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Yousef A, Gerrie S, Hurteau-Miller J. Imaging Review of Intestinal Malrotation and Midgut Volvulus. Radiographics 2025; 45:e240177. [PMID: 40146626 DOI: 10.1148/rg.240177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2025]
Abstract
Accurate diagnosis of intestinal malrotation and midgut volulus in pediatric radiology relies on assessment with US and/or upper gastrointestinal fluoroscopy, and timely diagnosis is crucial to avoid life-threatening consequences.
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Affiliation(s)
- Ayat Yousef
- From the Department of Medical Imaging, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON, Canada K1H 8L1 (A.Y., J.H.M.); Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada (A.Y., J.H.M.); Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada (S.G.); and Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada (S.G.)
| | - Samantha Gerrie
- From the Department of Medical Imaging, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON, Canada K1H 8L1 (A.Y., J.H.M.); Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada (A.Y., J.H.M.); Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada (S.G.); and Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada (S.G.)
| | - Julie Hurteau-Miller
- From the Department of Medical Imaging, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, ON, Canada K1H 8L1 (A.Y., J.H.M.); Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada (A.Y., J.H.M.); Department of Diagnostic and Interventional Radiology, The Hospital for Sick Children, Toronto, Ontario, Canada (S.G.); and Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada (S.G.)
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Yang M, Zheng S, Shu J, Yao Z. Diagnosis of adult midgut malrotation in CT: sign of absent retromesenteric duodenum reliable. Insights Imaging 2025; 16:35. [PMID: 39961975 PMCID: PMC11832868 DOI: 10.1186/s13244-025-01921-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2024] [Accepted: 02/02/2025] [Indexed: 02/20/2025] Open
Abstract
OBJECTIVES To compare the incidence of absent retromesenteric duodenum with other radiological signs and to assess its diagnostic significance for midgut malrotation in adults. METHODS This IRB-approved retrospective single-center study involved adult patients who underwent abdominal CT scans. Patients were screened for the presence of the absent retromesenteric duodenum sign. Signs observed included the position of the duodenal-jejunal junction (DJJ) and jejunum within the abdomen, the relationship between the superior mesenteric artery (SMA) and superior mesenteric vein (SMV), the locations of the ascending colon, cecum, and appendix, and the presence of intestinal volvulus. RESULTS A total of 5594 patients were included. Seven patients exhibited the sign of absent retromesenteric duodenum. Four of these patients were identified as those diagnosed with midgut malrotation in the past five years. The common features observed in all 11 patients were: the horizontal segment of the duodenum did not traverse behind the SMA but instead curved rightwards and forwards adjacent to it; the DJJ and jejunum were positioned in the right abdomen; the SMV was anterior to the SMA. In 7 patients (7/11), the ascending colon, cecum, and appendix were located in the left abdomen. 5 patients (5/11) showed a high cecum position, and 2 patients (2/11) exhibited a pelvic appendix. CONCLUSION The absent retromesenteric duodenum sign in CT diagnosis of adult midgut malrotation has proven to be more reliable. CRITICAL RELEVANCE STATEMENT Radiologists should routinely identify the course of the duodenum horizontal segment in CT images, to prevent misdiagnosis of adult midgut malrotation. KEY POINTS CT is suitable for the diagnosis of adult midgut malrotation. Absent retromesenteric duodenum for diagnosing adult midgut malrotation is more reliable than other signs. Diagnostic CT criteria for adult midgut malrotation need updating.
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Affiliation(s)
- Min Yang
- Department of Medical Imaging, Luzhou People's Hospital, Luzhou, China
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Shaokun Zheng
- Department of Medical Imaging, Luzhou People's Hospital, Luzhou, China
| | - Jian Shu
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Zhenwei Yao
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China.
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AlHarshan T, AlWakid I, Almeshawi I, AlGoraini Y. Late presentation of midgut malrotation with obstruction in a 5-year-old female: A case report. Radiol Case Rep 2024; 19:6108-6111. [PMID: 39364274 PMCID: PMC11447301 DOI: 10.1016/j.radcr.2024.09.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2024] [Revised: 09/11/2024] [Accepted: 09/13/2024] [Indexed: 10/05/2024] Open
Abstract
Midgut malrotations are rarely diagnosed beyond infancy. Delays in recognition and diagnosis can result in death. Here, we report the case of a 5-year-old girl who presented with a 1-year history of intermittent abdominal pain and vomiting. An abdominal computed tomography scan with contrast confirmed the diagnosis of midgut malrotation with obstruction; therefore, the Ladd procedure was performed, and the child was discharged uneventfully. Clinicians must maintain a high level of suspicion because this diagnosis is unusual in this age group.
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Affiliation(s)
- Tahani AlHarshan
- Pediatric Emergency Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ibrahim AlWakid
- Pediatric Emergency Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ibtihal Almeshawi
- Pediatric Medicine Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Yara AlGoraini
- Pediatric Emergency Department, King Fahad Medical City, Riyadh, Saudi Arabia
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Long B, Easter J, Koyfman A. High risk and low incidence diseases: Pediatric digestive volvulus. Am J Emerg Med 2024; 82:153-160. [PMID: 38908340 DOI: 10.1016/j.ajem.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/10/2024] [Accepted: 06/12/2024] [Indexed: 06/24/2024] Open
Abstract
INTRODUCTION Pediatric digestive volvulus is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of pediatric digestive volvulus, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Pediatric digestive volvulus is a deadly condition most commonly associated with malrotation. It occurs when the stomach or small intestine twists on itself, resulting in ischemia and potentially strangulation with necrosis and perforation. Presentation differs based on the gastrointestinal (GI) segment affected, degree of twisting, and acuity of the volvulus. Gastric volvulus most commonly presents with retching with or without nonbilious emesis and epigastric distension with pain, while midgut volvulus typically presents with bilious emesis in infants. Patients with GI necrosis and perforation may present with hemodynamic compromise and peritonitis. If suspected, emergent consultation with the pediatric surgery specialist is necessary, and if this is not available, transfer to a center with a pediatric surgeon is recommended. Imaging includes plain radiography, ultrasound, or upper GI series, while treatment includes resuscitation, administration of antibiotics, and emergent surgical decompression and detorsion of the involved segments. CONCLUSION An understanding of pediatric digestive volvulus and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Joshua Easter
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
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Bostancı SA, Öztorun Cİ, Erten EE, Akkaya F, Akbaş İ, Çayhan VS, Abay AN, Demir S, Ertürk A, Azılı MN, Şenel E. Clinical management of intestinal malrotation in different age groups. Pediatr Surg Int 2024; 40:204. [PMID: 39033256 PMCID: PMC11271324 DOI: 10.1007/s00383-024-05796-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2024] [Indexed: 07/23/2024]
Abstract
PURPOSE Intestinal malrotation, characterized by abnormal intestinal positioning, can lead to severe complications like volvulus and internal hernias, especially in neonates and children. Our aim was to evaluate the diagnostic methods, treatment results and postoperative follow-up of pediatric patients treated for intestinal malrotation. METHODS This retrospective study reviewed medical records of pediatric patients who underwent surgery for intestinal malrotation between January 2013 and January 2022. Data on demographics, symptoms, diagnostic approaches, surgical interventions, and postoperative outcomes were analyzed. RESULTS The study included 45 patients, with a male predominance (68.8%). Ages ranged from 1 day to 15 years, averaging 1.54 years. Presenting symptoms were acute abdomen (n = 21) and chronic abdominal pain with vomiting (n = 24). Diagnoses were established via physical exams and imaging, including upper gastrointestinal contrast studies and abdominal ultrasonography. All patients received the Ladd procedure, with some requiring necrotic bowel resection due to volvulus. CONCLUSION The diagnosis and management of pediatric intestinal malrotation present significant challenges due to its variable symptoms and potential for life-threatening complications. Early and accurate diagnosis, followed by appropriate surgical management, is crucial. This study emphasizes the importance of diligent postoperative follow-up to identify and mitigate complications, particularly in younger and severely affected patients.
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Affiliation(s)
- Süleyman Arif Bostancı
- Faculty of Medicine, Department of Pediatric Surgery, Ankara Yildirim Beyazit University, Ankara, Turkey.
| | - Can İhsan Öztorun
- Faculty of Medicine, Department of Pediatric Surgery, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Elif Emel Erten
- Department of Pediatric Surgery, Ankara Bilkent City Hospital, Childrens' Hospital, Universiteler Boulvard, 1604. Street, Çankaya, 06800, Ankara, Turkey
| | - Fahri Akkaya
- Department of Pediatric Surgery, Ankara Bilkent City Hospital, Childrens' Hospital, Universiteler Boulvard, 1604. Street, Çankaya, 06800, Ankara, Turkey
| | - İrem Akbaş
- Department of Pediatric Surgery, Ankara Bilkent City Hospital, Childrens' Hospital, Universiteler Boulvard, 1604. Street, Çankaya, 06800, Ankara, Turkey
| | - Vildan Selin Çayhan
- Department of Pediatric Surgery, Ankara Bilkent City Hospital, Childrens' Hospital, Universiteler Boulvard, 1604. Street, Çankaya, 06800, Ankara, Turkey
| | - Aslı Nur Abay
- Department of Pediatric Surgery, Ankara Bilkent City Hospital, Childrens' Hospital, Universiteler Boulvard, 1604. Street, Çankaya, 06800, Ankara, Turkey
| | - Sabri Demir
- Department of Pediatric Surgery, Health Science University, Ankara Bilkent City Hospital, Childrens' Hospital, Ankara, Turkey
| | - Ahmet Ertürk
- Faculty of Medicine, Department of Pediatric Surgery, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Müjdem Nur Azılı
- Faculty of Medicine, Department of Pediatric Surgery, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Emrah Şenel
- Faculty of Medicine, Department of Pediatric Surgery, Ankara Yildirim Beyazit University, Ankara, Turkey
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Mohamed Burhan MS, Hamid HA, Zaki FM, Ning CJ, Zainal IA, Ros IAC, Daud CZBC, Othman MYB, Hing EY. The performance of ultrasound and upper gastrointestinal study in diagnosing malrotation in children, with or without volvulus. Emerg Radiol 2024; 31:151-165. [PMID: 38289574 DOI: 10.1007/s10140-024-02201-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/09/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Rapid diagnosis is crucial for pediatric patients with midgut volvulus and malrotation to prevent serious complications. While the upper gastrointestinal study (UGIS) is the traditional method, the use of ultrasound (US) is gaining prominence. OBJECTIVES To assess the diagnostic sensitivity and specificity of US compared to UGIS for malrotation and midgut volvulus. METHODS A cross-sectional study was performed on 68 pediatric patients who underwent US and/or UGIS before surgery for suspected midgut volvulus or malrotation in Kuala Lumpur (PPUKM and HTA), referencing surgical outcomes as the gold standard. RESULTS US demonstrated a higher specificity (100%) than UGIS (83%) for diagnosing malrotation, with a slightly lower sensitivity (97% vs. 100%). For midgut volvulus, US surpassed UGIS in sensitivity (92.9% vs. 66.7%) while maintaining comparable specificity. The SMA/SMV criteria showed better sensitivity (91.1%) than the D3 assessment (78.9%) on US, though both had high specificity. CONCLUSION US is equivalent to UGIS for identifying malrotation and is more sensitive for detecting midgut volvulus, supporting its use as a primary diagnostic tool. The study advocates for combined US and UGIS when either yields inconclusive results, optimizing diagnostic precision for these conditions.
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Affiliation(s)
- Mohamad Sufian Mohamed Burhan
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
- Hospital Tunku Azizah, Ministry of Heath, Kuala Lumpur, Malaysia
| | - Hamzaini Abd Hamid
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Faizah Mohd Zaki
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Chai Jia Ning
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Isa Azzaki Zainal
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Izzat Arslan Che Ros
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | | | | | - Erica Yee Hing
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia.
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Meshaka R, Leung G, Easty M, Giuliani S, Loukogeorgakis S, Perucca G, Watson TA. Ultrasound as the first line investigation for midgut malrotation: a UK tertiary centre experience. Clin Radiol 2024; 79:150-159. [PMID: 38007334 DOI: 10.1016/j.crad.2023.10.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/23/2023] [Accepted: 10/29/2023] [Indexed: 11/27/2023]
Abstract
AIM To present the first 22-months experience of transitioning to an ultrasound-first pathway for suspected midgut malrotation. MATERIALS AND METHODS An "ultrasound-first" imaging pathway was initiated in October 2021. Twenty-two-months later, a search was undertaken of all <1-year-old patients with "bilious", "malrotation," or "volvulus" as the imaging indication. Reports and images from upper gastrointestinal fluoroscopy (UGI) and ultrasound were reviewed, and diagnoses and outcomes were documented. RESULTS The search yielded 101 eligible cases between October 2021 and July 2023. Of the patients, 63/101 (62%) had both ultrasound and UGI: 47/63 (75%) ultrasound first, 16/63 (25%) UGI first. Thirty-one per cent (31/101) had ultrasound only and 7/70 (10%) UGI only. The pathway diagnosed 7/8 (88%) infants with midgut malrotation with or without volvulus and one infant who had an inconclusive ultrasound examination with a suspected an internal hernia and who was found to have malrotation volvulus at surgery. Twenty-one infants who had confidently normal ultrasound examinations and who also had UGI all had a normal duodenojejunal flexure position. Ultrasound detected alternative pathology in eight children. Duodenal visualisation improved with time: 6/15 (40%) in the first 6 months to 23/34 (68%) after the first year. CONCLUSION The transition to ultrasound as the first diagnostic test for midgut malrotation can be done safely and effectively in a UK centre, which previously relied solely on UGI.
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Affiliation(s)
- R Meshaka
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK.
| | - G Leung
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - M Easty
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - S Giuliani
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - S Loukogeorgakis
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - G Perucca
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - T A Watson
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
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Girolamo M, Emanuela G, Yu WMC, Anna M, Marta P, Grazia CM, Gandullia P, Arrigo S, Stefano A, Beatrice DM. Diagnostic accuracy of upper gastrointestinal series in children with suspected intestinal malrotation. Updates Surg 2024; 76:201-208. [PMID: 37326933 PMCID: PMC10806024 DOI: 10.1007/s13304-023-01559-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 06/03/2023] [Indexed: 06/17/2023]
Abstract
Intestinal malrotation (IM) results from an altered or incomplete rotation of the fetal midgut around the superior mesenteric artery axis. The abnormal anatomy of IM is associated with risk of acute midgut volvulus which can lead to catastrophic clinical consequences. The upper gastro-intestinal series (UGI) is addressed as the gold standard diagnosis procedure, but a variable failure degree has been described in literature. The aim of the study was to analyze the UGI exam and describe which features are the most reproducible and reliable in diagnosing IM. Medical records of patients surgically treated for suspected IM between 2007 and 2020 at a single pediatric tertiary care center were retrospectively reviewed. UGI inter-observer agreement and diagnostic accuracy were statistically calculated. Images obtained with antero-posterior (AP) projections were the most significant in terms of IM diagnosis. Duodenal-Jejunal Junction (DJJ) abnormal position resulted to be the most reliable parameter (Se = 0.88; Sp = 0.54) as well as the most readable, with an inter-reader agreement of 83% (k = 0.70, CI 0.49-0.90). The First Jejunal Loops (FJL), caecum altered position and duodenal dilatation could be considered additional data. Lateral projections demonstrated an overall low sensitivity (Se = 0.80) and specificity (Sp = 0.33) with a PPV of 0.85 and a NPV of 0.25. UGI on the sole AP projections ensures a good diagnostic accuracy. The position of the third portion of the duodenum on lateral views showed an overall low reliability, therefore it was not helpful but rather deceiving in diagnosing IM.
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Affiliation(s)
- Mattioli Girolamo
- University of Genoa, DINOGMI, Genoa, Italy
- Pediatric Surgery Unit, IRCCS, Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy
| | | | - Wong Michela Cing Yu
- Pediatric Surgery Unit, IRCCS, Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy.
- , Via Gerolamo Gaslini, 5, 16148, Genoa, Italy.
| | - Marzoli Anna
- Radiology Unit, IRCCS, Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy
| | - Pongiglione Marta
- Radiology Unit, IRCCS, Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy
| | - Calevo Maria Grazia
- Epidemiology and Biostatistics Unit, Scientific Direction, IRCCS Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy
| | - Paolo Gandullia
- Pediatric Gastroenterology and Endoscopy Department, IRCCS, Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - Serena Arrigo
- Pediatric Gastroenterology and Endoscopy Department, IRCCS, Istituto Giannina Gaslini, 16147, Genoa, Italy
| | - Avanzini Stefano
- Pediatric Surgery Unit, IRCCS, Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy
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Lieu DQ, Dung TN, Long TB, Anh TN, Dung LQ, Duc NM. A rare case of Ladd's band causing duodenal occlusion in an adult with intestinal malrotation. Radiol Case Rep 2023; 18:3735-3738. [PMID: 37636537 PMCID: PMC10447930 DOI: 10.1016/j.radcr.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 07/08/2023] [Accepted: 08/01/2023] [Indexed: 08/29/2023] Open
Abstract
A congenital defect of the fetal intestinal rotation, known as malrotation of the gut, is most often identified as an acute intestinal occlusion in early infancy. Adults with this disease tend to be asymptomatic and extremely rare. We present a case of a 47-year-old woman with duodenal obstruction due to Ladd's band admitted with acute abdominal pain and vomiting.
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Affiliation(s)
- Dau Quang Lieu
- Department of Internal Medicine, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Tran Ngoc Dung
- Department of General Surgery, Hanoi Medical University Hospital, Hanoi, Vietnam
- Department of Experimental Surgery, Hanoi Medical University, Hanoi, Vietnam
| | - Tran Bao Long
- Department of General Surgery, Hanoi Medical University Hospital, Hanoi, Vietnam
- Department of General Surgery, Hanoi Medical University, Hanoi, Vietnam
| | - Tran Ngoc Anh
- Department of Internal Medicine, Hanoi Medical University Hospital, Hanoi, Vietnam
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Luu Quang Dung
- Department of General Surgery, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
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Youssfi M, Goncalves LF. Ultrasound for malrotation and volvulus - point. Pediatr Radiol 2022; 52:716-722. [PMID: 34633478 DOI: 10.1007/s00247-021-05154-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/10/2021] [Accepted: 07/12/2021] [Indexed: 11/28/2022]
Abstract
Upper gastrointestinal series is considered the gold standard imaging test to evaluate for malrotation and midgut volvulus. US has been explored for this purpose in recent years and has been shown to be a good alternative because of its relatively good accuracy, fast learning curve for sonographers and radiologists, as well as convenience for children, clinical staff and radiologists in the neonatal intensive care unit. In this article we describe our experience and review the evidence supporting the use of emergency US primarily to diagnose midgut volvulus as well as its use as a problem-solving tool for the diagnosis of malrotation. The examination technique, normal and abnormal findings are described, with emphasis on the whirlpool and superior mesenteric artery cutoff signs to diagnose midgut volvulus.
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Affiliation(s)
- Mostafa Youssfi
- Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA.,Department of Child Health and Radiology, University of Arizona College of Medicine, Phoenix, AZ, USA.,Department of Radiology, Mayo Clinic, Phoenix, AZ, USA.,Department of Radiology, Creighton University, Phoenix, AZ, USA
| | - Luis F Goncalves
- Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA. .,Department of Child Health and Radiology, University of Arizona College of Medicine, Phoenix, AZ, USA. .,Department of Radiology, Mayo Clinic, Phoenix, AZ, USA. .,Department of Radiology, Creighton University, Phoenix, AZ, USA.
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Can the Third Part of Duodenum Behind SMA Be Detected With Confidence on CT as a Proposed Mechanism for Imaging Suspected Malrotation in Children? A Preliminary Proof of Concept Study. J Comput Assist Tomogr 2022; 46:344-348. [PMID: 35285821 DOI: 10.1097/rct.0000000000001280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM The aims of this study were to determine frequency and reliability of computed tomography (CT) detection of anatomic landmarks for imaging suspected midgut malrotation in infants and children, and to calculate an estimated effective dose of an upper abdominal CT scan in our patient population. MATERIALS AND METHODS Fifty consecutive pediatric patients who underwent a CT scan that included their upper abdomen between August 2016 and February 2018 were included. Four pediatric radiology consultants independently reviewed CT scans for detection of the third part of the duodenum and defined their confidence level of this through identification of continuity with the pyloric antrum, D1, D2, and D4 components of the duodenum, as well as the duodenojejunal flexure.Interobserver variability was assessed using Fleiss κ for agreement. A dose estimate, per scan, was calculated using the scanner dose-length product and published conversion factors by Deak. RESULTS Thirty patients were boys. The average age was 7.5 ± 5.4 years (6 days to 16 years). The D3 segment was definitely identified in 70% of scans, with 68% to 73%, moderate agreement between the readers and a Fleiss κ of 0.47 to 0.52. The DJ flexure was definitely identified in only 30.5% cases, with 35%, poor agreement between readers (Fleiss κ of 0.03). The average estimated dose for a targeted CT scan of the abdomen was 0.9 mSv (0.04-2.4 mSv). CONCLUSIONS The third part of the duodenum, which is integral in excluding malrotation on cross-sectional studies, was "definitely" identified in 70% of CT scans of children in our study, with 68% to 73% agreement between the readers and a Fleiss κ of 0.47 to 0.52.These preliminary proof of concept results demonstrating a combination of a comparable CT dose in relation to upper gastrointestinal contrast studies and an acceptable number of cases delineating the third part of the duodenum with moderate agreement are a first step in suggesting low-dose CT for an imaging diagnosis of malrotation. Malrotation can be excluded in cases where D3 is well demonstrated in the normal position, which negates the need to automatically refer children with bilious emesis to specialist centers for upper gastrointestinal contrast studies.
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Ultrasound for Midgut Malrotation and Midgut Volvulus: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2022; 218:931-939. [PMID: 35107311 DOI: 10.2214/ajr.21.27242] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Midgut volvulus in association with malrotation is a pediatric surgical emergency. Prompt and accurate diagnosis is necessary to avoid bowel ischemia and necrosis, thereby reducing morbidity and mortality. Historically, the upper gastrointestinal (UGI) series has been the preferred imaging modality for the evaluation of both midgut malrotation and volvulus, although use of ultrasound (US) is increasing. In this narrative review, we describe the findings of midgut malrotation and volvulus on US, including practical tips for acquisition and interpretation; discuss the advantages and challenges of both imaging modalities; and propose a path and safeguards for possible transition to the use of US as the first-line modality for diagnosis, based on our experience in imaging children with midgut malrotation and volvulus.
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The diagnostic accuracy of ultrasound and upper gastrointestinal contrast studies for locating atresia/stenosis and intestinal malrotation and detecting annular pancreas in pediatric patients with duodenal atresia/stenosis. J Med Ultrason (2001) 2022; 49:299-309. [PMID: 34988762 DOI: 10.1007/s10396-021-01176-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 10/15/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This study aimed to evaluate the diagnostic performance of ultrasound to locate atresia/stenosis and other abdominal anomalies in pediatric patients with duodenal atresia/stenosis, including intestinal malrotation and annular pancreas. METHODS We classified 36 retrospective cases of duodenal atresia/stenosis based on intestinal malrotation status, and evaluated the diagnostic performance of ultrasound/upper gastrointestinal contrast studies to locate atresia/stenosis and intestinal malrotation, as well as ultrasound for detecting additional anomalies such as annular pancreas. The incidence of annular pancreas was compared between groups using Fisher's exact test. RESULTS Atresia/stenosis was correctly located by ultrasound in 33 (91.7%) cases and by upper gastrointestinal contrast study in 36 (100%) cases. Of the eight cases with intestinal malrotation, five and two were correctly diagnosed by ultrasound and upper gastrointestinal contrast study, respectively. Ultrasound correctly diagnosed annular pancreas in 6/14 cases. The incidence of annular pancreas was significantly different between the groups (present/absent in groups with vs. without intestinal malrotation: 6/2 vs. 8/20, P = 0.036). CONCLUSIONS Ultrasound has a relatively high capability in locating atresia/stenosis. However, some cases are misdiagnosed. In clinical practice, upper gastrointestinal contrast studies should be used complementarily during diagnosis. Additional anomalies may not be detected by preoperative examinations; therefore, surgeons should carefully evaluate for additional anomalies during surgery, especially coexisting intestinal malrotation and annular pancreas.
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Mushtaq N, Elwood E, Westwood E, Macdonald A, Saxena AK, Bretherton J. Intestinal malrotation and Meckel’s diverticulitis in a 19-month-old boy. BJR Case Rep 2022; 8:20210127. [PMID: 35136643 PMCID: PMC8803222 DOI: 10.1259/bjrcr.20210127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 11/22/2022] Open
Abstract
Acute intestinal obstruction is a common paediatric surgical emergency and should be considered in any child presenting with vomiting, abdominal pain and abdominal distension. Many causes of bowel obstruction arise from congenital anomalies and recognition of the underlying cause of obstruction can be challenging in these settings. These cases can be further complicated if two or more congenital anomalies are present. Malrotation of the gut is defined as a congenital developmental anomaly of the rotation of the intestine and encompasses a spectrum of abnormalities. Meckel’s diverticulum is another congenital anomaly which occurs secondary to the failure of the vitellointestinal duct to close and can present in 2% of the population. We describe an interesting case of a 19-month-old-boy who presented acutely with symptoms of bowel obstruction and was found to have both intestinal malrotation and Meckel’s diverticulum.
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Affiliation(s)
- Nida Mushtaq
- Department of Radiology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Elliot Elwood
- Department of Radiology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Esther Westwood
- Department of Paediatric Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Alexander Macdonald
- Department of Paediatric Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Amulya K Saxena
- Department of Paediatric Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Josephine Bretherton
- Department of Radiology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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Binu V, Nicholson C, Cundy T, Gent R, Piotto L, Taranath A, Goh DW. Ultrasound imaging as the first line of investigation to diagnose intestinal malrotation in children: Safety and efficacy. J Pediatr Surg 2021; 56:2224-2228. [PMID: 34030880 DOI: 10.1016/j.jpedsurg.2021.04.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/24/2021] [Accepted: 04/08/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Upper gastrointestinal contrast study is considered the gold standard investigation to diagnose intestinal malrotation and midgut volvulus which is potentially devastating condition. Ultrasound imaging is an alternative but has been considered unreliable due to significant false negative results. At our institution we have been using ultrasound imaging as the first line investigation to diagnose malrotation since 2008 with a preliminary study of 139 patients published in 2014. This is an ongoing audit of a further much larger cohort of patients to determine the efficacy and safety of ultrasound imaging in the diagnosis of intestinal malrotation. MATERIALS AND METHODS Following ethics approval, a retrospective analysis of a prospectively collected patient database undergoing ultrasound scans to exclude malrotation at our centre was performed from 2012 to 2019. RESULTS 539 patients underwent ultrasound to assess for malrotation. The mean age of presentation was 365 days (median 30 days, mode 1 day). Malrotation was diagnosed in 17 with 5 having volvulus, with findings confirmed at surgery. 12 had equivocal findings and subsequent contrast studies ruled out malrotation. The remaining 510 patients with no evidence of malrotation were managed conservatively. CONCLUSION We have shown ultrasound to be a safe and effective tool to assess intestinal malrotation without exposure to ionizing radiation. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Vineet Binu
- Department of Paediatric Surgery, Women's and Children's Hospital, South Australia, Australia.
| | - Cheryl Nicholson
- Department of Paediatric Surgery, Women's and Children's Hospital, South Australia, Australia
| | - Thomas Cundy
- Department of Paediatric Surgery, Women's and Children's Hospital, South Australia, Australia; Discipline of Surgery, University of Adelaide, South Australia, Australia
| | - Roger Gent
- Department of Medical Imaging, Women's and Children's Hospital, South Australia, Australia
| | - Lino Piotto
- Department of Medical Imaging, Women's and Children's Hospital, South Australia, Australia
| | - Ajay Taranath
- Department of Medical Imaging, Women's and Children's Hospital, South Australia, Australia
| | - Day Way Goh
- Department of Paediatric Surgery, Women's and Children's Hospital, South Australia, Australia; Discipline of Paediatrics, University of Adelaide, South Australia, Australia
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Nguyen HN, Kulkarni M, Jose J, Sisson A, Brandt ML, Sammer MB, Pammi M. Ultrasound for the diagnosis of malrotation and volvulus in children and adolescents: a systematic review and meta-analysis. Arch Dis Child 2021; 106:1171-1178. [PMID: 33879472 PMCID: PMC8526644 DOI: 10.1136/archdischild-2020-321082] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 03/15/2021] [Accepted: 03/28/2021] [Indexed: 02/01/2023]
Abstract
CONTEXT Despite the advantages of ultrasound (US), upper gastrointestinal contrast series (UGI) remains the first-line diagnostic modality in the diagnosis of midgut malrotation and volvulus in children. OBJECTIVE Evaluate the diagnostic accuracy of US in the diagnosis of malrotation with or without volvulus in children and adolescents aged 0-21 years, compared with the reference standard (diagnosis by surgery, UGI, CT, MRI, and clinical follow-up individually or as a composite). DATA SOURCES We searched the electronic databases Ovid-MEDLINE, Embase, Scopus, CINAHL, and the Cochrane library in October 2019 and updated on 18 August 2020. STUDY SELECTION Studies evaluating the diagnostic performance of US for diagnosis of midgut malrotation with or without volvulus in children (0-21 years). DATA EXTRACTION AND SYNTHESIS The data were extracted independently by two authors and a bivariate model was used for synthesis. RESULTS Meta-analysis of 17 cohort or cross-sectional studies and 2257 participants estimated a summary sensitivity of 94% (95% CI 89% to 97%) and summary specificity of 100% (95% CI 97% to 100%) (moderate certainty evidence) for the use of US for the diagnosis of malrotation with or without midgut volvulus compared with the reference standard. Subgroup analysis and meta-regression revealed better diagnostic accuracy in malrotation not complicated by volvulus, in the neonatal population and enteric fluid administration before US. CONCLUSIONS Moderate certainty evidence suggests excellent diagnostic accuracy and coupled with the advantages, a strong case exists for the use of abdominal US as the first-line diagnostic test for suspected midgut malrotation with or without volvulus in children and adolescents.
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Affiliation(s)
- HaiThuy N. Nguyen
- Edward B. Singleton Department of Radiology, Texas Children’s Hospital, Houston, Texas, USA,Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Madhulika Kulkarni
- Department of Pediatrics, Texas Children’s Hospital, Houston, Texas, USA,Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Jisha Jose
- Department of Pediatrics, Texas Children’s Hospital, Houston, Texas, USA,Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Amy Sisson
- The Texas Medical Center Library, Houston, Texas, USA
| | - Mary L. Brandt
- Department of Surgery, Children’s Hospital of New Orleans, Louisiana, USA,Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Marla B.K. Sammer
- Edward B. Singleton Department of Radiology, Texas Children’s Hospital, Houston, Texas, USA,Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Mohan Pammi
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Hunt TM, Thacker PG. Sonographic Detection of Congenital Intestinal Malrotation: A Case Report. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2021. [DOI: 10.1177/87564793211037612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Intestinal malrotation is a rare fetal anomaly resulting from the failure of midgut rotation and fixation. Sonography is typically the first modality of choice for assessing pediatric pathology due to its high sensitivity, portability, real-time imaging capability, and non-ionizing technique; however, its role in diagnosing small bowel rotational anomalies remains limited and controversial. Fluoroscopic upper gastrointestinal imaging (UGI) is the primary diagnostic examination at most institutions. However, even on UGI, imaging findings may be equivocal. In such cases, sonography may provide additional information at facilities where it is not used as a primary diagnostic tool. This case report represents the first reported case showing how patient position is important as the typical vascular sonographic features of rotation were normal in one position but abnormal in another. In addition, this case shows how congenital intestinal malrotation was decisively diagnosed using sonographic imaging.
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Nguyen HN, Navarro OM, Guillerman RP, Silva CT, Sammer MBK. Untwisting the complexity of midgut malrotation and volvulus ultrasound. Pediatr Radiol 2021; 51:658-668. [PMID: 33398405 DOI: 10.1007/s00247-020-04876-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/27/2020] [Accepted: 10/08/2020] [Indexed: 01/20/2023]
Abstract
Abdominal US is emerging as an alternative to the upper gastrointestinal (GI) series as the preferred diagnostic imaging test for midgut malrotation complicated by volvulus. Unlike the upper GI series, US is free from ionizing radiation, does not require oral contrast agent, and can be performed portably and at times remotely from the interpreting radiologist, expediting diagnosis. Although some institutions do not have a standardized US protocol for midgut volvulus, many routinely use US in the setting of an infant or child with acute abdominal signs or symptoms to evaluate for common conditions such as hypertrophic pyloric stenosis, intussusception, necrotizing enterocolitis and appendicitis. Because these common conditions can overlap in age and clinical presentation with midgut volvulus, the aim of this pictorial essay is to provide instruction on the technique and diagnostic findings of midgut volvulus on US to ensure confident, accurate interpretation, and prompt treatment.
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Affiliation(s)
- HaiThuy N Nguyen
- Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA. .,Department of Radiology, Baylor College of Medicine, Houston, TX, USA.
| | - Oscar M Navarro
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - R Paul Guillerman
- Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA.,Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Cicero T Silva
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Marla B K Sammer
- Singleton Department of Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA.,Department of Radiology, Baylor College of Medicine, Houston, TX, USA
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19
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Strouse PJ. Ultrasound for malrotation and volvulus: has the time come? Pediatr Radiol 2021; 51:503-505. [PMID: 33404784 DOI: 10.1007/s00247-020-04919-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/09/2020] [Accepted: 11/17/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Peter J Strouse
- Section of Pediatric Radiology,C. S. Mott Children's Hospital, Room 3-231,, Department of Radiology, Michigan Medicine, 1540 E. Hospital Drive, Ann Arbor, MI 48109-4252, USA.
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Munden MM, Paltiel HJ. The Gastrointestinal Tract. PEDIATRIC ULTRASOUND 2021:283-353. [DOI: 10.1007/978-3-030-56802-3_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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21
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Wadood Z, Sams CM. Imaging of the Pediatric Acute Abdomen. Semin Roentgenol 2020; 55:373-384. [PMID: 33220784 DOI: 10.1053/j.ro.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Zara Wadood
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Rhode Island Hospital/Hasbro Children's Hospital, Providence, RI
| | - Cassandra M Sams
- Department of Diagnostic Imaging, Warren Alpert Medical School of Brown University, Rhode Island Hospital/Hasbro Children's Hospital, Providence, RI.
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22
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Dehaini H, Nasser Eldine R, Doughan S, Khalifeh M, Khasawneh H, Hussain H, Sbaity E. Presentation of intestinal malrotation and midgut volvulus in adults: Case report & literature review. Int J Surg Case Rep 2020; 73:27-30. [PMID: 32629217 PMCID: PMC7338997 DOI: 10.1016/j.ijscr.2020.06.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Malrotation is considered a newborn disease. This case report sheds light on the rare, but possible late presentation of malrotation in adulthood, which if missed, can leave the patient in a detrimental state. PRESENTATION OF CASE 28-year-old female presented in critical state with acute abdomen. Computed tomography abdomen/pelvis showed midgut volvulus, requiring urgent laparotomy. The patient's bowels were discolored, yet they normalized upon detorsion, except for a small portion, which was equivocal and left for observation. Ladd's bands were excised, and the abdomen was closed with Bogota bag for re-exploration. The patient underwent two more laparotomies to observe the intestinal segment until it was back to normal. Ladd procedure was then completed, and an absorbable mesh was applied. Follow-up of 20 months has been uneventful, except for a small, asymptomatic, incisional hernia. DISCUSSION Malrotation in adults is often missed due to its subacute, nonspecific presentation. It is often diagnosed by CT abdomen, which shows inversion or vertical positioning of the superior mesenteric vessels. Symptomatic, but stable patients, can undergo laparoscopic Ladd procedure, which carries the benefit of less length of stay. While an incidental malrotation can be prophylactically operated on, correcting asymptomatic malrotation beyond age of 20 is ineffective and possibly harmful. CONCLUSION Intestinal malrotation presenting in an adult should be on the differential diagnosis when dealing with abdominal pain, especially in the context of small bowel obstruction in a virgin abdomen. It is vital to consider a patient's age prior to prophylactically operate on malrotation discovered incidentally.
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Affiliation(s)
- Hassan Dehaini
- Division of General Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
| | - Rakan Nasser Eldine
- Division of Vascular & Endovascular Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
| | - Samer Doughan
- Division of General Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
| | - Mohammad Khalifeh
- Division of General Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
| | - Hala Khasawneh
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
| | - Hero Hussain
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
| | - Eman Sbaity
- Division of General Surgery, Department of Surgery, Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
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The role of sonography in differentiating congenital intrinsic duodenal anomalies from midgut malrotation: emphasizing the new signs of duodenal and gastric wall thickening and hyperechogenicity. Pediatr Radiol 2020; 50:673-683. [PMID: 31970459 DOI: 10.1007/s00247-020-04616-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/27/2019] [Accepted: 01/10/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The clinical and plain radiographic differentiation of congenital intrinsic duodenal anomalies (atresia, web, stenosis) from intestinal malrotation is not always clear. Although sonography has been documented as an important diagnostic tool in the differentiation of these two entities, its role is still not widely appreciated and it is still not universally utilized in this clinical setting. OBJECTIVE To assess the usefulness of sonographic features of the duodenal and gastric wall in the differentiation of congenital intrinsic duodenal anomalies from midgut malrotation in a large series of neonates and to compare them with other features on abdominal radiographs, ultrasound and upper gastrointestinal series. MATERIALS AND METHODS Using the surgical database at our tertiary pediatric hospital, we identified neonates who had surgically proven congenital intrinsic duodenal anomalies or malrotation over a period of 15 years (2000-2015). We reviewed imaging findings in both groups of neonates (blinded to the final diagnosis) with attention to the echogenicity and thickness of the wall of the duodenum and stomach, the relationship between the superior mesenteric artery and vein, the position of the third portion of the duodenum and the presence of the whirlpool sign. Findings were compared between the groups using the unpaired t-test and Fisher exact test. RESULTS We included 107 neonates in the study, 40 with a congenital intrinsic duodenal anomaly, 49 with malrotation (36 with volvulus) and 18 with a combination of both. Duodenal and gastric wall thickening and hyperechogenicity were significantly more common in the group with a congenital intrinsic duodenal anomaly compared to those with malrotation (P<0.0001). Conversely, an abnormal relationship between the superior mesenteric artery and vein, abnormal position of the third part of the duodenum, and the whirlpool sign were significantly more common in neonates with malrotation than in those with congenital intrinsic duodenal anomalies (P<0.0001). CONCLUSION Duodenal or gastric wall thickening, and increased wall echogenicity are helpful sonographic features in the differentiation of congenital intrinsic duodenal anomalies from malrotation. Evaluation of the duodenal and gastric wall should thus be added to the features routinely assessed on ultrasound examinations in the clinical setting of suspected duodenal obstruction in the neonate.
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Wang MQ, Lee MY, El Teo H. Ultrasound in the evaluation of necrotic bowel in children: A pictorial essay. ULTRASOUND (LEEDS, ENGLAND) 2019; 27:207-216. [PMID: 31762778 DOI: 10.1177/1742271x18814864] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 10/19/2018] [Indexed: 11/16/2022]
Abstract
Necrotic bowel is a serious condition involving death of gastrointestinal tissue. The diagnosis is difficult to make clinically, and plain radiography is often inconclusive. Ultrasonography is an inexpensive, portable and readily available complementary diagnostic tool. In some cases, ultrasonography can detect features of necrotic bowel earlier than plain radiography or when plain radiography is equivocal and does not correlate with the clinical findings. This pictorial essay aims to compare the ultrasonography features of normal bowel and necrotic bowel in children. The role of ultrasonography and the ultrasonographic features of necrotic bowel will be illustrated by discussing some of the causes of necrotic bowel in children. Correlation with plain radiographs and pathological specimens is made. Frequent causes of necrotic bowel in neonates include necrotising enterocolitis, malrotation with small bowel volvulus and incarcerated inguinal hernias. Causes in older children include intussusception, complications of Meckel's diverticulum, post-surgical adhesions, internal hernias and vasculitic abnormalities. Ultrasonography features suggestive of necrotic bowel include persistently dilated loops of aperistaltic bowel, increase or decrease of bowel wall thickness, intramural or portal venous gas, loss of bowel wall perfusion, and free intraperitoneal gas and fluid. The diagnosis of necrotic bowel may be made earlier on ultrasonography than on abdominal radiographs alone. This pictorial essay will familiarise the reader with the role of ultrasonography and the ultrasonographic features of necrotic bowel through a wide range of conditions that may cause necrotic bowel in children. Familiarity with these findings will facilitate timely imaging diagnosis of necrotic bowel before complications develop.
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Affiliation(s)
- Mark Qw Wang
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore, Singapore
| | - Margaret Yw Lee
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore, Singapore
| | - Harvey El Teo
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore, Singapore
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Oudou AZ, Soumana ID, Souiki T, Majdoub KI, Toughrai I, Laalim SA, Mazaz K. [Total small bowel volvulus complicating common incomplete mesentery, an exceptional complication in adults: about a case]. Pan Afr Med J 2019; 33:220. [PMID: 31692801 PMCID: PMC6814366 DOI: 10.11604/pamj.2019.33.220.18159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 05/14/2019] [Indexed: 11/26/2022] Open
Abstract
Le volvulus total du grêle complique le mésentère commun incomplet correspond à un arrêt de la rotation à 180° de l'anse intestinale primitive. La racine du mésentère est très courte et l'ensemble de l'intestin grêle se trouve pédiculé sur l'axe artériel mésentérique supérieur. Cette situation est à très haut risque de volvulus du grêle et d'infarctus entero-mésentérique. Le volvulus aigu impose une intervention chirurgicale en urgence; l'imagerie ne doit pas retarder la prise en charge chirurgicale. Le geste chirurgical consiste à la détorsion du volvulus (dans le sens antihoraire), la viabilité de l'intestin appréciée. L'intestin est rangé position de mésentère commun complet: cœcum dans la fosse iliaque gauche. Nous rapportons l'observation d'un patient de 60 ans admis pour volvulus total du grêle sur mésentère commun incomplet, opéré en urgence avec une évolution postopératoire favorable.
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Affiliation(s)
| | | | - Tarek Souiki
- Service de Chirurgie Viscérale B, CHU Hassan 2, Fes, Maroc
| | | | - Imane Toughrai
- Service de Chirurgie Viscérale B, CHU Hassan 2, Fes, Maroc
| | | | - Khalid Mazaz
- Service de Chirurgie Viscérale B, CHU Hassan 2, Fes, Maroc
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A Multi-institutional Case Series With Review of Point-of-Care Ultrasound to Diagnose Malrotation and Midgut Volvulus in the Pediatric Emergency Department. Pediatr Emerg Care 2019; 35:443-447. [PMID: 30702647 DOI: 10.1097/pec.0000000000001737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Point-of-care ultrasound can be used to screen for malrotation with and without volvulus in the newborn with bilious vomiting, as well as children with unexplained intermittent abdominal pain. We discuss cases where infants and children presenting to pediatric emergency departments with bilious vomiting and/or intermittent abdominal pain were initially screened for small bowel pathology with point-of-care ultrasound. Bedside findings suggestive of midgut volvulus were confirmed with radiology-performed ultrasound or upper gastrointestinal fluoroscopy. In all cases, operative findings were consistent with malrotation of the small bowel with or without evidence of midgut volvulus.
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27
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Dekonenko C, Sujka JA, Weaver K, Sharp SW, Gonzalez K, St Peter SD. The identification and treatment of intestinal malrotation in older children. Pediatr Surg Int 2019; 35:665-671. [PMID: 30810798 DOI: 10.1007/s00383-019-04454-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE Intestinal malrotation is often diagnosed in infancy. The true incidence of malrotation outside of this age is unknown. These patients can present atypically or be asymptomatic and diagnosed incidentally. We evaluate the incidence, clinical presentation, ideal imaging, and intra-operative findings of patients with malrotation over 1 year of age. METHODS Retrospective review was conducted in patients older than 1 year, treated for malrotation at a single pediatric tertiary care center from 2000 to 2015. Data analyzed included demographics, presentation, imaging, intraoperative findings, and follow-up. Patients predisposed to malrotation were excluded. RESULTS 246 patients were diagnosed with malrotation, of which 77 patients were older than 1 year of age. The most common presenting symptoms were vomiting (68%) and abdominal pain (57%). The most common method of diagnosis was UGI (61%). In 88%, the UGI revealed malrotation. 73 of 75 were confirmed to have malrotation at surgery. Intra-operatively, 60% were found to have a malrotated intestinal orientation and 33% with a non-rotated orientation. Obstruction was present in 22% with 12% having volvulus. Of those with follow-up, 58% reported alleviation of symptoms. CONCLUSION Despite age malrotation should be on the differential given a variable clinical presentation. UGI should be conducted to allow for prompt diagnosis and surgical intervention.
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Affiliation(s)
- Charlene Dekonenko
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Joseph A Sujka
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Katrina Weaver
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Susan W Sharp
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Katherine Gonzalez
- Department of Surgery, John Hopkins All Children's Hospital, St. Petersburg, FL, 33701, USA
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA.
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Deniffel D, Goerke SM, Rummeny EJ, Laubenberger J. Novel variant of reversed midgut rotation - retro-arterial proximal jejunum and transverse colon: a case report and review of the literature. J Med Case Rep 2018; 12:261. [PMID: 30213270 PMCID: PMC6137938 DOI: 10.1186/s13256-018-1802-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 08/14/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Reversed rotation of the midgut is the rarest variation of midgut malrotations, which are congenital disorders that result from aberrant rotation and fixation of the midgut during embryological development. Common complications of these disorders are small bowel obstruction by volvulus or peritoneal bands, usually occurring in early infancy. CASE PRESENTATION A 23-year-old Caucasian woman presented with recurrent abdominal pain. A contrast-enhanced multidetector computed tomography study revealed a novel variant of reversed rotation of the midgut. Besides the specific finding of a retro-arterial transverse colon, we also found the proximal jejunum to cross posterior to the mesenteric root, a variation that has not been reported in the literature so far. In this case, substantial symptomatic relief was achieved with conservative management. CONCLUSIONS The hypothesis of a double reversed rotation of the pre-arterial segment of the umbilical loop around the superior mesenteric artery axis provides a possible explanation for this anomaly. There is no evidence-based consensus on the management of patients presenting with non-symptomatic or mildly symptomatic intestinal malrotations. In this case, radiologic and clinical presentations excluded acute small bowel obstruction, and surgical intervention was avoided.
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Affiliation(s)
- Dominik Deniffel
- Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 München, Germany
| | - Sebastian M. Goerke
- Department of Radiology, Ortenau Klinikum Offenburg-Gengenbach, Ebertplatz 12, 77654 Offenburg, Germany
| | - Ernst J. Rummeny
- Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 München, Germany
| | - Jörg Laubenberger
- Department of Radiology, Ortenau Klinikum Offenburg-Gengenbach, Ebertplatz 12, 77654 Offenburg, Germany
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Mimics of malrotation on pediatric upper gastrointestinal series: a pictorial review. Abdom Radiol (NY) 2018; 43:2246-2254. [PMID: 29500650 DOI: 10.1007/s00261-018-1537-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Intestinal malrotation is a continuum of congenital anomalies due to lack of rotation or incomplete rotation of the fetal intestine around the superior mesenteric artery axis. The abnormal bowel fixation (by mesenteric bands) or absence of fixation of portions of the bowel increases the risk of bowel obstruction, acute or chronic volvulus, and bowel necrosis. The clinical presentation of patients with malrotation without, with intermittent, or with chronic volvulus can be problematic, with an important minority presenting late or having atypical or chronic symptoms, such as intermittent vomiting, abdominal pain, duodenal obstruction, or failure to thrive. The diagnosis is heavily reliant on imaging. Upper GI series remain the gold standard with the normal position of the duodenojejunal junction lateral to the left-sided pedicles of the vertebral body, at the level of the duodenal bulb on frontal views and posterior (retroperitoneal) on lateral views. However, a variety of conditions might influence the position of the duodenojejunal junction, potentially leading to a misdiagnosis of malrotation. Such conditions include improper technique, gastric over distension, splenomegaly, renal or retroperitoneal tumors, liver transplant, small bowel obstruction, the presence of properly or malpositioned enteric tubes, and scoliosis. All of these may cause the duodenojejunal junction to be displaced. We present a series of cases highlighting conditions that mimic malrotation without volvulus to increase the practicing radiologist awareness and help minimize interpretation errors.
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Ismail M, Elgffar Helal AA. Laparoscopic diagnostic finding in atypical intestinal malrotation in children with equivocal imaging studies. Afr J Paediatr Surg 2018; 15:121-125. [PMID: 32769361 PMCID: PMC7646688 DOI: 10.4103/ajps.ajps_132_13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Atypical presentation of intestinal malrotation provide a diagnostic and therapeutic dilemma for the surgeon to answer the question is it wisdom to operate or not? Upper gastrointestinal (UGI) contrast study is essential for diagnosis; however, 'soft' radiologic findings place the responsibility of excluding malrotation directly on the surgeon. Recently, minimally invasive surgical techniques would be able to accomplish the identical evaluation and treatment of this group of patients. PATIENTS AND METHODS A total of 40 patients (25 male, 15 female), age of 2-14 years, presented with symptoms of chronic abdominal pain, intermittent upper intestinal obstruction, recurrent bilious vomiting and failure to thrive. On clinical examination, none of the patients had signs of acute abdominal emergency. UGI contrast study was done and it was equivocal. All patients underwent laparoscopic evaluation. RESULTS A total of 36 patients (90%) were found on laparoscopy to have a discrepant finding of chronic intestinal malrotation. With narrow mesenteric base which put them at significant risk of midgut volvulus. Two patients (5%) were found to have chronic appendicitis with extensive adhesion at the right iliac fossa, one patient (2.5%) has annular pancreas and one patient has negative laparoscopic exploration. Laparoscopic findings of chronic intestinal malrotation includes, huge dilated stomach and the first part of duodenum, ectopic site of caecum central in the abdomen or under the liver, medial and low position of duodenojejunal junction, congested mesenteric veins with lymphatic oedema, generalised mesenteric lymphadenopathy, reversed relation of superior mesenteric artery and vein, right-sided small bowel. CONCLUSION Laparoscopic diagnostic finding permits direct evaluation and treatment of undocumented malrotation in children, with equivocal UGI contrast study. Furthermore, laparoscopy provides an excellent opportunity to assess the base of the mesentery. Those children with a narrow base should undergo laparoscopic Ladd procedure to avoid catastrophic midgut volvulus.
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Affiliation(s)
- Maged Ismail
- Pediatric Surgery Unit, Al-Azhar University Hospitals, Cairo, Egypt
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Andronikou S, Arthur S, Simpson E, Chopra M. Selective duodenography for controlled first-pass bolus distention of the duodenum in neonates and young children with bile-stained vomiting. Clin Radiol 2018; 73:506.e1-506.e8. [PMID: 29397912 DOI: 10.1016/j.crad.2017.12.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 12/20/2017] [Indexed: 10/18/2022]
Abstract
AIM To compare "selective duodenograms" performed through nasogastric tubes advanced into the proximal duodenum against traditional contrast studies regarding visualisation of a first-pass bolus distention of the duodenum and frequency of inconclusive results. MATERIALS AND METHODS Retrospective comparison of "selective duodenograms" and traditional upper gastrointestinal contrast studies in neonates with bile-stained vomiting, regarding demonstration of the duodenal C-loop, first-pass bolus capture, degree of distention of the duodenum, and number of inconclusive studies. Statistical comparison was performed using the two-tailed Fishers exact and chi-squared tests. RESULTS There were 31 "selective duodenograms" and 70 traditional studies. The C-loop was demonstrated in 93% of traditional studies versus 100% in "selective duodenograms" and was demonstrated significantly more often during the first-pass (94% versus 73%; p=0.018) and more often with distention of the duodenum for "selective duodenography" (94% versus 56%, p<0.001). There were more inconclusive traditional studies (7% versus 3%; non-significant). CONCLUSION Emergency upper gastrointestinal tract studies performed in neonates using the "selective duodenogram" technique demonstrated the duodenum with 100% success, with significantly more frequent first-pass bolus visualisation and duodenal distention than traditional studies. The five (7%) inconclusive traditional studies, present a significant diagnostic conundrum in the emergency setting because emergency surgery must be contemplated without proof.
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Affiliation(s)
- S Andronikou
- Department of Paediatric Radiology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK; University of Bristol, Senate House, Tyndall Ave, Bristol, BS8 1TH, UK.
| | - S Arthur
- Department of Paediatrics, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK
| | - E Simpson
- Department of Paediatric Radiology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK
| | - M Chopra
- Department of Paediatric Radiology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK
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Fay JS, Chernyak V, Taragin BH. Identifying intestinal malrotation on magnetic resonance examinations ordered for unrelated indications. Pediatr Radiol 2017. [PMID: 28623416 DOI: 10.1007/s00247-017-3903-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Anatomical imaging findings indicating normal bowel rotation can be identified on cross-sectional imaging, including magnetic resonance imaging (MRI) performed for non-related indications. OBJECTIVE The goal of our study was to assess whether non-targeted MRI can accurately assess intestinal malrotation. MATERIALS AND METHODS Four anatomical landmarks were assessed on MRIs of the chest, spine or abdomen performed from January 2006 to June 2014, on patients who also had upper gastrointestinal series (UGI) performed within 10 years of the MRI date: 1) retroperitoneal duodenum, 2) left upper quadrant duodenojejunal junction, 3) superior mesenteric artery to the left of the superior mesenteric vein, and 4) right lower quadrant cecum. Two attending radiologists, one pediatric and one abdominal radiologist, independently reviewed the MR images. The pediatric radiologist reviewed images from UGI (considered the gold standard) to determine the intestinal rotation for each case. Validation of the criteria was performed on new patients imaged through January 2016. RESULTS The original cohort included 109 MRIs (15 chest, 41 spine and 53 abdomen) done on 109 patients (42% males, mean age: 10.2 years). If each of the 4 anatomical questions were answered "yes" (4-YES), specificity was 100% for each radiologist and malrotation was appropriately excluded. Using the 4-YES criteria, the pediatric radiologist excluded malrotation in 71 patients (65%) and the abdominal radiologist excluded it in 65 (60%), with concurrence for 57 patients. Validation of the 4-YES criteria in 23 new patients appropriately proved the 4-YES rule, with neither labeling the one new malrotation case 4-YES. CONCLUSION If a radiologist can confidently answer "yes" to the four questions evaluated in this study, then intestinal rotation can be safely considered normal. Normal bowel rotation should be commented upon in MRI reports when these four anatomical locations are imaged, thus helping patients avoid unnecessary UGI and radiation exposure.
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Affiliation(s)
- Jill S Fay
- Department of Diagnostic Radiology, Montefiore Medical Center, 111 E. 210th St, Bronx, NY, 10467, USA.
| | - Victoria Chernyak
- Department of Diagnostic Radiology, Montefiore Medical Center, 111 E. 210th St, Bronx, NY, 10467, USA
| | - Benjamin H Taragin
- Department of Diagnostic Radiology, Montefiore Medical Center, 111 E. 210th St, Bronx, NY, 10467, USA
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Karaman İ, Karaman A, Çınar HG, Ertürk A, Erdoğan D, Özgüner İF. Is color Doppler a reliable method for the diagnosis of malrotation? J Med Ultrason (2001) 2017; 45:59-64. [DOI: 10.1007/s10396-017-0794-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 05/02/2017] [Indexed: 12/11/2022]
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Open versus laparoscopic approach for intestinal malrotation in infants and children: a systematic review and meta-analysis. Pediatr Surg Int 2016; 32:1157-1164. [PMID: 27709290 DOI: 10.1007/s00383-016-3974-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE Although the principles of the Ladd's procedure for intestinal malrotation in children have remained unchanged since its first description, in the era of minimally invasive surgery it is controversial whether laparoscopy is advantageous over open surgery. The aim of our study was to determine whether the surgical approach for the treatment of malrotation had an impact on patient outcome. METHODS Using a defined strategy (PubMed, Cochrane, Embase and Web of Science MeSH headings), two investigators independently searched for studies comparing open versus laparoscopic Ladd's procedure in children. Case reports and opinion articles were excluded. Outcome measures included age at operation, time to full enteral feeding, length of hospital stay, and post-operative complications. Maneuvers were compared using Fisher's exact test and meta-analysis was conducted using RevMan 5.3. Data are expressed as mean ± SD. RESULTS Of 308 abstracts screened, 49 full-text articles were analyzed and nine (all retrospective) met our search criteria. Selected articles included 1003 patients, of whom 744 (74 %) underwent open surgery and 259 (26 %) laparoscopy. Patients who had open surgery were younger (0.9 ± 1.2 years) than those who underwent laparoscopy (2.6 ± 3 years; p < 0.0001). Laparoscopy was converted to open Ladd's in 25.3 % patients. Laparoscopy was associated with faster full enteral feeding (1.5 ± 0.3 days) in comparison to open surgery (4.6 ± 0.1 days, p < 0.0001). Length of hospital stay was shorter in the laparoscopic group (5.9 ± 4.3 days) than in the open group (11.2 ± 6.7 days; p < 0.0001). Open surgery was associated with higher overall post-operative complication rate (21 %) than laparoscopy (8 %; p < 0.0001). Although there was no difference in the prevalence of post-operative bowel obstruction (open, n = 10 %; laparoscopy, n = 0 % p = 0.07), post-operative volvulus was more frequent in the laparoscopy group (3.5 %) than in the open group (1.4 %, p = 0.04). CONCLUSION Comparative but non-randomized studies indicate that laparoscopic Ladd's procedure is not commonly performed in young children. Although one third of laparoscopic procedures is converted to open surgery, laparoscopy is associated with shorter time to full enteral feeds and length of hospital stay. However, laparoscopic Ladd's procedure seems to have higher incidence of post-operative volvulus. Prospective randomized studies with long follow-up are needed to confirm present outcome data and determine the safety and effectiveness of the laparoscopic approach.
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Ultrasound of the duodenum in children. Pediatr Radiol 2016; 46:1324-31. [PMID: 27003134 DOI: 10.1007/s00247-016-3564-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 01/06/2016] [Accepted: 01/26/2016] [Indexed: 10/22/2022]
Abstract
Ultrasound is well suited for examining the pediatric duodenum, given the small size of the patients, the lack of ionizing radiation and high-resolution imaging potential. Technical considerations, normal anatomy, congenital and acquired pathology of the duodenum, and the advantages and limitations of US are discussed and illustrated in this review.
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Brinkley MF, Tracy ET, Maxfield CM. Congenital duodenal obstruction: causes and imaging approach. Pediatr Radiol 2016; 46:1084-95. [PMID: 27324508 DOI: 10.1007/s00247-016-3603-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Revised: 01/25/2016] [Accepted: 03/01/2016] [Indexed: 12/14/2022]
Abstract
Bilious emesis is a common cause for evaluation in pediatric radiology departments. There are several causes of congenital duodenal obstruction, most of which require elective surgical correction, but the potential of malrotation with midgut volvulus demands prompt imaging evaluation. We review the various causes of congenital duodenal obstruction with an emphasis on the approach to imaging evaluation and diagnosis.
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Affiliation(s)
- Michael F Brinkley
- Department of Radiology, Duke University Medical Center, DUMC Box 3808, Durham, NC, 27710, USA.
| | - Elisabeth T Tracy
- Division of Pediatric Surgery, Duke University Medical Center, Durham, NC, USA
| | - Charles M Maxfield
- Department of Radiology, Duke University Medical Center, DUMC Box 3808, Durham, NC, 27710, USA
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Bravo Bravo M, García-Herrera Taillefer P. Qué hacer con el recién nacido obstruido. RADIOLOGIA 2016; 58 Suppl 2:70-9. [DOI: 10.1016/j.rx.2016.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 02/03/2016] [Accepted: 02/20/2016] [Indexed: 11/28/2022]
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Shah MR, Levin TL, Blumer SL, Berdon WE, Jan DM, Yousefzadeh DK. Volvulus of the entire small bowel with normal bowel fixation simulating malrotation and midgut volvulus. Pediatr Radiol 2015. [PMID: 26209961 DOI: 10.1007/s00247-015-3430-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Midgut volvulus is a complication of malrotation of bowel and mesenteric malfixation. In contrast, primary volvulus of the small bowel is a distinctly different and rare entity characterized by torsion of the entire small bowel with normal mesenteric fixation. OBJECTIVE To present the clinical and imaging findings in four infants with primary small bowel volvulus and normal bowel fixation in order to improve awareness of this entity among clinicians and radiologists and to discuss the potential etiologies of this entity to distinguish it from other causes of small bowel volvulus. MATERIALS AND METHODS A retrospective review of imaging studies (two ultrasounds and four upper gastrointestinal series) in four infants (three full-term and one premature) from three institutions with surgically proven volvulus of the entire small bowel and normal bowel fixation were reviewed by three board-certified pediatric radiologists and correlated with clinical and surgical reports when available. RESULTS The infants presented during the first week to 6 months of life and were acutely ill. The upper gastrointestinal series showed complete duodenal obstruction with beaking in one and partial duodenal obstruction in three. All studies were interpreted as highly suspicious for malrotation and midgut volvulus. Emergent laparotomy demonstrated primary small bowel volvulus with normal mesenteric fixation in all infants. The base of the small bowel mesentery was described by the operating surgeon as smaller than normal in one infant (case 3). There was no mesenteric defect or other abnormality predisposing to volvulus in the other three. In both infants who had abdominal US, a retroperitoneal position of the third portion of the duodenum was demonstrated. All infants survived. One infant required resection of the necrotic small bowel and currently has short gut syndrome, one has malabsorption and two were lost to follow-up. CONCLUSION Primary small bowel volvulus with normal fixation is indistinguishable from malrotation with midgut volvulus in the acutely ill infant or child. Radiographic diagnosis can be difficult in patients with intermittent or incomplete small bowel volvulus without malrotation. In these patients, neither an upper gastrointestinal series demonstrating a normal position of the duodenojejunal junction nor the sonographic demonstration of a retromesenteric third portion of the duodenum excludes the diagnosis. In young infants, the clinical and imaging findings may mimic necrotizing enterocolitis. Sonography may be useful to evaluate the bowel for signs of bowel wall compromise or a whirlpool sign.
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Affiliation(s)
- Mansi R Shah
- Division of Pediatric Radiology, Department of Radiology, Children's Hospital of Montefiore Medical Center, 111 E. 210th St., Bronx, NY, 10467, USA
| | - Terry L Levin
- Division of Pediatric Radiology, Department of Radiology, Children's Hospital of Montefiore Medical Center, 111 E. 210th St., Bronx, NY, 10467, USA.
| | - Steven L Blumer
- Department of Medical Imaging, Nemours/AI duPont Hospital for Children, Wilmington, DE, USA
| | - Walter E Berdon
- Division of Pediatric Radiology, Department of Radiology, Columbia University Medical Center, New York, NY, USA
| | - Dominique M Jan
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital of Montefiore Medical Center, Bronx, NY, USA
| | - David K Yousefzadeh
- Department of Radiology, University of Chicago Medical Center, Chicago, IL, USA
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Malrotation of midgut in adults, an unsuspected and neglected condition--An analysis of 64 consensus confirmed cases. Indian J Gastroenterol 2015; 34:426-30. [PMID: 26759264 DOI: 10.1007/s12664-015-0596-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 10/14/2015] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Malrotation of midgut is considered to be a condition of childhood. This study evaluated malrotation in adults with recurrent abdominal pain (RAP). METHODS Sixty-four consensus-confirmed cases of intestinal malrotation were reviewed. The diagnosis was based on radiological criteria, and the consensus was arrived at by at least three of the five authors in any individual case. RESULTS Abnormal duodenojejunal junction (DJJ) was a consensus finding in 64 cases referred for RAP. Most were in their fourth decade of life, and 12 were beyond 60 years. Besides RAP, intolerance to food was the next common symptom. Acute intestinal obstruction was seen in 16. Forty-two of 64 patients consented for surgery. Ladd's procedure was the commonest. All patients who underwent surgery were symptom free except for two, of which, one had liver cyst and the other had hernia. Of those who refused surgery (22), all had continued symptoms and 10 patients took alternative therapies. On follow up of initially unwilling patients (for surgery) with abnormal DJJ, only eight consented for surgery; three underwent open Ladd's procedure, and one had laparoscopic Ladd's done. CONCLUSION Malrotation is not uncommon as a cause of RAP in adults.
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Zhou LY, Li SR, Wang W, Shan QY, Pan FS, Liu JC, Xie XY. Usefulness of Sonography in Evaluating Children Suspected of Malrotation: Comparison With an Upper Gastrointestinal Contrast Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:1825-1832. [PMID: 26362146 DOI: 10.7863/ultra.14.10017] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 01/16/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES The purpose of this study was to prospectively evaluate the value of sonography in working up or ruling out malrotation by 3 sonographic features (inversion of the superior mesenteric artery and superior mesenteric vein, the whirlpool sign, and an intraperitoneal transverse duodenum) and comparing it with an upper gastrointestinal (GI) contrast study. METHODS A total of 70 pediatric patients who underwent detailed abdominal sonography to rule out intestinal malrotation were included. Twenty-three of them also underwent an upper GI contrast study. Surgery or clinical follow-up was taken as the reference standard. Statistical analysis was performed with the χ(2) test. RESULTS Twenty-three patients had a diagnosis of malrotation by surgical findings. With the combination of all 3 sonographic features, the sensitivity, specificity, and accuracy of sonography for determining malrotation were 100% (23 of 23), 97.8% (46 of 47), and 98.6% (69 of 70), respectively, whereas the sensitivity, specificity, and accuracy of the upper GI study were 40% (4 of 10), 64.3% (9 of 14), and 56.5% (13 of 23; P < .001). Combined anomalies in 2 patients and complications in 2 patients were also detected by sonography. CONCLUSIONS By combining inversion of the superior mesenteric artery and superior mesenteric vein, the whirlpool sign, and an intraperitoneal transverse duodenum, sonography might be more valuable for accurately working up or ruling out pediatric malrotation than an upper GI contrast study. In addition, sonography could provide extra information, such as combined anomalies and intestinal necrosis, to help management.
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Affiliation(s)
- Lu-yao Zhou
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound (L.Z., W.W., Q.S., F.P., X.X.) and Departments of Radiology (S.L.) and Pediatric Surgery (J.L.), First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shu-rong Li
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound (L.Z., W.W., Q.S., F.P., X.X.) and Departments of Radiology (S.L.) and Pediatric Surgery (J.L.), First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Wang
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound (L.Z., W.W., Q.S., F.P., X.X.) and Departments of Radiology (S.L.) and Pediatric Surgery (J.L.), First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Quan-yuan Shan
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound (L.Z., W.W., Q.S., F.P., X.X.) and Departments of Radiology (S.L.) and Pediatric Surgery (J.L.), First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Fu-shun Pan
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound (L.Z., W.W., Q.S., F.P., X.X.) and Departments of Radiology (S.L.) and Pediatric Surgery (J.L.), First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jun-cheng Liu
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound (L.Z., W.W., Q.S., F.P., X.X.) and Departments of Radiology (S.L.) and Pediatric Surgery (J.L.), First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao-yan Xie
- Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound (L.Z., W.W., Q.S., F.P., X.X.) and Departments of Radiology (S.L.) and Pediatric Surgery (J.L.), First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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Koch C, Taghavi K, Hamill J, Mirjalili SA. Redefining the projectional and clinical anatomy of the duodenojejunal flexure in children. Clin Anat 2015; 29:175-82. [PMID: 26378736 DOI: 10.1002/ca.22625] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/05/2015] [Accepted: 09/11/2015] [Indexed: 11/12/2022]
Abstract
The duodenojejunal flexure (DJF) is an important surgical landmark that enables the pediatric surgeon to establish whether normal intestinal rotation has occurred. The degree of variation in the position of the DJF has not been studied in the pediatric population, and there have been only limited studies on adults. The aim of the present study was to determine the position and relationships of the DJF in infants and children utilizing cross-sectional imaging. Computer tomography scans of 120 children were divided into three age groups and systematically analyzed. The DJF position was measured in relation to the vertebral body level, midline, anterior-posterior distance from the vertebral body, transpyloric plane, and mesenteric vessels. The position of the third part of the duodenum and the length of the mesenteric root were also determined. There was considerable variation in the DJF position with respect to the above landmarks in all three age groups. The vertebral body level of the DJF was centered on L1, but ranged between T11 and L3. In 3% of children with normal rotation the SMA/SMV relationship was abnormal. The third part of the duodenum was consistently found to be retromesenteric. The length of the mesenteric root ranged from 7 to 22 cm, and generally lengthened with increasing age. Owing to its variable position in infants and children, the DJF on its own may not be a reliable landmark for establishing normal intestinal rotation. Assessing for normal rotation is multifaceted and further comparative studies are required to characterize the anatomical features of normal and abnormal rotation.
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Affiliation(s)
- Christine Koch
- Department of Radiology, Auckland City Hospital, New Zealand
| | - Kiarash Taghavi
- Department of Pediatric Surgery, Wellington Hospital, New Zealand
| | - James Hamill
- Department of Pediatric Surgery, Starship Hospital, Auckland, New Zealand
| | - S Ali Mirjalili
- Department of Anatomy with Radiology, University of Auckland, New Zealand
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Laparoscopic diagnostic findings in atypical intestinal malrotation in children with equivocal imaging studies. ANNALS OF PEDIATRIC SURGERY 2015. [DOI: 10.1097/01.xps.0000469157.12636.6f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Coulibaly M, Boukatta B, Derkaoui A, Sbai H, Ousadden A, Kanjaa N. [Incomplete small bowel volvulus on common mesentery--a severe and rare complication in adults: report of 1 case]. Pan Afr Med J 2015; 20:157. [PMID: 26113900 PMCID: PMC4469452 DOI: 10.11604/pamj.2015.20.157.4182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 02/17/2015] [Indexed: 11/11/2022] Open
Abstract
Le mésentère commun résulte d'une anomalie de rotation du tube digestif. Il est caractérisé par la persistance d'une disposition anatomique embryonnaire secondaire à une anomalie de rotation de l'anse ombilicale primitive, constituant ainsi un méso commun à toute l'anse intestinale et une racine du mésentère extrêmement courte. Cette insuffisance de rotation est le plus souvent associée à un défaut d'accolement. Ces anomalies de rotation intestinale peuvent aboutir à des complications redoutables parfois mortelles, qui surviennent généralement au cours de la période néonatale où à l’âge pédiatrique. On estime que la prévalence de ces malformations congénitales à l’âge adulte est de l'ordre de 0,2% à 0,5% âge auquel elles demeurent très souvent asymptomatiques et donc non diagnostiquées. Le diagnostic de volvulus total du grêle peut se faire dans des circonstances très variées: en urgence devant un tableau d'occlusion intestinale aiguë, voire un état de choc pouvant conduire au décès, devant un tableau de douleurs abdominales répétées plus ou moins associées à des troubles du transit. Nous rapportons l'observation d'un patient de 18 ans admis pour volvulus total du grêle sur mésentère commun incomplet chez qui l’évolution était favorable.
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Affiliation(s)
| | - Brahim Boukatta
- Service d'Anesthésie-Réanimation Polyvalente, CHU Hassan II de Fès, Maroc
| | - Ali Derkaoui
- Service d'Anesthésie-Réanimation Polyvalente, CHU Hassan II de Fès, Maroc
| | - Hicham Sbai
- Service d'Anesthésie-Réanimation Polyvalente, CHU Hassan II de Fès, Maroc
| | | | - Nabil Kanjaa
- Service d'Anesthésie-Réanimation Polyvalente, CHU Hassan II de Fès, Maroc
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Malrotación-vólvulo intestinal: hallazgos radiológicos. RADIOLOGIA 2015; 57:9-21. [DOI: 10.1016/j.rx.2014.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 07/13/2014] [Accepted: 07/21/2014] [Indexed: 11/21/2022]
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Abstract
OBJECTIVES Midgut volvulus with malrotation is typical in newborns. We present our experience to emphasize the importance of suspecting midgut volvulus as a cause of abdominal pain also beyond infancy, particularly in relation to malrotation, and the relevance of ultrasonographic (US) signs in its diagnosis. METHODS A total of 34 patients (10 boys, 24 girls; ages between 1 day and 12 years) diagnosed as having malrotation or malrotation with volvulus, surgically confirmed, between 2006 and 2013 were retrospectively selected among all of the patients referred to our institution for acute abdomen and bilious vomiting. All of them underwent US and color Doppler examination before surgery. The US examinations were performed with 6 to 10 MHz microconvex and 7.5 to 10 Mhz linear transducer. The transducer was placed under xiphoid, and, with axial projection, the presence of anatomic position reversed between superior mesenteric vein (SMV) and superior mesenteric artery (SMA), as a sign of malrotation, and the presence of "whirlpool sign" (WS) (wrapping of the SMV and the mesentery around the SMA), as a sign of midgut volvulus, were evaluated. RESULTS In 27 of these 34 patients, midgut volvulus was present; 7 patients had intestinal malrotation. In 2 of 7 (28%) patients with malrotation, SMA and SMV were inverted. Among the patients with volvulus, 2 showed reversed vessel position and 22 patients presented the WS in association with SMA/SMV inversion (22/27, 81%). CONCLUSIONS Midgut volvulus with malrotation can appear beyond the neonatal age group as demonstrated in our case. The WS sign is sufficiently sensitive for its diagnosis and should be routinely researched at all ages of pediatric population. Anatomic inversion between SMV and SMA seems to be not enough sensitive in isolated malrotation diagnosis.
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Case 1: a newborn with bilious emesis. Pediatr Radiol 2014; 44:1462-9. [PMID: 25331023 DOI: 10.1007/s00247-014-2923-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Revised: 11/01/2013] [Accepted: 02/05/2014] [Indexed: 10/24/2022]
Abstract
In the introductory article of a new series geared toward pediatric radiology trainees, the radiological management of newborn bilious emesis is discussed through the details of a specific case.
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Tackett JJ, Muise ED, Cowles RA. Malrotation: Current strategies navigating the radiologic diagnosis of a surgical emergency. World J Radiol 2014; 6:730-736. [PMID: 25276316 PMCID: PMC4176790 DOI: 10.4329/wjr.v6.i9.730] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 04/15/2014] [Accepted: 07/17/2014] [Indexed: 02/06/2023] Open
Abstract
The most accurate and practical imaging algorithm for the diagnosis of intestinal malrotation can be a complex and sometimes controversial topic. Since 1900, significant advances have been made in the radiographic assessment of infants and children suspected to have anomalies of intestinal rotation. We describe the current methods of abdominal imaging of malrotation along with their pros and cons. When associated with volvulus, malrotation is a true surgical emergency requiring rapid diagnosis and treatment. We emphasize the importance of close cooperation and communication between radiology and surgery to perform an effective and efficient diagnostic evaluation allowing prompt surgical decision making.
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Common and uncommon applications of bowel ultrasound with pathologic correlation in children. AJR Am J Roentgenol 2014; 202:946-59. [PMID: 24758646 DOI: 10.2214/ajr.13.11661] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this article is to describe the indications and techniques for bowel ultrasound for inflammatory bowel disease and other common and uncommon entities and describe and illustrate their imaging appearances, including endoscopic or surgical correlation. CONCLUSION Ultrasound is a useful tool for the evaluation of inflammatory bowel disease and many other bowel diseases. Radiologists must become familiar with the full potential of ultrasound in the evaluation of the bowel in children because the need for alternative radiation-free imaging techniques continues to grow.
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Khatami A, Mahdavi K, Karimi MA. Ultrasound as a feasible method for the assessment of malrotation. Pol J Radiol 2014; 79:112-6. [PMID: 24860630 PMCID: PMC4031226 DOI: 10.12659/pjr.890219] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/13/2014] [Indexed: 11/21/2022] Open
Abstract
Background In malrotation the position of third portion of duodenum (D3) is always intramesenteric. Demonstration of normal retromesenteric-retroperitoneal position of D3 on ultrasound (US) can rule out malrotation. The aim of this study was to evaluate the feasibility of US in demonstrating the retroperitoneal D3. Material/Methods Abdominal US study was done for various indications in 60 newborns and infants (mean age: 33 days [range: 4–100 days]; 56.7% male) by an expert pediatric radiologist. The position of D3 and its adjacent structures was evaluated in axial and longitudinal planes by linear and curved transducers. Results A normal retromesenteric-retroperitoneal D3 located between the superior mesenteric artery and the aorta was seen on US in all patients, including those with extensive gas in the bowel. The mean time of D3 observation was 47.8 s (10–180 s). Ultrasound was also capable of demonstrating D3 structure, diameter, content, adjacent structures, relative position of the superior mesenteric artery and vein. Conclusions Ultrasound is a simple, fast and highly accurate tool to confirm the retroperitoneal position of D3. Ultrasound can be used as a screening method for malrotation eliminating the need for unnecessary barium studies.
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Affiliation(s)
- Alireza Khatami
- Department of Radiology, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kiarash Mahdavi
- Department of Radiology, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Karimi
- Department of Radiology, Mofid Children's Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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