Von Wahl Sign in Sigmoid Volvulus Patient with Cerebrovascular Disease

In addition to radiological imaging, physical examination is also of great importance in the diagnosis of sigmoid volvulus. The presence of a palpable sigmoid colon on abdominal examination is known as the von Wahl sign. A 77year-old female patient with a history of paraplegia caused by CVD was admitted to the emergency service with abdominal pain and obstipation. Abdominal examination of the patient revealed asymmetric distension in the abdomen in inspection and von Wahl sign in palpation. The coffee bean appearance on the plain radiograph supported the sigmoid volvulus. Successful colonoscopic detorsion was applied to the patient. Six months later, sigmoid volvulus recurrence occurred in the patient who refused elective surgery. Sigmoid colon resection and Hartmann's procedure were performed. The patient, who developed respiratory failure, died on the second postoperative day. In addition to imaging in patients with neurodegenerative disease, findings such as von Wahl sign in the physical examination are supportive in the diagnosis of sigmoid volvulus.


INTRODUCTION
Sigmoid volvulus is the rotation of the sigmoid colon around itself. As a result, obstruction and closed-loop obstruction develop in the left colon. Various specific clinical and radiological findings have been described in the diagnosis of sigmoid volvulus. As a result of the displacement of the rotating sigmoid colon from the left lower quadrant to the right upper quadrant, there is a gap in the left lower quadrant, and this is included in the literature as an "emptiness of the left iliac fossa" (1). In some patients with a thin abdominal wall and severe dilation of the sigmoid colon, palpability of distended sigmoid colon is known as the "von Wahl sign". While there are sigmoid volvulus-specific appearances such as coffee bean, omega, inverted U, and horseshoe on plain abdominal X-ray, whirl sign for sigmoid volvulus has been described on computed tomography (2).
In our clinical experience, asymmetric abdominal distention and von Wahl sign findings on physical examination of sigmoid volvulus patients were two important findings at the time of diagnosis. We wanted to share the importance of this examination finding through one of our patients who developed sigmoid volvulus with a diagnosis of cerebrovascular disease (CVD).

CASE REPORT
A 77-year-old female patient with a history of paraplegia due to CVD was admitted to the emergency service with abdominal pain and constipation. Abdominal examination of the patient revealed asymmetric distension in the abdomen on inspection and von Wahl sign in palpation ( Figure 1). There was no stool in the rectal examination. The present findings were consistent with the sigmoid volvulus, and a standing direct abdominal radiography supported this diagnosis. (Figure 2). Successful colonoscopic detorsion was applied to the patient. Then, an elective operation was planned for the patient. However, the operation was not accepted by the relatives of the patient. The patient presented again with an attack of sigmoid volvulus six months later. Colonoscopic detorsion was tried but not successful. Thereupon, the patient was taken into operation and gangrene was found in the sigmoid colon on exploration. Sigmoid colon resection and Hartmann's procedure were performed. The patient, who developed respiratory failure during intensive care follow-ups, died on the second postoperative day.

DISCUSSION
It may be difficult to diagnose sigmoid volvulus in patients with neurodegenerative diseases such as spinal cord injury and CVD (3). In the differential diagnosis of sigmoid volvulus, there are different spectrum diagnoses such as colorectal neoplasms, pseudo-obstruction of the colon, and paralytic ileus. Plain abdominal X-rays have diagnostic value in 57-90% of the patients (4). In the plain abdominal X-ray taken with the patient in the supine position, the rotating sigmoid colon rises above the transverse colon. However, the dilated sigmoid colon in the paralytic ileus is under the transverse colon. In the literature, this finding is known as a northward orientation (5). In our patient, there was a coffee bean appearance on plain abdominal X-ray and supported the diagnosis of sigmoid volvulus. Neurodegenerative diseases cause constipation and dolichocolon, and the frequency of sigmoid volvulus is increased in these patients (6,7). In endemic regions such as Turkey sigmoid volvulus is encountered frequently. In our study involving 184 patients, we had 10 (5.4%) sigmoid volvulus patients with Alzheimer's, CVD, and Parkinson's disease (8). Our patient was diagnosed with CVD and sigmoid volvulus developed secondary to constipation and immobility. In today's technology, these patients can be diagnosed easily with imaging methods. However, suspicion is important in diagnosis. Comorbidity of patients, absence of stool, and asymmetric distension should bring to mind the sigmoid volvulus. Neurodegenerative patients are generally immobile and their anamnesis and examination findings are limited. These patients are usually consulted with surgery during intensive care follow-ups. As in our patient, such patients can be mortal. In patients with these physical examination findings, the diagnosis of sigmoid volvulus should be considered and insistence should be initiated in the emergency detorsion phase.

CONCLUSION
In the abdominal examination, if the sigmoid colon is palpable (von Wahl sign) in addition to asymmetric distension, the diagnosis of sigmoid volvulus should be kept in mind.