Barber Pole Sign in CT Angiography, Adult Presentation of Midgut Malrotation: A Case Report

Adult midgut volvulus is a challenging diagnosis because of its low incidence and nonspecific symptoms. Diagnostic delay and long-term complaints are frequent in this clinical scenario. We reported a patient referred to our diagnostic imaging unit with intermittent abdominal pain, bloating and episodic vomiting for several years. He underwent barium gastrointestinal transit and abdominal ultrasound, which revealed severe gastric dilatation, food retention and slow transit until a depressed duodenojejunal flexure, with malrotation of the midgut and jejunal loops being located in the right upper quadrant. Computed tomography angiography was performed, showing rotation of the small intestine around the mesentery root, suggestive of midgut malrotation. In addition, an abnormal twisted disposition of superior mesenteric artery with corkscrew appearance was seen, shaping the pole-barber sign which was evident in volume rendering three-dimensional reconstructions. The patient underwent scheduled surgical treatment without any complication and had good outcome after hospital discharge and follow-up. Computed tomography plays an important role in evaluation of adult midgut volvulus. In addition, angiographic reconstructions can help us to assess the anatomic disposition of mesenteric vascular supply. Both of these assessments are useful in preoperative management.