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

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. Key words: Malrotation; Midgut volvulus; Treitz; Ladd; Heterotaxy; Infant Core tip: Malrotation, especially when associated with midgut volvulus, is a surgical emergency that must be astutely recognized, quickly diagnosed, and emergently treated operatively. While the diagnosis depends heavily on clinical acumen and suspicion, radiologic imaging is critical in determining which patients need surgery. Surgeons and radiologists must cooperate and communicate effectively during the radiographic evaluation of a child with malrotation. Additionally, the algorithm for imaging malrotation must be adapted based upon the tools and staff available at any given institution. INTRODUCTIONSurgeons are often consulted for evaluation of pediatric abdominal problems presenting to the emergency department. It is common for these patients to be evaluated by radiographic imaging in addition to a focused history and physical examination. The surgeon and radiologist must always have a particularly high-level of suspicion in cases of possible malrotation that may require emergency surgery after evaluation. CASE PRESENTATIONA 5-day-old full term male infant presents to the emergency department with continuous bilious non-bloody vomiting and irritability after his last three feeds. He was born by normal spontaneous vaginal delivery without complications and was noted to be breast-feeding well prior to discharge on day-of-life 2; he continued breastfeeding and passing stools at home for the past 4 d until this evening. On exam, his abdomen is minimally distended and he is crying constantly. The clinical picture suggests an obstruction distal to the ampulla of Vater,

A study on clinical profile and outcome of malrotation of intestine in children

“…3 Radiographs are often the first step in the imaging evaluation of pediatric patients with suspected malrotation and are concerned to explore the presence of doble bubble sign. 12 In the present study, X-ray findings were suggestive in 35 (50%) children, normal in 16 (23%) and double bubble sign was noticed in 5 (7%) children. But in new born, they cannot rule out the incidence of malrotation.…”

Volvulus in term and preterm infants ‐ clinical presentation and outcome

“…The vulnerability of the immature intestine of the preterm infants and increased intra-abdominal pressure, due to distended bowel loops as an adverse effect of CPAP treatment, can be discussed as a contributing factors. However, the practicability of these investigations depends on the clinical condition of the infant and the interpretation requires a considerable amount of expertise, which is not usually available 24/7 (16)(17)(18). Our case series illustrated that the clinical symptoms in preterm infants were nonspecific and the findings on abdominal plain radiographs of infants were often nonspecific in the most immature infants (Fig.…”

“…More extensive radiological investigations, like an upper gastrointestinal series (14) or a detailed sonography (15), have been considered helpful. However, the practicability of these investigations depends on the clinical condition of the infant and the interpretation requires a considerable amount of expertise, which is not usually available 24/7 (16)(17)(18). Therefore, it is difficult to distinguish volvulus from necrotising enterocolitis (NEC) or paralytic ileus during sepsis.…”

Neonatologist performed point‐of‐care bowel ultrasound: Is the time right?

“…Malrotation is a congenital malformation with incidence estimated to be present in one in 500 live births. Seventy‐five per cent present in the neonatal period with midgut volvulus . Malrotation is caused when normal rotation and fixation of the gut have been arrested or deviated at various developmental stages in early embryological period.…”

“…Although plain abdominal radiography in preterm infants with bile stained aspirates showing normal gas pattern can be reassuring, the most common finding on plain radiography in neonate with malrotation is normal bowel gas pattern . BUS can be used to determine the position of the superior mesenteric vessels and their relationship to the third portion of the duodenum.…”