Intestinal malrotation in children: tutorial on radiographic diagnosis in difficult cases

Anomalies of intestinal rotation and fixation: consequences of late diagnosis beyond two years of age

The malrotation and no well fixation anomalies of the digestive tract is also frequent in older child, young and adult, with characteristic and specific clinical presentation. Actually, the diagnostic and treatment seem to be late, after suffering prolonged symptoms and/or in emergency. We present nine cases of anomalies in the embryonic development of the digestive tract which were diagnosed and treated in infants or young, all above 2 years old. Eight cases were of more or less complete intestinal malrotation; one of them was a complete malrotation with an intrinsic duodenal stenosis associated (no bands of Ladd) and another one was a right paramesocolic hernia, always accompanied by malrotation. The association with other extra-digestive anomalies, especially urological, was 70%. The predominant symptom was intermittent abdominal pain (IAP)-80%-sometimes accompanied by vomiting (35%) and episodes of diarrhoea (25%). In all the cases, while the clinical background was early, diagnosis was late. Indeed, in 60% of the cases diagnosis was made intra-operatively in emergency surgical interventions. The imaging procedures employed were scanning and Doppler ultrasound, CT scan, and contrast gastrointestinal series (GIS). Up to 30% of errors in interpretation occurred, although they were eventually corrected with other tests. The most reliable diagnostic procedures were GIS and CT scan with contrast, although partial interpretation errors occurred with the latter procedure. Surgery was essential in 80% of the pre-operative cases, and in another two it was required as a preventative measure. Post-operatively, there was notable persistence of SBS in the cases of intestinal necrosis, and of other lesser symptoms in the rest. We conclude that: intestinal malrotations and malfixations are still being diagnosed very late, with serious systemic consequences such as intestinal obstructions or necroses, and prolonged clinical suffering. This could all be avoided if more attention were paid to the digestive symptoms associated with IAP, and to subocclusion or other abdominal phenomena (distension,...), together with, in the case of doubt about the findings with the previous procedures, the opportune imaging tests (e.g., abdominal Doppler ultrasound, CT scan with contrast, and barium GIS). Unlike other authors, we consider that the morbidity/mortality associated with cases of late diagnosis of these anomalies is high, and calls for earlier surgical treatment.

Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series

Intestinal malrotation, which is defined by a congenital abnormal position of the duodenojejunal junction, may lead to midgut volvulus, a potentially life-threatening complication. An evaluation for malrotation is part of every upper gastrointestinal (GI) tract examination in pediatric patients, particularly neonates and infants. Although the diagnosis of malrotation is often straightforward, the imaging features in approximately 15% of upper GI tract examinations are equivocal and lead to a false-positive or false-negative interpretation. The clinical manifestations and upper GI tract findings of malrotation in older children and adults are less specific than are those in younger patients, and for this reason diagnosis of the condition may be more difficult. Successful differentiation between a normal variant and malrotation requires the use of optimal techniques in acquiring and interpreting the upper GI series. Familiarity with the upper GI series appearance of both normal and abnormal anatomic variants allows the radiologist to increase both diagnostic accuracy and confidence in the diagnosis of malrotation.

Disorders of intestinal rotation and fixation ("malrotation")

Malrotation with volvulus is one of the true surgical emergencies of childhood. Prompt radiological diagnosis is often paramount to achieving a good outcome. An understanding of the normal and anomalous development of the midgut provides a basis for understanding the pathophysiology and the clinical presentation of malrotation and malrotation complicated by volvulus. In this essay, the radiologic findings of malrotation and volvulus are reviewed and illustrated with particular attention to the child with equivocal imaging findings.

Investigation in vomiting children

This article discusses how to investigate various surgical causes of vomiting. Particular emphasis is placed on plain radiographic, ultrasound, and contrast study findings. The article touches upon nineteen different diseases, and encompasses diseases found in neonates to adolescents.

Frequency of right lower quadrant position of the sigmoid colon in infants and young children

PURPOSE

To evaluate the frequency of right lower quadrant positioning of the sigmoid colon in infants and young children.

MATERIALS AND METHODS

Findings in 169 patients who underwent enema examination were retrospectively reviewed. Sigmoid colon position was categorized as in the left or right lower quadrant or midline. Patients who had an anatomic abnormality that affected colonic position (eg, malrotation or abdominal mass) or had previously undergone abdominal surgery were excluded. The frequency of right lower quadrant sigmoid position was evaluated for a relationship with patient age (analysis of variance) and sex (chi(2) test).

RESULTS

Patient ages were 1 day to 5 years (mean age, 13 months). The sigmoid colon was in the right lower quadrant in 74 (44%), in the left lower quadrant in 73 (43%), and in the midline in 18 (11%). The position was variable in one patient and indeterminate in three. When the sigmoid colon was within the right lower quadrant, it often extended laterally, overlying the position of the cecum and ascending colon. There were no significant correlations between right lower quadrant position and patient age (P =.262) and sex (P =.162).

CONCLUSION

In children, the sigmoid colon is often within the right lower quadrant. Knowledge of this high frequency should reduce the likelihood of misinterpreting air within a redundant right-sided sigmoid colon as air within the cecum in children suspected of having abnormalities such as intussusception.

CT appearance of midgut volvulus with malrotation in a young infant

Computed tomography (CT) appearances of small bowel malrotation and midgut volvulus (MGV) have rarely been described in paediatric patients. We present spiral CT images of a surgically proven case in a young infant. The literature on imaging techniques to diagnose these conditions is reviewed. Radiation doses of upper gastrointestinal series (UGI) and spiral CT are estimated and compared.

Laparoscopic Ladd's procedure in infants with malrotation

PURPOSE

This clinical study was undertaken to examine the feasibility of a laparoscopic approach for the treatment of documented malrotation.

METHODS

From May 1994 through January of 1997, 12 patients, aged 5 days to 4 months, weighing 3 to 7 kg, underwent laparoscopic Ladd's procedure for malrotation. All patients had symptoms of intermittent upper intestinal obstruction, and malrotation was documented by an upper gastrointestinal contrast study. None of the patients had acute volvulus or compromised bowel. The procedure was performed using 3 trocars of 3.5 mm diameter. Ports were placed in the infraumbilical ring, and the right and left mid to lower quadrants. A standard Ladd's procedure with appendectomy was performed in all cases.

RESULTS

All procedures were completed successfully through the laparoscope. Operative times averaged 58 minutes (35 to 120 minutes). One patient with Pierre-Robin underwent a laparoscopic Nissen fundoplication and gastrostomy tube placement at the same time requiring 120 minutes. Feedings were started on postoperative day (POD) 1 in 10 cases and POD 2 in two cases. Hospital stay ranged from 2 to 4 days (average, 2.2) in the patients with isolated malrotation. The patient with Pierre-Robin had a prolonged hospitalization because of chronic respiratory problems not associated with surgery. There were no complications. All patients had resolution of their symptoms.

CONCLUSIONS

Laparoscopic Ladd's procedure is a safe and effective technique. It can be performed in neonates in times equivalent to standard open techniques, and it appears to allow for earlier feeds and decreased hospital stays.

Controversies in abdominal imaging

Technologic improvement in ultrasound equipment, together with new clinical information, has altered the imaging of the abdomen in infants. Improvements in ultrasound equipment have allowed this to become the diagnostic test of choice for hypertrophic pyloric stenosis. Barium upper gastrointestinal radiography still remains the diagnostic test of choice for malrotation. New technologies for reduction of intussusception include air reduction and saline enemas with ultrasound monitoring. Controversies surrounding the different technologies and imaging strategies are discussed.