Sonographic assessment of the retroperitoneal position of the third portion of the duodenum: an indicator of normal intestinal rotation

The performance of ultrasound and upper gastrointestinal study in diagnosing malrotation in children, with or without volvulus

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.

Variation of the ileocolic artery and superior mesenteric artery in a patient with right-sided colon cancer with Lynch syndrome: a case report

Background

Complete mesangectomy and central vascular detachment are the core elements of laparoscopic right hemicolectomy. Failure to identify vascular variations in patients undergoing laparoscopic right hemicolectomy can result in unwanted bleeding, a prolonged surgical time, transfer to open surgery, and an elevated risk of postoperative complications. In this case report, we describe a new vascular variation that has not yet been reported in the literature. Parallelly vascular variation and the management of vessels in key areas are essential for successful surgery.

Case Description

The patient was a 32-year-old female who was referred to the department of gastrointestinal surgery of our hospital due to intermittent abdominal pain accompanied by changes in stool habits for 3 months. She had not experienced other symptoms. Physical examination revealed mild tenderness in the right lower abdomen. Subsequently, she underwent laparoscopic radical right hemicolectomy for ascending colon cancer under general anesthesia in our hospital. Preoperative abdominal contrast-enhanced computed tomography (CT) and intraoperative photos confirmed that there were two ileocolic arteries derived from the superior mesenteric artery (SMA). On the other side, the SMA and superior mesenteric vein (SMV) were found to be accompanied like "X"-shaped variant. The final surgical pathological diagnosis was pT3N1aM0 adenocarcinoma of the ascending colon. Given the patient's family history of colon and uterine cancer combined with the results of immunohistochemical staining and next-generation sequencing, we concluded that she had Lynch syndrome (LS).

Conclusions

This report describes the first case of simultaneous variation of the ileocolic artery (ICA) and SMA in a female patient with colon cancer. This type of vascular variation should be fully recognized by surgeons in order to avoid unnecessary intraoperative bleeding.

Vascular Anatomy and Variants: Knowledge during Laparoscopic Right Colectomy

From the review of the literature and clinical data, it is clear that the anatomy of the vessels of the right colon is remarkably variable, especially those of Henle branch. This justifies why the laparoscopic colectomy (LRC) plus complete mesocolon excision (CME) is often difficult to perform with the conversion rate due to the lesion of the vessels. The objective of this study was to retrospectively review the videos and literature of the right laparoscopic colectomy plus CME to highlight the greatest number of vascular variations of the right colon, to record them, and to highlight the methods by which cope with these variations during surgery.

Ultrasound for malrotation and volvulus - point

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.

Sonographic diagnosis of malrotation: it's complicated - counterpoint

Focused abdominal sonography (US) has been suggested as a first-line modality for the diagnosis of malrotation and volvulus in newborns. In this paper, the author reviews the strengths and weaknesses of US in the diagnosis and exclusion of malrotation and volvulus. The author reviews published implementation programs for using US in both conditions and describes the anatomical variations that limit the utility of US depiction of a retromesenteric duodenum in the exclusion of malrotation.

Ultrasound for Midgut Malrotation and Midgut Volvulus: AJR Expert Panel Narrative Review

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.

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

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.

Ultrasound imaging as the first line of investigation to diagnose intestinal malrotation in children: Safety and efficacy

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.

Sonographic Detection of Congenital Intestinal Malrotation: A Case Report

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.

ACR Appropriateness Criteria® Vomiting in Infants

Vomiting in infants under the age of 3 months is one of the most common reasons for parents to seek care from their doctor or present to an emergency room. The imaging workup that ensues is dependent on several factors: age at onset, days versus weeks after birth, quality of emesis, bilious or nonbilious vomiting, and the initial findings on plain radiograph, suspected proximal versus distal bowel obstruction. The purpose of these guidelines is to inform the clinician, based on current evidence, what is the next highest yield and most appropriate imaging study to pursue a diagnosis. The goal is rapid and accurate arrival at a plan for treatment, whether surgical or nonsurgical. The following modalities are discussed for each variant of the symptom: plain radiography, fluoroscopic upper gastrointestinal series, fluoroscopic contrast enema, ultrasound of the abdomen, nuclear medicine gastroesophageal reflux scan. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

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

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.

Variations in right colic vascular anatomy observed during laparoscopic right colectomy

Background

This study aimed to analyze right colonic vascular variability.

Methods

The study included 60 consecutive patients who underwent laparoscopic radical right colectomy and D3 lymph node dissection for malignant colonic cancer on the ileocecal valve, ascending colon or hepatic flexure (March 2013 to October 2016). The videos of the 60 surgical procedures were collected. Variations of right colonic vascular anatomy were retrospectively analyzed based on 60 high-resolution surgical videos of laparoscopic surgery.

Results

The superior mesenteric artery and vein were present in all cases; 95.0% (57/60) had the superior mesenteric artery on the left side of the superior mesenteric vein. The ileocolic artery and vein occurred in 96.7% (58/60) and 100% (60/60) of cases, respectively; 50.0% (29/58) had the ileocolic artery passing the superior mesenteric vein anteriorly. Thirty-three (55.0%) cases had a right colic artery, and 2 (3.33%) had a double right colic artery; 90.9% (30/36) had the right colic vein passing anterior to the superior mesenteric artery. Fifty-six (93.3%) cases had a right colic vein; 7 (12.5%) had a right colic vein accompanied by a right colic artery, 66.1% (37/56) had the right colic vein draining into the gastrocolic trunk of Henle, 23.2% (13/56) had the right colic vein directly draining into superior mesenteric vein, and 10.7% (6/56) had one right colic vein draining into the superior mesenteric vein and the other into the gastrocolic trunk of Henle. Fifty-three (88.3%) cases had a gastrocolic trunk of Henle: a gastrocolic trunk in 35.8% (19/53), a gastropancreatic trunk in 9.4% (5/53), and a gastropancreaticocolic trunk in 54.7% (29/53). The frequencies of middle colic artery and vein were respectively 100% (60/60) and 93.3% (56/60).

Conclusions

Right colonic vascular variations were classified in Chinese patients. Notable findings included a superior mesenteric artery positioned to the right of the superior mesenteric vein and variation in middle colic artery length. This knowledge may be helpful to colorectal surgeons and could potentially help to improve safety by reducing vascular complications during minimally invasive procedures.

Selective duodenography for controlled first-pass bolus distention of the duodenum in neonates and young children with bile-stained vomiting

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.

The efficiency of sonography in diagnosing volvulus in neonates with suspected intestinal malrotation

This study is to prospectively evaluate the efficiency of sonography for volvulus diagnosis in neonates with clinically suspected intestinal malrotation.A total of 83 patients with suspected intestinal malrotation who underwent detailed abdominal sonography and upper gastrointestinal contrast study were included. Malrotation was characterized by inversion of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) in sonographic examination. The "whirlpool sign" of Color Doppler Sonography was recognized as a characteristic for malrotation with volvulus. The degrees of rotation of the SMV winding around SMA were also detected by sonography. Surgery was performed in patients with sonography diagnosed malrotation.A total of 39 patients were sonographically diagnosed as malrotation which was subsequently confirmed by surgery. The sensitivity and positive predictive value of the sonographic diagnosis were both 100% (39/39). The sensitivity, specificity and accuracy of "whirlpool sign" for the detection of midgut volvulus were 95.2% (20/21), 88.9% (16/18), and 92.3% (36/39), respectively. Greater degrees of rotation (equal or greater than 720°) showed higher risk (odds ratio, 5.0; P < .01) for intestinal necrosis occurrence.Sonography is more accurate in diagnosing suspected malrotation than upper gastrointestinal contrast study. Specific sonographic "whirlpool sign" related to volvulus may be used as a potential indicator for intestinal necrosis. In addition, sonography can exclude malrotation and may help the diagnosis of other diseases, such as annular pancreas and duodenal atresia.

Ultrasound assessment of the bowel: inflammatory bowel disease and conditions beyond

Ultrasound (US) is a versatile imaging study for the evaluation of the bowel in children. US imaging of the bowel can be used as the initial examination or in follow-up for many common pediatric diseases. In this article, we highlight our bowel US technique and describe how US can depict the features of a select group of bowel pathologies relevant to pediatric practice.

Emergency ultrasonography of the gastrointestinal tract of children

Ultrasonography (US) is widely used to evaluate most body parts in pediatric patients because it is simple, noninvasive, easy to use, and applicable in a wide variety of clinical situations. US is the modality of choice for the initial evaluation of acute abdominal pain in pediatric patients because of their small body habitus and the presence of less fat tissue in the abdominal wall and peritoneal cavity. The most important factor in performing pediatric emergency US is the graded compression technique and selection of the proper transducer. The careful evaluation of bowel wall thickening combined with ancillary findings such as fluid collection, increased echogenicity of the mesenteric fat tissue, enlarged lymph nodes, hyperemic bowel changes, and abnormal bowel peristalsis can increase the diagnostic capability of US.

Ultrasound of the duodenum in children

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.

Congenital duodenal obstruction: causes and imaging approach

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.

Diagnosis of pediatric gastric, small-bowel and colonic volvulus

Digestive volvulus affects the stomach, small bowel and mobile segments of the colon and often has a developmental cause. Reference radiologic examinations include upper gastrointestinal contrast series for gastric volvulus, possibly with ultrasonography for small-bowel volvulus, and contrast enema for colonic volvulus. Treatment is usually surgical. This pictorial essay describes the embryological development and discusses the clinical and radiologic presentation of volvulus, depending on location, and details the appropriate radiologic examinations.

Usefulness of Sonography in Evaluating Children Suspected of Malrotation: Comparison With an Upper Gastrointestinal Contrast Study

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.

Asymptomatic malrotation: Diagnosis and surgical management: An American Pediatric Surgical Association outcomes and evidence based practice committee systematic review

OBJECTIVE

Patients with malrotation, or an intestinal rotation abnormality (IRA), can experience serious adverse events. Increasingly, asymptomatic patients are being diagnosed with malrotation incidentally. Patients with symptomatic malrotation require surgery in an urgent or semiurgent manner to address their symptoms. The treatment of asymptomatic or incidentally discovered malrotation remains controversial.

METHODS

Data were compiled from a broad search of Medline, Cochrane, Embase and Web of Science from January 1980 through January 2013 for five questions regarding asymptomatic malrotation.

RESULTS

There is minimal evidence to support screening asymptomatic patients. Consideration may be given to operate on asymptomatic patients who are younger in age, while observation may be appropriate in the older patient. If reliably diagnosed, atypical malrotation with a broad-based mesentery and malposition of the duodenum can be observed. Regarding diagnostic imaging, the standard of care for diagnosis remains the upper gastrointestinal contrast study (UGI), ultrasound may be useful for screening. A laparoscopic approach is safe for diagnosis and treatment of rotational abnormalities. Laparoscopy can aid in determining whether a patient has true malrotation with a narrow mesenteric stalk, has nonrotation and minimal risk for volvulus, or has atypical anatomy with malposition of the duodenum. It is reasonable to delay Ladd procedures until after palliation on patients with severe congenital heart disease. Observation can be considered with extensive education for family and caregivers and close clinical follow-up.

CONCLUSIONS

There is a lack of quality data to guide the management of patients with asymptomatic malrotation. Multicenter and prospective data should be collected to better assess the risk profile for this complex group of patients. A multidisciplinary approach involving surgery, cardiology, critical care and the patient's caregivers can help guide a watchful waiting management plan in individual cases.

Redefining the projectional and clinical anatomy of the duodenojejunal flexure in children

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.

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

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.

Gastrointestinal ultrasound in neonates, infants and children

Today US plays an important and increasing role in the assessment of many, partially age-specific conditions in the GI tract in neonates, infants and children. Knowledge of the potential capabilities of US and its restrictions together with a skillful performance of GI US examination can provide essential anatomic and functional diagnostic information in many pediatric GI disorders. The aim of this review is to highlight the potential of ultrasound (US) in the evaluation of the gastrointestinal (GI) tract in neonates, infants and children. Basic and potential applications of modern US tools in pediatric GI tract are addressed, the GI US examination technique is discussed - including some common and/or typical clinical applications of and indications for US.

Utility of sonographic assessment of the position of the third part of the duodenum using water instillation in intestinal malrotation: a single-center retrospective audit

BACKGROUND

Intestinal malrotation and particularly volvulus are potentially devastating conditions. Upper gastrointestinal (UGI) contrast studies have been considered the gold standard for diagnosis. However the use of ultrasonography (US) has been increasingly described. We describe a method for delineating the duodenal anatomy with US as a means to exclude malrotation.

OBJECTIVE

To report our experience using US to assess intestinal rotation.

MATERIALS AND METHODS

We conducted a retrospective audit of US scans performed at a tertiary referral centre to exclude malrotation for paediatric surgery between 2008 and 2011.

RESULTS

One hundred thirty-nine infants were included, of whom 114 had a normal US scan. Of the 114, nine had subsequent upper gastrointestinal contrast studies that confirmed the initial results; there were no false-negatives. There were abnormal US scans in four infants associated with midgut volvulus and malrotation; there were no false-positives. The other 21 US scans were equivocal, and 11 of these had a confirmatory UGI contrast study; only one required surgery to correct malrotation.

CONCLUSION

US has been a safe and effective tool in the assessment of intestinal rotation at our institution. The main advantages of US imaging are its lack of ionising radiation and its rapid and accurate diagnosis of volvulus.

Disorders of midgut rotation: making the correct diagnosis on UGI series in difficult cases

BACKGROUND

In some series of malrotation small numbers of children are described in whom the position of the duodenojejunal flexure was considered to be normal on straight anteroposterior (AP) view of an upper gastrointestinal (UGI) series.

OBJECTIVE

The purpose of this study was to illustrate children with disorders of midgut rotation in whom the diagnosis was difficult because on the straight AP view of the UGI series the duodenojejunal flexure was either not clearly depicted or was projected to the left of the midline close to its expected normal position at or close to the level of the duodenal cap.

MATERIALS AND METHODS

We reviewed 111 children with malrotation to determine the frequency that duodenojejunal flexure was not clearly depicted or was close to normal position.

RESULTS

Seven patients had close to normal position of duodenojejunal flexure on AP view. The correct diagnosis was made on initial UGI series in four patients based on other features on AP and lateral views. In two of the other three patients, a repeat UGI series facilitated the correct diagnosis. In the final patient, an abnormal position of a nasojejunal tube suggested the correct diagnosis.

CONCLUSION

Accurate diagnosis of anomalies of midgut rotation requires careful assessment of the entire duodenal sweep on both AP and lateral views to avoid false-negative interpretations.