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A 50-year-old woman reported symptoms of generalised abdominal discomfort 4 days after coronary artery bypass surgery. As well as the discomfort she had some localised left upper quadrant pain, reduced appetite, mild nausea but no vomiting. She had good urine output but had not opened her bowels for 9 days.
On examination, the patient's baseline observations were stable. Her abdomen was grossly distended with localised left upper quadrant tenderness. She did not exhibit signs of peritonism and her bowel sounds were quiet but present.
Her significant history included colon cancer treated with an anterior resection 3 years previously.
She was investigated with an abdominal X-ray (figure 1), which showed a classical ‘coffee bean’ sign of intestinal volvulus. Owing to her previous anterior resection it was decided by the radiologist that this represented a caecal volvulus. Early findings of ‘Rigler’s sign’ are also visible on this film, which may represent early bowel necrosis and can be an indication for immediate surgery. However, prolonged discussion between the cardiac and colorectal surgeons and the radiologists followed. It was eventually decided that the patient should be taken to theatres. The diagnosis was confirmed, the patient underwent a right hemicolectomy and the volvulus was resected (figure 2). Of note was the dusky hue to the bowel, which represents early bowel ischaemia and confirms the radiological findings.
Gastrointestinal complications occur in around 1% of cardiothoracic operations.1 Of those presenting with discomfort and bloating, ileus or pseudo-obstruction are the most common.1 These pathologies are usually treated conservatively or medically.2 ,3 It is therefore important that correct radiological assessment is carried out in these patients and any obstruction of mechanical aetiology,4 such as volvulus, is differentiated from non-mechanical ileus and correct surgical intervention is carried out to reduce the risk of bowel ischaemia and perforation.
Adequate and timely investigation and diagnosis of postoperative patients presenting with gastrointestinal symptoms is crucial.
Differentiation between mechanical and non-mechanical pathologies is vital to correctly guide management decisions.
Swift surgical intervention is essential in removing any mechanical bowel obstruction, thus preventing ischaemia caused by a volvulus.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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