An extremely rare case of whirl sign in combination with colonic pneumatosis intestinalis: What is your provisional diagnosis?

Volvulus of the intestine is a surgical emergency with the clinical triad of constipation, progressive abdominal distension, and severe abdominal pain. A typical whirl sign on computed tomography can be observed in bowel volvulus. Pneumatosis intestinalis is another rare radiographic finding characterized by the presence of intramural gas-filled cysts in the bowel wall. It also could be a life-threatening entity requiring emergency surgical intervention. Although image findings of either a whirl sign or pneumatosis intestinalis are not pathognomonic, evidence has shown that a combination of these two findings is extremely rare and strongly associated with a fulminant bowel infarction caused by intestinal volvulus. However, we report a 22-year-old man with a whirl sign as well as intramural bowel gas over the sigmoid colon on imaging but with no evidence of an intra-abdominal crisis. This case discloses that it may be a nonsignificant finding and does not uniformly mandate surgical exploration. It is important to understand that both radiographic signs must be interpreted relative to the patient’s overall clinical condition, and the emergency physician should keep these factors in mind in daily practice.