended and medially displaced proximal ascending colon and cecum. The cecal pole is now lying in the left upper abdominal quadrant (C). At least 2 or 3 haustrations are seen in the distended large bowel, which is consistent with cecal volvulus. No air fluid levels were demonstrated in this case. Right: A single contrast barium study of the same patient showing free barium flow through the sigmoid colon in to the mid ascending colon. The proximal ascending colon and the cecum are void of barium due to obstruction at the level of the mid ascending colon.

A post evacuation film from the same 48-year-old patient as in the previous images. This image shows a medially pointed end column of the barium (beak sign) in the mid ascending colon. Distally the large bowel is distended with gas and represents the cecal volvulus.

As little barium as possible should be allowed to flow proximal to the site of obstruction, because flooding the bowel proximal to the obstruction site might precipitate a complete obstruction. When the barium enema is administered, overdistention should also be avoided, because this can lead to perforation. An attempt should always be made to reduce the volvulus. This reduction may be achieved during colonic filling by barium, but reduction occasionally occurs during barium evacuation. With an intermittent volvulus, the barium enema results may be normal, but a postevacuation radiograph may reveal the twist.[9, 11]
Degree of confidence

Plain radiographic findings can be diagnostic of a cecal volvulus in most patients. In others, the findings on the plain images only suggest the diagnosis, and barium enema examination is necessary to confirm the diagnosis.
False positives/negatives

Rarely, the dilated displaced cecum and ascending colon in the left upper quadrant may be confused with a normal or abnormally distended stomach. A redundant looplike cecal volvulus may be confused with a sigmoid volvulus. In the presence of a double obstruction of the colon (left colon obstruction associated with a cecal volvulus), evaluation of the right colon may not be possible, and the diagnosis of volvulus must be based on plain radiographic findings alone.

Computed Tomography
CT scans demonstrate a mechanical intestinal obstruction, show the site of obstruction and its severity, and can be used to differentiate between mechanical obstruction and adynamic ileus. A volvulus or strangulation generally causes a closed-loop obstruction, and CT scans characteristically demonstrate a U-shaped distended bowel segment and signs of ischemia. These signs include mural thickening, infiltration of the mesenteric fat, and pneumatosis intestinalis. In the presence of a cecal or sigmoid volvulus, a whirl sign may be apparent because of a tight torsion of the mesentery that is caused by a twist between the afferent and efferent loops.[3, 4, 5]

Degree of confidence

Several studies have shown the superiority of CT scanning compared with plain abdominal radiography in the diagnosis of intestinal obstruction. However, the use of CT scanning remains controversial. The present consensus is that abdominal CT scanning should be performed in the presence of mechanical intestinal obstruction when the plain radiographic and clinical examination findings are inconclusive, especially in patients in whom the identification of the cause of obstruction may affect treatment. The whirl sign on CT scans is not specific for cecal volvulus and may also occur in other types of volvulus, including sigmoid volvulus.[3]
False positives/negatives

The detection of a transitional zone between the dilated proximal bowel loops and collapsed distal loops distal to the obstructed site is important in diagnosing bowel obstruction on CT scans. However, a false-negative diagnosis may occur in a mixed type of ileus or in a mild partial obstruction. A false-positive diagnosis of intestinal obstruction may be made when a distended air-filled right colon is seen in the presence of a collapsed left colon.

Ultrasonography
Ultrasonography is usually the first modality used in the emergency department to investigate an acute abdomen. Cecal volvulus is usually associated with a small-bowel obstruction. The small-bowel loops are distended with fluid, and to-and-fro peristalsis is often visible. Cecal volvulus may be depicted as a grossly distended fluid-filled cecum at a lead point of smallbowel obstruction, but the appearances are generally nonspecific.[6]
Degree of confidence

Ultrasonograms may suggest a diagnosis or indicate a more appropriate investigation for diagnosis. However, ultrasonography is not a sensitive technique in the workup of a cecal volvulus.

Sigmoid volvulus is the most common form of volvulus of the gastrointestinal tract; it is responsible for 8% of all intestinal obstructions. Sigmoid volvulus is particularly common in elderly persons. Patients present with abdominal pain, distention, and absolute constipation.[1, 2] Predisposing factors to sigmoid volvulus include chronic constipation, megacolon, and an excessively mobile colon. Plain abdominal radiograph findings are usually diagnostic. (See the images below.)

This radiograph demonstrates a greatly dilated sigmoid that almost fills the entire abdomen. Note the coffee bean sign. The remainder of the large bowel is not dilated, presumably because the proximal point of the twist is not causing obstruction and thus allows drainage into the sigmoid.

Erect abdominal radiograph. This image shows fluid levels in the distended sigmoid loop.

Decompression may be achieved with the introduction of a stiff tube per the rectum, aided by endoscopy or fluoroscopy. The mortality rates associated with sigmoid volvulus are 20-25%, depending on the interval between when the diagnosis is made and treatment is rendered. Therefore, early radiographic recognition of sigmoid volvulus is important. (See the image below.)[1, 2, 3, 4, 5, 6]

This radiograph shows decompression of the sigmoid loop following retrograde passage of a flatus tube.

The key radiologic features of sigmoid volvulus are those of a double-loop obstruction, which has been reported in approximately 50% of patients. The key finding consists of a dilated loop of pelvic colon, associated with features of small-bowel obstruction and retention of feces in an undistended proximal colon. The dilated loop usually lies in the right side of the abdomen, and the limbs taper inferiorly into the right lower quadrant. Medial deviation of the distal descending colon is a rare but highly specific finding.
Preferred examination

Plain abdominal radiographic findings are usually diagnostic of sigmoid volvulus. Decompression may be achieved by the introduction of a stiff tube per rectum, aided by endoscopy or fluoroscopy. A single-contrast barium enema examination is usually adequate if it is required, as in cases when the diagnosis is in doubt. Computed tomography (CT) scanning is the least invasive imaging technique that allows assessment of mural ischemia. Unlike barium enema examination, CT scanning has a high likelihood of revealing other causes of abdominal pain if the source of the patient's symptoms is not sigmoid volvulus. Results of conventional mesenteric angiography with intravenously administered contrast material or magnetic resonance angiography (MRA) may be more definitive in the diagnosis of mesenteric ischemia. Plain radiographs readily permit the distinction of sigmoid volvulus from primary volvulus of the small intestine and from other nonobstructive surgical emergencies. However, volvulus of the right colon, closed-loop small intestinal obstruction, and sigmoid volvulus complicated by peritonitis may simulate sigmoid volvulus on radiographs. Sigmoidoscopy, rather than barium enema examination, is the procedure of choice if an ileosigmoid knot is suspected.
Limitations of techniques

Diagnostic difficulties may occur with plain abdominal radiographs if the degree of proximal dilatation is so marked that the sigmoid loop may not be recognized as such. Similar difficulties may be encountered when a large amount of fluid is associated with a small amount of air. This situation causes poor definition of the sigmoid colon on a supine radiograph, and the high air-fluid levels demonstrated on erect images may be inadequate to define the sigmoid loop accurately.

Barium enema examination is contraindicated in patients in whom a gangrenous bowel is suspected or when a pneumoperitoneum is noted on a plain abdominal radiograph or erect chest radiograph. Barium enema examination is also contraindicated in patients who have clinical signs of peritonitis.

Radiography
Plain radiographs show a markedly distended sigmoid loop, which assumes a bent inner tube or inverted U -shaped appearance, with the limbs of the sigmoid loop directed toward the pelvis.[7] (See the images below.)

This radiograph demonstrates a greatly dilated sigmoid that almost fills the entire abdomen. Note the coffee bean sign. The remainder of the large bowel is not dilated, presumably because the proximal point of the twist is not causing obstruction and thus allows drainage into the sigmoid.

Erect abdominal radiograph. This image shows fluid levels in the distended sigmoid loop.

This radiograph shows decompression of the sigmoid loop following retrograde passage of a flatus tube.

Supine abdominal radiograph in a 6-year-old child from an area in which roundworms are endemic. This image shows a sigmoid volvulus. The sigmoid loop is dilated and associated with mild proximal large-bowel dilatation.

This erect radiograph shows fluid levels in the sigmoid loop and in the transverse colon.

Erect abdominal radiograph demonstrating a giant sigmoid diverticulum. This image shows a dilated loop of bowel with air-fluid levels and intraluminal feces. This appearance mimics that of an enlarged cecum or sigmoid loop.

Radiograph from an enema examination with water-soluble contrast material in an unprepared bowel. This image shows a giant sigmoid diverticulum that contains feces.

The colonic haustra are lost, and progressive distention elevates the sigmoid loop under one side of the diaphragm. An upright radiograph shows a greatly distended sigmoid loop with air-fluid levels mainly on the left side of the abdomen and extending toward the right hemidiaphragm.

The involved bowel walls are edematous, and the contiguous walls form a dense white line on radiographs. This line is surrounded by the curved and dilated gas-filled lumen, resulting in a coffee bean-shaped structure; this is the coffee bean sign.[8] If more fluid than air is in the obstructed loop of the sigmoid, the volvulus may be demonstrable by a soft-tissue mass or a pseudotumor sign. A dilated sigmoid colon that ascends to the transverse colon (northern exposure sign) is said to be a reliable sign of a sigmoid volvulus on a supine abdominal radiograph.[9]
Barium enema

A single-contrast barium enema examination is adequate because the barium readily enters the empty rectum and usually encounters a complete stenosis, which is likened to a beak, the so-called bird's beak or bird-of-prey sign. Barium enema examination demonstrates obstruction at the rectosigmoid junction. The most common and clinically significant twist of the sigmoid occurs in the mesenteric axis, although a less frequent and more benign form of the twist may occur around the longitudinal axis of the sigmoid loop. This longitudinal twist has been variably termed the kink, axial torsion, or physiologic incomplete torsion. Patients with this twist are usually not symptomatic, and it may be an incidental finding on a routine barium enema examination. If barium can enter the obstructed segment, spiraling of the mucosal folds may be seen. Signs of bowel ischemia, such as thumbprinting, transverse ridging, and mucosal ulceration, may be observed. Take care not to perform a barium enema examination in patients with suspected gangrenous bowel, a pneumoperitoneum (as seen on plain abdominal radiographs), or clinical signs of peritonitis. Sigmoidoscopy, rather than barium enema examination, is the procedure of choice if an ileosigmoid knot is suspected.
Degree of confidence

In 60-70% of patients, the diagnosis of sigmoid volvulus can be made by using plain abdominal radiographic findings. In 20-30% of patients, the 2 limbs of the twisted sigmoid colon may overlap or deviate to the right or left, obscuring the remainder of the colon. In these instances, the findings are those of a nonspecific large-bowel obstruction, and barium enema examination is required for confirmation of the diagnosis.
False positives/negatives

Other forms of large-bowel obstruction, especially those due to sigmoid colon carcinoma, pseudo-obstruction, cecal volvulus, and an ileosigmoid knot, may mimic or be confused with a sigmoid volvulus. At times, emphysematous cystitis and a giant sigmoid diverticulum may also mimic a sigmoid volvulus.

Computed Tomography
CT scan findings of sigmoid volvulus include the whirl sign, which represents tension on the tightly twisted mesocolon by the afferent and efferent limbs of the dilated colon.[10, 11, 12] CT scanning may be useful in identifying the etiology and site of the obstruction that result from other pathologies, as well as in demonstrating ischemia that results from strangulation. CT scan signs of ischemia include a serrated beak at the site of the obstruction, mesenteric edema or engrossment, and moderate to severe thickening of the bowel wall. Intramural gas or portal venous gas may be seen (grave prognostic signs), and in patients in whom a perforation has occurred, a large amount of free intraperitoneal gas or fluid may be noted.
Degree of confidence

CT scanning is the least invasive imaging technique that allows assessment of mural ischemia. This imaging modality helps in identifying the cause of an acute large-bowel obstruction in 74-86% of cases, although the sensitivity of the investigation is not yet defined.
False positives/negatives

False-positive findings may involve other forms of volvulus or obstruction and causes of large-bowel ischemia.

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) has been used successfully in the assessment of largebowel obstruction (not specifically in sigmoid volvulus). These examinations were performed with the retrograde insufflation of 1000-1200 mL of air through a Foley catheter that was placed in the rectum and with scopolamine to inhibit peristalsis in order to demonstrate the site of bowel obstruction. In addition, MRI has been used in the diagnosis of mural necrosis in infants and, theoretically, this modality can be used in adults.[13]

Ultrasonography
Ultrasonography might occasionally be useful in assessing large-bowel obstruction.[14, 15] However, the confidence level for ultrasonography in the diagnosis of sigmoid volvulus is low. In the limited experience in diagnosing sigmoid volvulus by ultrasonography, the images fail to depict the cause in most patients.