Sonographic diagnosis of fetal intestinal volvulus with ileal atresia: a case report

"Keyboard sign" and "coffee bean sign" in the prenatal diagnosis of ileal atresia: A case report

BACKGROUND

Ileal atresia is a congenital abnormality where there is significant stenosis or complete absence of a portion of the ileum. The overall diagnostic accuracy of prenatal ultrasound in detecting jejunal and ileal atresia is low. We report a case of ileal atresia diagnosed prenatally by ultrasound examination with the "keyboard sign" and "coffee bean sign".

CASE SUMMARY

We report a case of ileal atresia diagnosed in utero at 31 weeks' of gestation. Prenatal ultrasound examination revealed two rows of intestines arranged in an 'S' shape in the middle abdomen. The inner diameters were 1.7 cm and 1.6 cm, respectively. A typical "keyboard sign" was observed. The intestine canal behind the "keyboard sign" showed an irregular strong echo. There was no normal intestinal wall structure, showing a typical "coffee bean sign". Termination of the pregnancy and autopsy findings confirmed the diagnosis.

CONCLUSION

The prenatal diagnosis of ileal atresia is difficult. The sonographic features of the "keyboard sign" and "coffee bean sign" are helpful in diagnosing the location of congenital jejunal and ileal atresia.

Intrauterine volvulus: systemic review of the literature with pooled analysis

Our objective is to analyse the observations related to intrauterine volvulus and assess how clinical manifestations and treatment strategies impact prognosis. We conducted a comprehensive search on Pubmed and ClinicalTrials.gov from inception to July 2022, using search terms like "intrauterine volvulus" or "foetal volvulus," supplemented by manual scrutiny of reference lists in relevant texts and articles. Our review encompassed 57 case reports/case series, involving 88 cases. The presence of foetal bradycardia during prenatal visits (p = 0.002) and the existence of meconium cyst or pseudocyst (p = 0.038) significantly influence survival rates. Preterm labour occurred more frequently among cases resulting in mortality (54% vs 21%; p = 0.055). Our study's limitations include the inability to access all reported cases and reliance solely on available data. We advocate for vigilant monitoring of foetuses exhibiting signs of intestinal obstruction, and consideration of an emergent caesarean section as a pre-emptive measure before foetal biophysical profile deterioration worsens.

Antenatal Diagnosis and Management of Fetal Intestinal Volvulus: Case Series and Literature Review

Fetal intestinal volvulus is a rare condition that can lead to hemorrhage, bowel necrosis, and urgent surgical treatment after birth. Thus, prompt diagnosis and treatment are essential to avoiding fetal or neonatal demise. Prenatal ultrasound is a keystone tool in the diagnostic course. However, sonographic findings tend to be non-specific, with limited understanding of the pathophysiology behind their atypical presentation. With a literature review and a case series, we aim to optimize the antenatal diagnosis and management of this rare but life-threatening condition. Six cases from our institution were retrospectively analyzed over 12 years. A literature review was conducted until December 2022. A total of 300 articles matched the keyword "Fetal volvulus", and 52 studies were eligible for the review. Our 6 cases are added to the 107 cases reported in the literature of fetal intestinal volvulus with antenatal ultrasound assessment and without associated gastroschisis or omphalocele. Several prenatal symptoms and ultrasound markers, even if not specific, were more frequently reported. Different experiences of management were described regarding follow-up, the timing of delivery, the mode of delivery, and surgery outcomes. This paper highlights the importance of suspecting and assessing fetal volvulus at routine ultrasound scans, describing the most frequent antenatal presentations and management in order to improve fetal and neonatal outcomes.

Intestinal volvulus in utero causing torsion of dilated bowel with ileal atresia: a case report

BACKGROUND

In utero intestinal volvulus with intestinal atresia is a rare and life-threatening condition that can cause torsion of the dilated bowel. The management and outcomes of this disease remain unclear.

CASE PRESENTATION

A 19-year-old woman noticed a decrease in fetal motion at 35 weeks. Fetal ultrasound showed dilated fetal bowel and the whirlpool sign. The patient was referred to our hospital for an emergency cesarean section. The neonate's abdomen was dark and severely distended, and a laparotomy was performed. Necrotic ileum and cord-type intestinal atresia (Type II) were observed in the dilated terminal ileum. The necrotic ileum was resected, and a second-look surgery was performed the following day. Then, we anastomosed the remaining intestine, and the total intestine length was 52 cm. There were no surgical complications, and the patient was discharged without requiring total parenteral nutrition or fluid infusion. The patient's height and weight were within the - 2 standard deviation range of the growth curve at 5 months.

CONCLUSIONS

Emergency and appropriate management of intestinal volvulus in utero causing torsion of the dilated bowel resulted in good outcomes in a patient with intestinal atresia. Perinatal physicians should be aware of this emergency condition and plan their treatment approach accordingly.

Prenatal imaging features and perinatal outcomes of foetal volvulus-A literature review

OBJECTIVE

To conduct a review of the literature on foetal volvulus with emphasis on prenatal imaging, pregnancy characteristics and clinical outcomes.

METHODS

A review of all published cases of foetal volvulus diagnosed prenatally and indexed in Medline, EBSCOhost, CINAHL, SOCIndex and Healthy Policy Reference Centre. Studies without antenatal sonographic signs of foetal volvulus and without a postpartum surgical diagnosis were excluded. Data were analysed for frequencies and distributions and tested for statistical significance.

RESULTS

Eighty-eight cases of foetal volvulus were identified from 58 published case reports/series. The most common ultrasound findings were dilated bowel/stomach (77.3%), polyhydramnios (30.7%) and whirlpool/snail sign (28.4%). Median gestation at diagnosis was 31.9 weeks (IQR 27-34) and mean gestation at delivery was 34.5 weeks (SD 2.8). Underlying aetiology included intestinal malrotation (15.9%), cystic fibrosis (14.8% of all cases, 32.5% of tested cases) and abnormal mesenteric fixation (12.5%). Complications included intestinal atresia (36.4%) and foetal anaemia (9.1%). The overall perinatal mortality rate was 14.5%.

CONCLUSION

Foetal volvulus is a rare condition with high rates of preterm birth and perinatal mortality. Intestinal malrotation and cystic fibrosis are common predisposing causes, although the majority are idiopathic. Bowel and/or gastric dilatation is by far the most common sonographic finding.

Difficulty in prenatal diagnosis of the volvulus of the small intestine: A peculiar clinical course of two cases with massive bowel dilatation and loss of peristalsis

We report two cases of fetal intestinal volvulus (jejunum in case A, ileum in case B) with massive bowel dilatation and loss of peristalsis, which suddenly appeared in the third trimester. The bowel was dilated to different sizes and there were various echogenic patterns of the intestines in case A and a sausage-like appearance in case B. Case A developed polyhydramnios, whereas case B did not. Among 47 cases of fetal intestinal volvulus (29 articles) in which 32 were diagnosed prenatally, almost all cases with a prenatal diagnosis showed "whirlpool sign" or "coffee bean sign" by sonography and/or findings indicating intestinal hemorrhage. Even without these findings, the presence of dilatation of the intestines and loss of peristalsis occurring in the third trimester were diagnostic clues. The presence of different sizes and various patterns of bowel dilation and hydramnios may be helpful for predicting the involved site of intestinal volvulus.

Intestinal volvulus in the pump twin of a twin reversed arterial perfusion (TRAP) sequence after laser therapy at 18 weeks: a case report

Background

Twin reversed arterial perfusion sequence is a rare and potentially lethal condition affecting approximately 1% of monochorionic twin pregnancies and 1 in 35,000 pregnancies overall. An apparently normal (pump) twin perfuses its severely malformed cotwin with deoxygenated blood via retrograde flow in direct arterioarterial anastomoses between the umbilical arteries of each twin. Fetal intestinal volvulus is a rare condition usually manifesting after birth. We report a unique case of twin reversed arterial perfusion sequence in association with intestinal volvulus in the surviving pump twin.

Case presentation

A 32-year-old Hispanic primigravida was referred to our clinic after a fetoscopy procedure of laser photocoagulation of anastomoses at 18 weeks of gestation. Follow up scans in the ex-pump twin revealed dilated bowel loops and a typical “whirlpool sign” at 26 weeks of gestation, and intrauterine intestinal volvulus was suspected. At 29 weeks of gestation, preterm premature rupture of membranes occurred, and an emergency cesarean section was performed. The newborn was diagnosed in the early neonatal period with intestinal perforation. The diagnosis was postnatally confirmed by surgery and histopathology.

Conclusions

The type of fetal intervention and late gestational age of the procedure increase the risk of complications. This case alerts health providers to be vigilant in the follow-up of patients with complicated monochorionic pregnancies.

The role of sonography for depiction of a whirlpool sign unrelated to midgut malrotation in neonates

BACKGROUND

The sonographic whirlpool sign of volvulus due to midgut malrotation is well recognized. However, variations of the whirlpool sign may be seen in other conditions, but this observation has received little attention in the literature.

OBJECTIVE

This study presents a series of neonates with a variety of causes of congenital intestinal obstruction, all associated with a whirlpool sign (unrelated to midgut volvulus), which was correctly recognized preoperatively on sonography. We also emphasize the pivotal role of sonography in managing congenital obstruction of the intestinal tract in neonates.

MATERIALS AND METHODS

This is a retrospective analysis of clinical, imaging and surgical findings in 11 neonates with congenital intestinal obstruction associated with a whirlpool sign (unrelated to midgut volvulus) that was recognized preoperatively on sonography and in whom the cause for the whirlpool was documented at surgery.

RESULTS

Eleven neonates (eight male, three female) had clinical and radiographic evidence of intestinal obstruction in whom sonography depicted a whirlpool sign, which was recognized on the initial sonogram in nine and on a repeat sonogram in two. The whirlpool was located in the upper abdomen in only two, mid-abdomen in five and right lower quadrant in four. The whirlpool was only 1-2 cm in diameter. An upper gastrointestinal series in three neonates failed to depict the cause of obstruction. Contrast enema in three cases had findings suggesting the site of obstruction was in the ileum but none depicted the exact cause of the obstruction. At surgery, the whirlpool sign correlated with a segmental volvulus of the small intestine in eight neonates and with the coiled distal small intestine associated with apple-peel atresia in the other three.

CONCLUSION

This study illustrates neonates in whom a whirlpool sign (unrelated to midgut volvulus) was correctly recognized on sonography before surgery. Sonography proved more useful than an upper gastrointestinal series or contrast enema in depicting the exact cause of the obstruction. Pediatric radiologists must make the effort to search throughout the entire abdomen and pelvis for a small whirlpool sign on sonography, even in the absence of midgut malrotation, in neonates with congenital intestinal obstruction. Its recognition preoperatively will facilitate a rapid diagnosis and will obviate the necessity for contrast examinations of the gastrointestinal tract, which require ionizing radiation.

Prenatal diagnosis of antenatal midgut volvulus: Specific ultrasound features

OBJECTIVE

To assess specific, direct, and indirect prenatal ultrasound features in cases of fetal midgut volvulus.

METHODS

Retrospective case series of neonatal volvulus, based on postnatal and prenatal imaging findings that occurred from 2006-2017. Prenatal and postnatal signs including the specific "whirlpool sign" were computed. Postnatal volvulus was confirmed by pathology examination after surgery or neonatal autopsy.

RESULTS

Thirteen cases of midgut volvulus were identified. Though not a specific sign, a decrease in active fetal movements was reported in eight patients (61.5%). The prenatal whirlpool sign was directly seen in 10 cases, while an indirect but suggestive sign, a fluid-filled level within the dilated loops, was present in five cases. No intestinal malrotation was observed. Pregnancy outcomes were two terminations of pregnancy, both associated with cystic fibrosis, one early neonatal death, three prenatal spontaneous regressions, and seven favorable outcomes after neonatal surgery with resection of midgut atresia.

CONCLUSIONS

Identification of the whirlpool sign or of a fluid-filled level within the dilated loops improves the accuracy of ultrasound findings for suspected volvulus. In the absence of total volvulus (in cases of intestinal malrotation) or association with cystic fibrosis, the prognosis appears good.

Worsening anemia associated with volvulus in a stable neonate with intestinal obstruction

Intrauterine intestinal obstruction complicated by midgut volvulus is a serious life-threatening diagnosis. Immediate surgical intervention is generally the course of action upon diagnosis to prevent morbidity and mortality. We report a case of intrauterine intestinal obstruction where the neonate then presented with an unusual onset of volvulus within the first 12 hours of life. The patient was born with generalized edema, a distended abdomen, and pallor. Unlike many cases, the patient did not present with typical signs of volvulus. Diagnostic imaging preceding delivery and the stable postnatal clinical course did not offer a justification for immediate laparotomy. Less than 24 hours later, the patient's hemoglobin significantly dropped leading to an emergent laparotomy. Findings included a volvulus of the terminal ileum and large amounts of intraluminal blood. Our case report includes an analysis of clinical observations that should be considered so that patients presenting with similar signs receive earlier surgical intervention.

Prenatal diagnosis of gastric and small bowel atresia: a case series and review of the literature

OBJECTIVE

To describe seven cases of gastrointestinal tract (GIT) obstructions and to report a skewed review of the literature.

METHODS

We performed a search of our permanent perinatal database about cases with prenatal ultrasound and MRI diagnosis of gastrointestinal tract obstructions between 2006 and 2013. All cases were followed until hospital discharge and pre-natal diagnosis were confirmed by fetal MRI, postnatal imaging and/or intra-operative findings. Maternal age, parity, gestational age at diagnosis, ultrasound findings, gestational age at delivery, Apgar scores at 1 and 5 min and postnatal outcome have been recorded.

RESULTS

We identified seven cases of gastric and small bowel atresia. Karyotype was normal in six cases and abnormal in one co-twin [46,XY dup (20) (qq13.1q13.3)dn] of a dichorionic-diamniotic pregnancy. The mean ± SD for maternal age, gestational age at diagnosis, gestational at delivery, birth weight and Apgar scores at 1 and 5 min were 30.8 ± 4.8 years, 29.8 ± 3.7 weeks, 2507.5 ± 727.5 g and 5.6 ± 2.1, 7.6 ± 1.6, respectively. All fetuses' undergone surgical procedures in the postnatal period and all of them were discharged live from the hospital.

CONCLUSION

Prompted antenatal detection of gastrointestinal tract obstruction using ultrasound proved to be diagnostic in all cases. Fetal MRI aid was a useful complementary diagnostic investigation. Correct pre-natal diagnosis allows adequate counseling, delivery planning and management care by a multidisciplinary team.

Fetal midgut volvulus: report of eight cases

OBJECTIVE

To evaluate whether prenatal diagnosis of intestinal midgut volvulus (a rare condition due to the small bowel loops twisting) can improve the prognosis of the newborns.

METHODS

In our Prenatal Diagnosis Center, eight cases of intestinal volvulus observed between 2007 and 2014 were retrospectively considered. Ultrasonographic signs can be direct and specific (whirlpool sign, coffee bean sign) or indirect and non-specific (abdominal mass, dilated bowel loops, pseudocysts, ascites, polyhydramnios).

RESULTS

Prenatal diagnosis was performed at 20-34 weeks of gestation. All newborns were exposed to an emergency surgery: the major complication was due to cystic fibrosis.

CONCLUSIONS

An early suspicion of intestinal volvulus allows the clinician to refer the patient to a tertiary center so to confirm the diagnosis and perform an appropriate follow-up in order to identify the proper time of delivery. The prognosis of the babies with prenatal intestinal volvulus depends on the length of the segment involved, on the level of intestinal obstruction, on the presence of meconium peritonitis and on the gestational age at birth. Our experience, according with the literature, suggests that ascites and absence of abdominal peristalsis are ultrasonographic signs that, in the third trimester of pregnancy, correctly lead to an immediate delivery intervention.

Perinatal survival of a fetus with intestinal volvulus and intussusception: a case report and review of the literature

Fetal intestinal volvulus is a rare life-threatening condition. Late diagnosis of volvulus contributes to high rate of morbidity and mortality. It has variable degrees of presentation and survival. Intrauterine volvulus may be complicated by intestinal atresia due to ischemic necrosis. To our knowledge, there are three reported cases of term fetal demise. We report a case of fetal intestinal volvulus with perinatal survival of the largest term infant described with this complication to date. The volvulus was associated with type 3A jejunal atresia and intestinal pathology was noted on prenatal ultrasound. The infant was born via urgent cesarean delivery at 37(6/7) weeks of gestation and underwent emergent exploratory laparotomy with resection of small bowel and primary end-to-end anastomosis. Intrauterine intestinal volvulus may be suspected on prenatal ultrasound but only definitively diagnosed postnatally. Signs of fetal distress and volvulus are rarely associated with reports of survival in the term fetus. We review reported cases of prenatally suspected volvulus in infants documented to survive past the neonatal period. As fetal volvulus and most intestinal atresias/stenoses manifest during the third trimester, we recommend that the limited fetal anatomical survey during growth ultrasounds at 32 to 36 weeks routinely include an assessment of the fetal bowel.