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Long B, Easter J, Koyfman A. High risk and low incidence diseases: Pediatric digestive volvulus. Am J Emerg Med 2024; 82:153-160. [PMID: 38908340 DOI: 10.1016/j.ajem.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 06/10/2024] [Accepted: 06/12/2024] [Indexed: 06/24/2024] Open
Abstract
INTRODUCTION Pediatric digestive volvulus is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of pediatric digestive volvulus, including the presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Pediatric digestive volvulus is a deadly condition most commonly associated with malrotation. It occurs when the stomach or small intestine twists on itself, resulting in ischemia and potentially strangulation with necrosis and perforation. Presentation differs based on the gastrointestinal (GI) segment affected, degree of twisting, and acuity of the volvulus. Gastric volvulus most commonly presents with retching with or without nonbilious emesis and epigastric distension with pain, while midgut volvulus typically presents with bilious emesis in infants. Patients with GI necrosis and perforation may present with hemodynamic compromise and peritonitis. If suspected, emergent consultation with the pediatric surgery specialist is necessary, and if this is not available, transfer to a center with a pediatric surgeon is recommended. Imaging includes plain radiography, ultrasound, or upper GI series, while treatment includes resuscitation, administration of antibiotics, and emergent surgical decompression and detorsion of the involved segments. CONCLUSION An understanding of pediatric digestive volvulus and its many potential mimics can assist emergency clinicians in diagnosing and managing this deadly disease.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Joshua Easter
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
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Mohamed Burhan MS, Hamid HA, Zaki FM, Ning CJ, Zainal IA, Ros IAC, Daud CZBC, Othman MYB, Hing EY. The performance of ultrasound and upper gastrointestinal study in diagnosing malrotation in children, with or without volvulus. Emerg Radiol 2024; 31:151-165. [PMID: 38289574 DOI: 10.1007/s10140-024-02201-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 01/09/2024] [Indexed: 04/05/2024]
Abstract
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.
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Affiliation(s)
- Mohamad Sufian Mohamed Burhan
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
- Hospital Tunku Azizah, Ministry of Heath, Kuala Lumpur, Malaysia
| | - Hamzaini Abd Hamid
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Faizah Mohd Zaki
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Chai Jia Ning
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Isa Azzaki Zainal
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | - Izzat Arslan Che Ros
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia
| | | | | | - Erica Yee Hing
- Department of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
- Hospital Canselor Tuanku Muhriz, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, Malaysia.
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Meshaka R, Leung G, Easty M, Giuliani S, Loukogeorgakis S, Perucca G, Watson TA. Ultrasound as the first line investigation for midgut malrotation: a UK tertiary centre experience. Clin Radiol 2024; 79:150-159. [PMID: 38007334 DOI: 10.1016/j.crad.2023.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/23/2023] [Accepted: 10/29/2023] [Indexed: 11/27/2023]
Abstract
AIM To present the first 22-months experience of transitioning to an ultrasound-first pathway for suspected midgut malrotation. MATERIALS AND METHODS An "ultrasound-first" imaging pathway was initiated in October 2021. Twenty-two-months later, a search was undertaken of all <1-year-old patients with "bilious", "malrotation," or "volvulus" as the imaging indication. Reports and images from upper gastrointestinal fluoroscopy (UGI) and ultrasound were reviewed, and diagnoses and outcomes were documented. RESULTS The search yielded 101 eligible cases between October 2021 and July 2023. Of the patients, 63/101 (62%) had both ultrasound and UGI: 47/63 (75%) ultrasound first, 16/63 (25%) UGI first. Thirty-one per cent (31/101) had ultrasound only and 7/70 (10%) UGI only. The pathway diagnosed 7/8 (88%) infants with midgut malrotation with or without volvulus and one infant who had an inconclusive ultrasound examination with a suspected an internal hernia and who was found to have malrotation volvulus at surgery. Twenty-one infants who had confidently normal ultrasound examinations and who also had UGI all had a normal duodenojejunal flexure position. Ultrasound detected alternative pathology in eight children. Duodenal visualisation improved with time: 6/15 (40%) in the first 6 months to 23/34 (68%) after the first year. CONCLUSION The transition to ultrasound as the first diagnostic test for midgut malrotation can be done safely and effectively in a UK centre, which previously relied solely on UGI.
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Affiliation(s)
- R Meshaka
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK.
| | - G Leung
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - M Easty
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - S Giuliani
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - S Loukogeorgakis
- Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - G Perucca
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - T A Watson
- Radiology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
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Svetanoff WJ, Srivatsa S, Diefenbach K, Nwomeh BC. Diagnosis and management of intestinal rotational abnormalities with or without volvulus in the pediatric population. Semin Pediatr Surg 2022; 31:151141. [PMID: 35305800 DOI: 10.1016/j.sempedsurg.2022.151141] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Intestinal malrotation is a congenital anomaly that can be associated with midgut volvulus, requiring an emergent operation in order to maintain blood supply to the compromised intestine. It results from an abnormal rotation of the intestines, leading to three types of malrotation. Non-rotation is complete failure of the intestines to rotate, while the most common configuration is associated with the cecum in the mid-upper abdomen, close to a malpositioned duodenal-jejunal (DJ) flexure. This configuration has a narrow mesentery that has a high risk of volvulus. The final form of malrotation is incomplete rotation, where the DJ flexure and cecum are malpositioned, but the mesentery is not narrowed. The benefits of performing a Ladd's procedure for these individuals is controversial. Workup for malrotation should be considered in all patients who present with abdominal pain/distention and bilious emesis. An upper gastrointestinal contrast study is 93-100% sensitive and will show a corkscrew appearance when a volvulus is present. While the basic tenets of the Ladd's procedure have not changed and include detorsion of a volvulus, adhesiolysis of Ladd's bands and broadening of the mesentery, how this is accomplished and in whom are controversial. Laparoscopic Ladd's is associated with shorter hospital stays but also has a higher incidence of recurrent volvulus compared to an open approach. Patients with heterotaxy syndrome also represent a controversial group with some studies showing no difference in post-operative complications despite a higher mortality due to underlying cardiac disease, while other studies show a low incidence of volvulus and question the need for Ladd's in those who are asymptomatic. This review highlights the major aspects of diagnosing and treating malrotation, including the pathophysiology, workup, surgical options and areas of controversy.
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Affiliation(s)
- Wendy Jo Svetanoff
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205
| | - Shachi Srivatsa
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, 43210
| | - Karen Diefenbach
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205; Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, 43210
| | - Benedict C Nwomeh
- Division of Pediatric Surgery, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205; Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, 43210.
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Nguyen HN, Kulkarni M, Jose J, Sisson A, Brandt ML, Sammer MB, Pammi M. Ultrasound for the diagnosis of malrotation and volvulus in children and adolescents: a systematic review and meta-analysis. Arch Dis Child 2021; 106:1171-1178. [PMID: 33879472 PMCID: PMC8526644 DOI: 10.1136/archdischild-2020-321082] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 03/15/2021] [Accepted: 03/28/2021] [Indexed: 02/01/2023]
Abstract
CONTEXT Despite the advantages of ultrasound (US), upper gastrointestinal contrast series (UGI) remains the first-line diagnostic modality in the diagnosis of midgut malrotation and volvulus in children. OBJECTIVE Evaluate the diagnostic accuracy of US in the diagnosis of malrotation with or without volvulus in children and adolescents aged 0-21 years, compared with the reference standard (diagnosis by surgery, UGI, CT, MRI, and clinical follow-up individually or as a composite). DATA SOURCES We searched the electronic databases Ovid-MEDLINE, Embase, Scopus, CINAHL, and the Cochrane library in October 2019 and updated on 18 August 2020. STUDY SELECTION Studies evaluating the diagnostic performance of US for diagnosis of midgut malrotation with or without volvulus in children (0-21 years). DATA EXTRACTION AND SYNTHESIS The data were extracted independently by two authors and a bivariate model was used for synthesis. RESULTS Meta-analysis of 17 cohort or cross-sectional studies and 2257 participants estimated a summary sensitivity of 94% (95% CI 89% to 97%) and summary specificity of 100% (95% CI 97% to 100%) (moderate certainty evidence) for the use of US for the diagnosis of malrotation with or without midgut volvulus compared with the reference standard. Subgroup analysis and meta-regression revealed better diagnostic accuracy in malrotation not complicated by volvulus, in the neonatal population and enteric fluid administration before US. CONCLUSIONS Moderate certainty evidence suggests excellent diagnostic accuracy and coupled with the advantages, a strong case exists for the use of abdominal US as the first-line diagnostic test for suspected midgut malrotation with or without volvulus in children and adolescents.
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Affiliation(s)
- HaiThuy N. Nguyen
- Edward B. Singleton Department of Radiology, Texas Children’s Hospital, Houston, Texas, USA,Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Madhulika Kulkarni
- Department of Pediatrics, Texas Children’s Hospital, Houston, Texas, USA,Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Jisha Jose
- Department of Pediatrics, Texas Children’s Hospital, Houston, Texas, USA,Department of Pediatrics, Section of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Amy Sisson
- The Texas Medical Center Library, Houston, Texas, USA
| | - Mary L. Brandt
- Department of Surgery, Children’s Hospital of New Orleans, Louisiana, USA,Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Marla B.K. Sammer
- Edward B. Singleton Department of Radiology, Texas Children’s Hospital, Houston, Texas, USA,Department of Radiology, Baylor College of Medicine, Houston, Texas, USA
| | - Mohan Pammi
- Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Binu V, Goh DW, Taranath A, Piotto L, Gent R. Ultrasound as a first-line investigation to diagnose malrotation in children. Pediatr Radiol 2021; 51:2100. [PMID: 34374839 DOI: 10.1007/s00247-021-05141-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 06/06/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Vineet Binu
- Department of Paediatric Surgery, Women's and Children's Hospital, 72 William Road, North Adelaide, SA, 5006, Australia.
| | - Day Way Goh
- Department of Paediatric Surgery, Women's and Children's Hospital, 72 William Road, North Adelaide, SA, 5006, Australia
| | - Ajay Taranath
- Department of Medical Imaging, Women's and Children's Hospital, North Adelaide, SA, Australia
| | - Lino Piotto
- Department of Medical Imaging, Women's and Children's Hospital, North Adelaide, SA, Australia
| | - Roger Gent
- Department of Medical Imaging, Women's and Children's Hospital, North Adelaide, SA, Australia
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Oates AJ, Suleman NJ, Low SBL, Patel HJ, Thyagarajan M. The radiological diagnosis of midgut volvulus - wow, it's difficult! Pediatr Radiol 2021; 51:1936-1937. [PMID: 34136925 DOI: 10.1007/s00247-021-05123-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 04/07/2021] [Accepted: 06/03/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Adam J Oates
- Radiology Department, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK.
| | - Nageena J Suleman
- Radiology Department, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Samantha B L Low
- Radiology Department, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Hiten J Patel
- Radiology Department, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Manigandan Thyagarajan
- Radiology Department, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
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Nguyen HN, Guillerman RP, Seghers VJ, Sammer MBK. The eyes see what the mind knows - a need for midgut volvulus ultrasound education: reply to Strouse. Pediatr Radiol 2021; 51:673. [PMID: 33608741 DOI: 10.1007/s00247-021-05001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/13/2021] [Accepted: 02/04/2021] [Indexed: 11/26/2022]
Affiliation(s)
- HaiThuy N Nguyen
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - R Paul Guillerman
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Victor J Seghers
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Marla B K Sammer
- Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Houston, TX, 77030, USA.
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA.
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