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E2408. Twist and Shout: Radiographic Appearance of Twisted and Torsed Organs
Authors
  1. Gregory Brody; Morristown Medical Center
  2. Joshua Katz; Morristown Medical Center
Background
Torsion can occur with many organs and can result in an emergent situation once diagnosed with imaging. This exhibit aims to identify the radiographic appearance of bowel and genitourinary organs in the setting of torsion.

Educational Goals / Teaching Points
1. To review when to suspect torsion of organs based on symptoms. 2. Discuss the radiographic appearance of torsed organs on different modalities.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
1. Testicular torsion - Ultrasound - may see twisted and edematous spermatic cord – specific and sensitive. Altered blood flow, absence, or diminished in comparison. Increased size of testicle and epididymis. 2. Ovarian torsion - Ultrasound - enlarged > 4 cm ovary, most sensitive. Little to no venous flow is common, absent arterial flow is less common, and a poor prognosis. 3. Gastric volvulus - Fluoroscopic Upper GI series and CT - distended stomach extending into thorax with inversion of the stomach, 180° can cause obstruction. Appearance depends on degree of twisting, stomach will be distended with antropyloric transition point at or superior to the level of the fundus, if there is ischemia, may see pneumatosis. 4. Closed loop bowel obstruction - Contrast-enhanced CT - small bowel distension > 3 cm, C or U shaped small bowel loops, “double beak sign” which is the tapering of bowel at the two points of obstruction, “whirl sign” of twisted mesentery, adjacent collapsed loops of bowel, signs of ischemia. 5. Sigmoid volvulus - Abdominal Radiograph - Coffee bean sign, which represents dilated sigmoid colon where the inner wall represents the double wall thickness of opposed bowel twisted together. Contrast-enhanced CT - large bowel dilatation lacking haustra forming a closed loop obstruction, may see whirling mesentery, crossing loops of bowel at the site of transition.

Conclusion
Early recognition of torsed organs using different imaging modalities is imperative to effective patient care.