Malrotation: Current strategies navigating the radiologic diagnosis of a surgical emergency

Table 1 Positive and negative attributes of commonly used imaging modalities when applied to cases of suspected malrotation

Imaging modality	Pros	Cons
Plain film	Inexpensive, quick, may demonstrate classic appearance of duodenal obstruction, may give earlier indication for operative exploration	May masquerade as other abnormalities, may delay treatment (especially when read as “normal”), cannot exclude malrotation
Ultrasound	Avoids radiation exposure, may demonstrate “whirlpool sign” indicative of volvulus, duplex to determine relationship of D3 and superior mesenteric vessels, Possibility to evaluate normal abdominal anatomy	Normal sonogram may not exclude malrotation, quality related to technician experience
Upper GI	Currently considered the “gold standard”, relatively non-invasive, available at pediatric centers, easily demonstrates duodenal obstruction, allows for visualization of the duodenojejunal junction, delayed imaging may show position of the cecum	Small amount of radiation, challenge to position patient for optimal imaging, may be distorted by bowel distention or indwelling tubes, duodenojejunal junction may have normal variation in position
Barium Enema	Easily demonstrates position of entire large bowel (especially cecum) quickly	Small amount of radiation, normal cecum position does not rule out proximal malrotation
CT	Quick, allows for viewing position of SMA/SMV, may demonstrate “whirlpool sign” indicative of volvulus, visualization of all abdominal anatomy	High radiation exposure, requires patient to remain still for short period of time, normal relationship between SMA/SMV does not exclude malrotation
MRI	No radiation exposure, allows for viewing position of SMA/SMV, may demonstrate “whirlpool sign”, visualization of all abdominal anatomy	Requires patient to remain still for a longer period of time, expensive, not accessible

CT: Computed tomography; MRI: Magnetic resonance imaging; GI: Gastrointestinal imaging; SMA: Superior mesenteric artery; SMV: Superior mesenteric vein.