Sonographic diagnosis of malrotation: it's complicated - counterpoint

Identification and treatment of intestinal malrotation with midgut volvulus in childhood: a multicenter retrospective study

Background

Intestinal malrotation is a rare condition, and its delayed diagnosis can lead to fatal consequences. This study aimed to investigate the identification and treatment of malrotation in children.

Methods

Clinical data, imaging, operative findings, and early postoperative outcomes of 75 children with malrotation were retrospectively analyzed.

Results

The mean age was 6.18 ± 4.93 days and 51.26 ± 70.13 months in the neonatal group (56 patients) and non-neonatal group (19 patients), respectively. Sixty-seven patients were under the age of 1 year at the time of diagnosis. The occurrence of bilious vomiting and jaundice was significantly higher in the neonatal group (89.29%) than that in the non-neonatal group (37.5%), p < 0.05 and p < 0.01, respectively. The incidence of abnormal ultrasound (US) findings was 97.30% and 100%, respectively, and the sensitivities of the upper gastrointestinal series were 84.21% and 87.5%, respectively. Sixty-six (88%) patients had midgut volvulus, including in utero volvulus (two patients) and irreversible intestinal ischemia (four patients). Most neonates (89.29%) underwent open Ladd's procedure with a shorter operative time (p < 0.01). Reoperation was performed for postoperative complications (four patients) or missed comorbidities (two patients).

Conclusions

Non-bilious vomiting was the initial symptom in >10% of neonates and nearly 40% of non-neonates. This highlights the importance for emergency physicians and surgeons to be cautious about ruling out malrotation in patients with non-bilious vomiting. Utilizing US can obviate the need for contrast examinations owing to its higher diagnostic accuracy and rapid diagnosis and can be recommended as a first-line imaging technique. Additionally, open surgery is still an option for neonatal patients.

Esophageal Perforation of a Neonate Following Placement of an Oral Gastric Tube

We present a case of neonatal esophageal perforation following routine oral gastric (OG) tube placement in the neonatal intensive care unit. This is a rare complication primarily affecting premature infants and can have significant morbidity and mortality. This case demonstrates the initial radiographic presentation of esophageal perforation and the subsequent imaging to confirm the diagnosis. Clinical management of this condition in the neonatal patient is also discussed. A unique highlight of this case is the difference in radiographic presentation on the initial study as compared to the later study.

US for Evaluation of Acute Abdominal Conditions in Neonates

US is the imaging modality of choice for evaluation of a variety of abdominal conditions, and in recent years it has also become useful and promising as a bedside technique for assessment of acute abdominal conditions in neonates. Bedside US can help, complement, and sometimes replace radiographic or contrast-enhanced studies in critically ill and labile neonates who are difficult to transport to the fluoroscopy suite. Some of the features of bedside US can be applied as point-of-care US (POCUS) of the sick neonate. Some of the abdominal conditions in neonates that can be assessed and monitored with bedside US are necrotizing enterocolitis and its complications, malrotation with a midgut volvulus, segmental volvulus, meconium peritonitis, and complicated inguinal hernia. High-resolution US with the use of 15-MHz and higher-frequency probes allows characterization of the bowel anatomy and features of intestinal abnormalities in neonates in fine detail. Color Doppler US and microvascular imaging improve accuracy in the detection and characterization of bowel vascularity, which is important in the treatment and follow-up of patients with intestinal conditions. ^© RSNA, 2023 Quiz questions for this article are available through the Online Learning Center. The slide presentation from the RSNA Annual Meeting is available for this article.