Swirl Sign — Intestinal Volvulus after Roux-en-Y Gastric Byp
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.

http://www.nejm.org/doi/full/10.1056/NEJMicm1601775
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